NATIONAL INSURANCE COMPANY LIMITED Vs. HARJEET KAUR

JUDGEMENT

(1.) THIS appeal, under Section 15 of the Consumer Protection Act, 1986 , is directed against the order dated 13.10.2004 in Complaint No. 133/2004 of the Consumer Disputes Redressal Forum, Raipur (hereinafter called the District Forum for short) whereby the appellant/insurer was directed to pay Rs. 1 lac with interest @ 9% per annum payable thereon from 19.11.2003, under the Medi Claim Policy obtained by the complainant/respondent No. 1, besides Rs. 1,000 as cost of the complaint.

(2.) THE complainant/respondent herein obtained Group Mediclaim Policy for Rs. 1 lac for the period from 8.9.2002 to 7.9.2003. The averments of the complainant were that there were complications in the uterus which she got checked up and was ultimately operated at Bombay Hospital on 28.5.2003. She had to remain in the Bombay Hospital from 28.5.2003 to 12.6.2003. According to the complainant, a total expenditure of Rs. 1,21,370 was incurred by her in the above treatment. She submitted the claim with the appellant/insurer along with necessary documents. However, the claim of the complainant was repudiated by the appellant/insurer by their letter dated 19.11.2003. Aggrieved by the repudiation as above, the complainant preferred the complaint before the District Forum.

(3.) THE appellant/insurer resisted the complaint. According to them, the surgery/treatment involving Hysterectomy was not covered during the first year of the policy, in view of the Exclusion Clause under the Medi Claim Policy. Therefore, the expenditure for the treatment of the complainant was not payable.