United India Insurance Co. Ltd. vs Mehtab Singh

-RESPONDENT had taken a medi-claim insurance policy from the appellant for a period of one year. The claim of the respondent for a sum of Rs. 65,000/- spent by him was repudiated by the appellant on the ground that the respondent had concealed pre-existing disease and was, therefore, not entitled to any claim. Vide impugned order dated 24.3.1998 passed by the District Forum the claim of the respondent was allowed with interest @ 18% p.a.

THE solitary plea taken by the appellant while assailing the impugned order is that the District Forum did not take into account the opinion of Dr. Vipin Gupta (Annexure R-4) by observing that the appellant has failed to either produce Dr. Vipin Gupta or the fact that the opinion was actually given by Dr. Vipin Gupta. THE opinion of Dr. Vipin Gupta produced by the appellant is as under: "As per my opinion the present case is not within the purview of mediclaim policy since the disease is pre-existing. Insured had taken the present policy from the under writers for the first time on 14.3.1997. He cannot develop the disease of such severity in just four months. He must be having present disease for many years. Admittedly Dr. Vipin Gupta was not the person who had either examined the respondent or given him the treatment. He was merely on the panel of the appellant and gave the opinion on perusal of the record of the treatment provided by Kalra Hospital of Kirti Nagar, New Delhi.

There is no indication in the prescription as well as the treatment provided by Kalra Hospital showing that the respondent did not suffer from the said disease which is known as COPD (Acute Exacerbation) and CHF (Pyresia) - a disease of asthma and heart. Had the respondent been suffering from this disease there would have been some reference to the period for which the respondent was suffering and also the disease the respondent has been suffering.

THE concept of pre-existing disease in our view means the disease which was existing at the time of taking of the policy or at the time of the treatment one gets from the hospital. A person might have received the treatment for similar disease few years back and had been enjoying good health at the time of taking the policy. THE appellant Insurance Company is not entitled to repudiate the claim of such a person on the ground of concealment of pre-existing disease by the insured. Even otherwise the Insurance Company was expected to be careful while issuing policy by ruling out any such disease, which may disentitle the person from taking the policy by subjecting him to minimum requisite medical examination. We do not find any merit in the appeal but feel inclined to reduce the rate of interest from 18%, which appears to be on higher side to that of 9%. The amount shall be paid to the LRs of the deceased respondent within one month as he died during the pendency of this appeal.

THE appeal is disposed of with aforesaid modifications. THE FDR, if any deposited by the appellant be returned forthwith after completing necessary formalities. A copy of this order as per statutory requirements be forwarded to the parties free of charges and also to the concerned District Forum and thereafter the file be consigned to record room. Appeal disposed of.