STAR HEALTH & ALLIED INSURANCE CO LTD & ANOTHER Vs. PERMANENT LOK ADALAT (PUBLIC UTILITY SERVICES), JIND & OTHERS

JUDGEMENT

(1.) The petitioner has challenged the order dated 23.11.2016 passed by the Permanent Lok Adalat (Public Utility Services), Bhiwani, Camp Court at Jind (hereinafter referred to as the "Permanent Lok Adalat"), by which the application filed by respondent no.2 under Section 22-C of the Legal Services Authority Act, 1987 (hereinafter referred to as the "Act") has been allowed.

(2.) Brief, respondent no.2 along with his family members obtained a Family Health Optima Insurance Policy No.P/211119/01/2014/001738 dated 16.03.2013 for a sum of Rs5 lakhs. The said policy was renewed in the year 2014. The petitioner fell ill and was admitted in Max Health Care Super Specialty Hospital, Mohali on 09.06.2014. He was diagnosed with dilated cardiomyopathy, i.e. enlargement of heart due to which it cannot pump the blood effectively. Respondent No.2 spent an amount of Rs9,26,040/- on his treatment and applied for the insured amount from the Insurance Company and since it was not paid, therefore, filed the aforesaid application before the Permanent Lok Adalat. The petitioners contested the application on the ground that respondent no.2 was though admitted in hospital on 09.06.2014 but as per the record, he was a known case of dilated cardiomyopathy for the past one and half years prior to the inception of the policy in question. The petitioners communicated the rejection of the claim to the hospital as well as respondent no.2. The case of the petitioners is that as per the consultation letter dated 12.05.2014 from AIIMS, the insured was diagnosed with dilated cardiomyopathy for the past one and half years and at the time of inception of the policy dated 16.03.2013, respondent no.2 did not disclose his medical history in the proposal form, therefore, amounts to misrepresentation/nondisclosure of material facts on account of which the Insurance Company is not liable.

(3.) Sole issue before the Perament Lok Adalat was as to whether the petitioners were justified in rejecting the claim of respondent no.2 vide letter Ex.R8/R4 dated 31.10.2014. The Permanent Lok Adalat has observed that respondent no.2 fell ill after one year and three months as he had obtained the policy on 16.03.2013 and was admitted to hospital on 09.06.2014 and before that, he did not suffer from any symptom of dilated cardiomyopathy. Thus, the Permanent Lok Adalat has allowed the application filed by respondent no.2 vide the impugned order dated 23.11.2016.