ORIENTAL INSURANCE COMPANY LIMITED Vs. ASHOK RATHI

JUDGEMENT

(1.) THIS appeal under Section 15 of the Consumer Protection Act, 1986 , is directed against the order dated 16.1.2003, in Complaint No. 276/2002 by District Consumer Disputes Redressal Forum, Raipur (hereinafter called District Forum for short) whereby the appellant insurer has been directed to pay a sum of Rs. 1,00,000/ - to the complainant/respondent under the mediclaim policy issued by the appellant insurer to the complainant/respondent.

(2.) UNDISPUTABLY , the appellant and his wife Smt. Leela Rathi obtained a mediclaim policy from the appellants, which was effective from 12.2.2001 to 11.2.2002. The requisite premium was also paid by the insured to the appellant under the said policy. Smt. Leela Rathi suffered from heart disease and got herself treated at Apollo Hospital, Hyderabad. The treatment required heavy expenditure. The complainant claimed reimbursement of the said expenditure. However, the appellant insurer did not reimburse the expenses as above and intimated the complainant about disclaimer by their letter dated 7.3.2002. The complainant, therefore, preferred the complaint.

(3.) THE appellant resisted the complaint, it was averred that the insured Smt. Leela Rathi suffered from heart disease from before the issuance of the policy by the appellant. However, she did not disclose the above fact to the appellant/insurer and obtained the policy by suppression of material facts. It was averred that since the insured Smt. Leela Rathi suffered from the heart disease from before obtaining the policy, she was not entitled to get the mediclaim under the same in view of Condition 4/1 of the exclusion clause.