New India Assurance Company Ltd. vs GIRISH CHANDRA PALIVAL

-THIS is an appeal against the judgment and order dated 23.1.2002 passed by District Consumer Forum, Bulandshahr in Complaint Case No. 196 of 2000.

THE facts of the case stated in brief are that the complainant obtained a Medi-claim insurance policy on 7.9.1998 but the Medi-claim policy was issued on 11.9.1998. THE complainant developed pain in the chest and he consulted Dr. S.K. Goyal. He advised the complainant to contact Dr. Gambhir in the Pant Hospital. On 14.9.1998 the complainant went to the Pant Hospital and on 15.9.1998 angiography was done in which it was found that 90% and 70% of the arteries are blocked for which angioplasty and staling was done. THE complainant was discharged from the hospital on 24.9.1998. THE complainant informed the Insurance Company about the disease on 22.9.1998. A sum of Rs. 1,17,588/- was spent on medical expenses for which a claim was put forward to the Insurance Company by the complainant. A Surveyor was appointed but nothing was done by the Insurance Company inspite of notice issued on 13.7.1999. THE complainant has filed a claim before the District Forum for Rs. 1,17,588/- along with Rs. 20,000/- as damages and cost. As none appeared on behalf of the opposite party the complaint proceeded ex parte.

On the basis of evidence filed by the complainant the learned District Forum came to the conclusion that there was deficiency on behalf of the opposite party and hence it directed for payment of Rs. 1,15,588/- along with 10% per annum interest to be paid within a period of 45 days. A sum of Rs. 5,000/- as damages and Rs. 500/- as cost were also awarded. If the compliance is not done within a period of 45 days, then interest shall be payable at the rate of 12% per annum.

AGGRIEVED against the order of the learned District Forum, the opposite party New India Assurance Company Limited, has come in this appeal and has challenged the correctness of the order passed by the District Forum. We have heard the learned Counsel for the parties. The only question involved in the present case is whether the complainant is entitled to any claim within 30 days of the issuance of policy. Learned Counsel for the appellant has argued that in terms of Clause 4.2 no claim is payable to the complainant. For the sake of convenience this exclusion Clause 4.2 is re-produced below : "Any expenses on hospitalisation/domicilliary hospitalization incurred during first 30 days from the date of commencement of insurance cover except in case of injury arising out of accident."

A perusal of this clasue will go to show that if within 30 days of issuance of the policy the person is ill and the person lodges a medical claim, then no amount is liable to be paid by the Insurance Company. This exclusion clause excludes all expenses incurred in connection with the disease which causes hospitalization within first 30 days of the date of commencement of the policy. In this case the policy was taken by the complainant on 7.9.1998. Therefore, the complainant could not have get any expenses for hospitalization upto 7.10.1998. The complainant has claimed the expenses for the period 14.9.1998 to 24.9.1998. Thus the learned District Forum has not considered this aspect of the matter and has wrongly decreed the claim. The appeal is, therefore, liable to be allowed. ORDER The appeal is allowed and the judgment and order of the learned District Forum are set aside and the complaint is dismissed. There will be no order as to the costs. Let copy as per rules be made available to the parties. Appeal allowed.