Oriental Insurance Co. Ltd. vs R.K.S.KHARBANDA

ON a complaint instituted by Shri RKS Kharbanda, the District Forum, UT, Chandigarh, ordered on 8.5.1997 that the Oriental Insurance Company shall pay a sum of Rs. 62,750/- together with interest @ 12% p.a. and costs Rs. 3,000/-. Aggrieved against it, the present appeal has been attempted.

BRIEFLY the facts as alleged are that the complainant secured a Hospitalisation and Domiciliary Hospitalisation Benefit Policy (also briefly known as Mediclaim Insurance Policy) from Oriental Insurance Company, Sector 22B, Chandigarh, and it was issued on 18.1.1991 for a period of one year. He had been of sound health, but it was in March, 1991 that he felt breathlessness and consulted Dr. Lal of Lal Medical Centre, Chandigarh and Dr. B.S. Bhatia of Bhatia Heart & Diabetes Centre, Chandigarh. He was advised to consult Escorts Heart Institute and Research Centre, New Delhi. He was admitted there and he had to undergo Bye-pass surgery on 1.6.1991 and discharged from the hospital on 11.6.1991. He demanded a sum of Rs. 99.680/- from the appellant, but the claim was repudiated. The complaint was instituted in the District Forum on 18.3.1992. The main plea raised on behalf of the appellant here is that the respondent was required to intimate and give notice regarding the claim within 15 days of the completion of the treatment. The relevant note may be reproduced here as well: "Failure to give notice or file such claim in time as provided in conditions 3 and 4 may not invalidate or reduce any claim, if it is substantiated that it was not reasonably possible for the insured person to give notice or file claim within the prescribed time." Though the respondent was admitted on 21.5.1991 yet the intimation regarding his treatment and request for demand Form was conveyed on 22.4.1991, 21.5.1991 and 24.5.1991. Thus it does not appear to be a case of delay.

Another plea raised on behalf of the appellant was that Shri R.K.S. Kharbanda aged 47, an Executive Engineer in Punjab, knew about his ailment and he availed of leave from 1.1.1991 to 11.1.1991. Shri Brij Bhushan Sharma, Superintendent of the office of the Chief Engineer, PWD, B & R, Patiala was examined in the District Forum, and brought the original record, told that though earned leave was applied for the period 1.1.1991 to 11.1.1991, yet it was not actually availed of by the respondent. It was got cancelled as per service record of the respondent brought by him. A revised discharge summary dated 12.9.1991 Annexure P 17 shows the patient felt shortness of breath only 2 or 2 months prior to his admission in the Escorts. The Bye-pass grafting was performed on 1.6.1991. This report together with the fact that the respondent did not avail any earned leave at all in January, 1991 goes to show that it was not a case that the respondent already had illness of the nature now under consideration much less it was concealed at the time this policy was obtained.

AFTER considering all these aspects, the finding of deficiency on the part of the appellant arrived at by the District Forum is affirmed. The appeal is dismissed. The sum of Rs. 62,750/- based on the report of the Surveyor together with interest and costs awarded by the Forum is hereby affirmed. Appeal dismissed.