AMIT CHAUDHARI Vs. ORIENTAL INSURANCE COMPANY LIMITED

JUDGEMENT

(1.) THIS appeal is directed against order dated 8.2.2008, passed by District Consumer Disputes Redressal Forum, Raipur (hereinafter called as "District Forum" for short) in Complaint Case No. 230/2005, whereby complaint of appellant in respect of medical reimbursement under Mediclaim policy, has been dismissed, on the ground of concealment of material fact at the time of making proposal for the insurance.

(2.) IN nut shell, the facts of the case are that appellant/complainant purchased a Mediclaim policy No. 341/2005 from Respondent Insurance Company for the period between 27.7.2004 to 26.7.2005. During that period on 17.3.2005, complainant/appellant felt some heaviness in the chest along with mild pain. He was examined by family Physician Dr. P.S. Deshpande and then certain test was advised. Such tests were conducted in Escorts Heart Centre, Raipur where Reversible Myocardial Ischaemia was detected and he was advised to undergo coronary angiography. During that coronary angiography Double Vessel Disease of heart was detected and surgery for Coronary Artery Bypass Grafting (CABG) was done. It was assured by representative of Insurance Company at the time of admission for examination and tests that expenses for treatment and the operation, would be borne by the Insurance Company, but later on the Insurance Company had repudiated the claim of the complainant, on the ground that he was suffering from Hypertension before making proposal for insurance and suppressed this material facts at the time of making proposal for insurance. The complainant was to spend in all Rs. 3,09,756 for his treatment and that amount was claimed from respondent Insurance Company by filing complaint under Section 12 of the Consumer Protection Act, 1986 .

(3.) IN written version, it has been asserted by the Insurance Company that as per admission ticket of the complainant in Escort Heart Centre, Raipur, history of having Hypertension for last 10 years, was given and he has been described as a known case of Hypertension. He was taking treatment for blood pressure for last so many years and this fact was concealed by him from the Insurance Company, so no claim was payable.