ORIENTAL INSURANCE COMPANY LIMITED Vs. SARLA GARGA

JUDGEMENT

(1.) THIS is an appeal by the Oriental Insurance Company Ltd. against the judgment and order of District Consumer Disputes Redressal Forum. Fatehgarh Sahib (hereinafter called the "District Forum") dated 4.5.2006 by which the complaint of the complainant was allowed in the following terms : "For the foregoing reasons and discussion, we accept the complaint and direct the opposite parties to make the payment of Rs. 90,000 as medical claim with interest at the rate of Rs. 9% since 22.9.2003 i.e. the date of the operation and we also direct the respondents/opposite parties to give the complainant compensation of Rs. 10,000 for mental agony and harassment and Rs. 1,000 as cost of the petition." Brief facts may be noticed :

(2.) THE complainant had been taking mediclaim policies from the Insurance Company from the year 1999 onwards. Every year these were being renewed. We are concerned herewith the policy which was valid upto 24.9.2003. The complainant was treated for the disease, namely, " Lumber Canal Stenosis with Spondylothesis". The complainant was admitted in the G. B. Pant Hospital, New Delhi on 17.9.2003 and was operated upon on 22.9.2003. A claim in the sum of Rs. 90,000 was lodged but the Insurance Company refused to honour the claim and rather repudiated it vide letter dated 27.2.2004, which led the complainant to file a complaint before the District Forum.

(3.) THE primary ground for repudiating the claim was that the complainant had a pre -existing disease at the time the policy was taken. The District Forum, after appreciating the evidence and the arguments, gave the relief as aforesaid. Hence the present appeal. The only point to be seen is : Is there any evidence that the complainant had the pre -existing disease? According to us, since it is a case of continuous policy being taken one after the other, we will have to see whether the disease was pre -existing at the time when the first policy was taken and not when the last policy was taken. We may notice here clauses 4.0 to 4.3 of the Exclusion Clauses in the policy :