NATIONAL INSURANCE COMPANY LIMITED Vs. MUKESH KUMAR ARORA

JUDGEMENT

(1.) AT the outset, we may observe that the case has been argued very well by the Counsel for both the parties. We could not make up or mind one way or the other and this led us to pass an order on the last date of hearing i.e., 17.2.2005 that the Director, P.G.I., Chandigarh be requested to depute a Heart Specialist from the Cardiology Department to assist us in this matter. In response to that order, Dr. Manoj Kumar Rohit, M.D.; D.M. (Cardiology), Fellowship (RAHC -Sydney), Assistant Professor Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh is present in Court. As to what is his opinion in the matter, we will notice that hereinafter.

(2.) BRIEF facts giving rise to this appeal may be noticed. Respondent -complainant, Sh. Mukesh Kumar Arora, had obtained a Medi -claim Policy from appellant -National Insurance Company Limited (in short NIC) on 11.8.2000 for one year which was to last upto 10.8.2001 and another Mediclaim Policy for a year from 22.8.2001 for Rs. one lac which was to last upto 21.8.2002. During the currency of the second policy, the complainant was admitted in Ranjit Hospital, Amritsar, on 5.9.2001. Echocardiography was done there and he was referred to Escorts Heart Institute and Research Centre Ltd., New Delhi. He was admitted in the Escorts Heart Institute firstly on 27.9.2001 and was discharged on the same day after cardiac catheterisation and was to be re -admitted on 5.10.2001 for surgery. He was re -admitted on 5.10.2001 and discharged after surgery on 17.10.2001. He spent Rs. 2,11,450/ - on his treatment. It may be stated here that under the Insurance Policy, the Company was to reimburse the mediclaim of the complainant to the extent of Rs. 1 lac and Rs. 5,000/ - as cumulative bonus. Claim was lodged with the Insurance Company but the Insurance Company repudiated the claim on the ground that the case fell in the Exclusion Clause in the policy to which reference would be made hereinafter. Firstly, we may notice as to what was diagnosed at the Escorts Heart Institute, New Delhi. In Ex. C -9 which is a discharge summary of Escorts Heart Institute dated 27.9.2001, under the head Discharge Diagnosis it is mentioned as under:

(3.) ULTIMATELY after the operation, when the complainant was discharged after the surgery, another Discharge Summary, Ex. C -12, was prepared on 17.10.2001 by the Escorts Heart Institute and under the head Discharge Diagnosis , it is mentioned as under :