New India Assurance Co.Ltd. vs RENU CHUGH

THE New India Assurance Company Ltd. has come up in appeal against the order dated 18.4.1996 passed by the District Consumer Forum, Bhiwani, whereby the complaint of Dr. (Mrs.) Renu Chugh claiming a sum of Rs. 24,700/- by way of medical expenses, has been allowed against the Insurance Company.

THE complainant had approached the District Consumer Forum, Bhiwani, with the grievance that she had obtained a ''Mediclaim'' insurance policy from the appellant-Company on 1.10.1992 for a period of one year. However, within 3/4 months thereafter, the complainant had to undergo an operation at New Delhi on 13.1.1993 for dilatation curettage (D & C) and histopathology etc. THEreafter, she was operated for the removal of tumor of proliperate on 23.1.1993 and her uterus was removed. For this treatment she had to spend a sum of Rs. 24,700/- for which she lodged a-claim with the appellant-Company, but the claim was repudiated. In their reply, the Insurance Company pleaded that the complainant had undergone the operations for certain disease which was pre- existing at the time she had taken out the insurance policy and that the material facts were not disclosed by her. Moreover, it was further pleaded that the Insurance Company was not liable to cover the risk for the complainant''s operation etc. during the first year of the policy. Despite all this, the District Forum allowed the complaint by taking the view that there was no suppression of facts on the part of the complainant as the disease was not pre-existing. In the appeal before us, the learned Counsel for the appellant has vehemently contended that the complainant, who is herself a doctor by profession, should be given the credit of atleast knowing the existence of the disease she was suffering from at the time she got herself insured. Moreover, she being an expert Gynaecologist of Bhiwani, who had been running a Nursing Home there, must be credited with the knowledge of the gravity and extent of the disease which within three months resulted in the removal of her uterus. On the other hand, the learned Counsel for the respondent-complainant vigorously pleaded that the operation was conducted as per medical advice and not as per the choice of the complainant and that the existence of the disease had come to her notice during the process of medical tests etc.

After hearing the learned Counsel for the parties and having gone through the record, we are of the considered view that the repudiation of the claim by the Insurance Company was legally justified and they were not liable to pay the medical claim to the complainant by virtue of the terms and conditions of the insurance policy. Even if it is assumed for the sake of argument that there is no suppression of any material fact on the part of the complainant as she was not in the know of the disease being pre-existing on the date she got herself insured, yet the Insurance Company has certainly excluded its liability and got itself immuned from paying the medical claim in the first year of the policy. Therefore no legal infirmity can be found with the bona fide repudiation of the claim by the Insurance Company. Consequently, we accept the appeal, set aside the order passed by the learned District Consumer Forum, Bhiwani, and dismiss the complaint with no order as to costs. Appeal allowed.