ORIENTAL INSURANCE CO.LTD. Vs. HANS RAJ KHURANA

JUDGEMENT

(1.) VIDE impugned order dated 2.12.2003 passed by the District Forum, the appellant has been directed to make payment of Rs. 45,007 towards medical expenses incurred by the respondent with interest @ 9% p.a. and also pay Rs. 2,000 as compensation for harassment and mental agony and Rs. 500 as litigation cost. Feeling aggrieved the appellant has preferred this appeal.

(2.) RESPONDENT filed the instant complaint before the District Forum when his claim for medical claim was rejected by the appellant company on the ground that respondent had concealed the factum of pre -existing disease. The case of respondent before the District Forum, in brief, was that he had obtained a mediclaim policy from the appellant which he used to get renewed every year. According to the respondent, his wife fell sick suddenly on 2.03.01 and he took her to Shanti Mukand Hospital where he was informed that she had stones in gall bladder. He told the doctor that his wife had got herself operated from Tirath Ram Hospital in 1994 in respect of stones upon which the doctor asked him to show the reports of 1994. He informed the doctor that those reports had already been submitted to the insurance company and the same were not available with him. Thereafter Shanti Mukand Hospital got necessary tests done and advised operation since the gall bladder had stones. He got his wife admitted in the hospital on 8.3.01 and was operated upon. The respondent stated that he informed the appellant about it and submitted bills for Rs. 45,007 along with reports of the hospital to appellant for payment of the claim. He pursued the appellant for 5 -6 months but no action for payment was taken and subsequently in August, 2002 he received letter dated 11.12.01 whereby the claim was repudiated.

(3.) THE appellant -company invoked clause 4 of the insurance contract for justifying the rejection of the claim providing that the insurance company is not required to make any payment under the policy in respect of the expenses incurred in respect of diseases which had been in existence at the time of proposing the insurance and also contained an undertaking by the proposer that if after the insurance is effected, it is found that the statements or particulars in the proposal form were incorrect, the insurance company shall not incur any liability under the insurance.