Oriental Insurance Co. Ltd. vs SHEHANAZ

THIS appeal, by the opposite party, is directed against the order dated 14-5-1993, passed by the District Forum, Belgaum, in Complaint No. 113/ 92, directing the opposite party-Insurance Company to pay a sum of Rs. 7,440/- towards mediclaim and a sum of Rs. 2,500/- towards compensation to the complainant. The facts, briefly stated, are as follows: 1. The complainant had taken a Mediclaim Policy from the opposite party on 11-3-1991. It was for a period of one year, that is, from 11-3-1991 to 10-3-1992. The complainant made a payment of the premium in a sum of Rs. 1,170/- to the opposite party. The complainant underwent an ulcer operation on 7-5-1991 at Dr. D.A. Jagadale Clinic, Belgaum. She was discharged from the hospital oh 26-5-1991. The complainant made a claim for the medical expenses incurred for the operation with the O.P. under the said Mediclaim Policy. When the O.P. repudiated the claim made by the complainant, the complainant filed a complaint claiming the medical expenses incurred by her.

THE opposite party-Insurance Company, filed its objections and admitted that a mediclaim policy was taken by the complainant as averred by her and premium was paid in that regard and the policy was of a period of 12 months commencing from 11-3-1991. THE opposite party further averred that since the complainant had suffered disease during the first 30 days, from the date of commencement of the policy and so the company was not liable to pay the claim made by the complainant. It relied on the exclusion clause contained under clause 1, which reads as under: "1. Any disease suffered by the insured person during the first 30 days from the commencement date of the policy. This exclusion shall not however, apply if in the opinion of panel of Medical Practitioners, constituted by the Company for the purpose, the insured person could not have known the existence of the disease or any symptoms thereof at the time of making the proposal of Insurance to the company."

THE opposite party, having regard to these facts, repudiated the claim made by the complainant and averred that it was not liable to reimburse the claim made by the complainant. The District Forum, Belgaum, held that since the complainant had undergone an operation after 30 days of the issuance of the policy, the Insurance Company cannot take shelter under this clause and refuse to pay the compensation amount.

We have called for the records and received. We have also heard the learned Counsel for the parties.

THE opposite party had obtained the medical report from Dr. Jagadale and it produced the same before the District Forum. It shows that the complainant had consulted Dr. Jagadale on 18-3-1991 for some Abdominal Pain for which Dr. Jagadale had given some prescription. It is not disputed that the complainant under-went ulcer operation on 7-5-1991. This fact that she had consulted Dr. Jagadale on 18-3-1991 for same pain in her stomach would not be sufficient to hold that the complainant had contracted the said disease on or before 18-3-1991. THE claim of the appellant-Insurance Company that their liability was excluded under clause 1, is not substantiated. THE said clause provides that the Company shall not be liable to make any payment under the policy in respect of expenses whatsoever incured in connection with or in respect of any disease contracted by the insured person during the first 30 days from the date of commencement of the policy. In the present case, the policy commenced from 11-3-1991 and the operation was conducted on 7-5-1991 and the expenses incurred towards that operation and treatment were claimed. Thus, it is evident that the expenses incurred by the insured were in respect of disease suffered by her after a period of 30 days from the date of the policy. Having regard to these facts and in the circumstances of the case, the District Forum, Belgaum, held that the repudiation of the claim of the complainant made by the opposite party-Insurance Company, amounted to deficiency of service. Having regard to these facts and in the circumstances of the case, we do not find any infirmity in the finding recorded by the District Forum, Belgaum. There are no grounds for us to interfere in the finding recorded by the District Forum, Belgaum. ORDER In the result, therefore, this appeal fails and it is dismissed. The appellant-Insurance Company shall pay a sum of Rs. 500/- (Rupees five hundred only) to the complainant towards costs in this appeal. Appeal dismissed with costs.