NITIN MAHESHWARI Vs. NEW INDIA ASSURANCE CO LTD

JUDGEMENT

(1.) THIS appeal has been filed against the order dated 20.7.2005 passed by the learned District Forum, Udaipur whereby the complaint of the Complainant was dismissed. The Complainant obtained a Mediclaim policy from New India Assurance Co. Ltd., validity of which was from 15.2.2001 to 14.2.2002. The Complainant took treatment for Nasopharyngeal Angiofybroma in Apollo Hospital, Delhi. He filed claim for the reimbursement but vide letter dated 19.8.2002, the claim was repudiated by the Assurance Company on the ground that the disease for which the treatment was taken was pre -existing at the time of taking the policy. Besides this, during the first year of the operation of insurance cover, such a claim was not payable and for that Exclusion Clauses 4.1 and 4.3 were referred to. The question for consideration is whether the disease Nasopharyngeal Angiofybroma was already existing before the policy was taken by the insured.

(2.) AS per the medical literature, patients with Nasopharyngeal Angiofybroma usually present with one side nasal obstruction and recurrent bleeding. It is said that this disease is treated by surgery.

(3.) THE Complainant had consulted Dr. Sudhir Bahadur in All -India Institute of Medical Sciences (AIIMS), New Delhi and the OPD notes show that there was a history of bleeding from nose for the last 4 -5 months. There was a history of biopsy also from nose which shows that the disease was Angiofybroma. Discharge summary of Apollo Hospital mentions that the patient was admitted with the complaint of nasal blockage 4 days, bleeding from the nose 4 days. On examination, a mass was seen in Nasopharyn, which was firm extending to nose. In the background of this disease, it has to be seen whether this disease was already existing before the policy. There was no dispute on this point that Nitin Maheshwari, the Complainant was examined by the Investigator whose statements are on record. He has stated that on 3.2.2001, he had gone to Udaipur to attend a marriage where Shri S.N. Maheshwari, a relative advised him to take Mediclaim. He has further stated that he had problem about the coryza for which he had taken treatment from Govt.Hospital, Fateh Nagar. From 15.3.2001 to 20.3.2001 he happened to visit his uncle in Meerut where all of sudden the nose started bleeding. He consulted local Doctors and they referred him to AIIMS and Apollo Hospital, Delhi. In the light of these statements, a certificate issued by the Govt. Hospital, Fateh Nagar was perused which goes to show that he had consulted Doctor for acute respiratory infection/upper respiratory infection on 13.1.2001, 20.1.2001, 14.2.2001, 22.2.2001, 27.2.2001, 23.3.2001 and 4.4.2001. There is no reason to disbelieve this certificate in view of the statements given by the Complainant himself wherein he has admitted that he had taken treatment from Govt. Hospital, Fateh Nagar. This upper acute respiratory infection was the root cause for Angiofybroma. The OPD notes of AIIMS, New Delhi also show that there was history of bleeding from nose for the last 4 -5 months and there was history of biopsy also from the nose. These are the indications of disease known as Angiofybroma. Taking treatment in the hospital from 13.1.2001 to 4.4.2001 and visited hospital 7 times for check -up further show that the Complainant had the knowledge that he was suffering from disease but he did not disclose this fact at the time of taking the policy. We agree with the findings recorded by the learned District Forum that this is a case of suppression of material fact. On this ground alone, the claim was not payable. Even otherwise, claim was not payable as per the condition of policy. During first year of the operation of insurance cover sinusitis and related disorders are not payable. Sinuses is a inflammation of the membramous lining of one or more of the sinuses. Sinusitis may also be referred to as rhinosinusitis because inflammation of the nasal mucosa generally precedes and accompanies sinusitis. The present disease may not be exactly sinusitis but the disease may be put in the category of other related disorder and during first year, the claim for this disease was not payable as per the policy condition.