NATIONAL INSURANCE COMPANY LTD. Vs. USHA PURI

JUDGEMENT

(1.) RESPONDENT had taken a group medical insurance policy from the appellant which covered the benefit till 30.9.1999 i.e. till the respondent attained the age of 70 years. In the year 1993 the respondent and her husband got themselves insured under the mediclaim policy of the appellant. In the same year respondent had fallen twice in her house and suffered injury and pain in both her knees. She was examined by Dr. Ashok Raj Pal who advised replacement of both the knees joint in June 2000. The operation was carried out at Sita Ram Bhartia Institute of Science and Research on 26.6.2000. The respondent paid a sum of Rs. 3,03,150. She also paid post -operated treatment.

(2.) THE appellant repudiated the claim of the respondent on the ground of non -disclosure of pre -existing disease by the respondent which in terms of exclusion Clause 4.1 disentitles the respondent from reimbursement of medical expenses. Consequently the respondent filed the instant complaint before the District Forum.

(3.) VIDE impugned order dated 20.7.2007 which is not at all a happily worded order nor has even referred to the contentions of the appellant averred in the reply, the complaint was allowed with the following directions: (i) Appellant will pay Rs. 3,32,961 to the respondent inclusive of post operation medical expenses. (ii) Appellant will pay Rs. 40,000 to the respondent for causing mental agony, harassment and deficiency in service by wrongfully rejecting the claim. (iii) Appellant will pay Rs. 3,000 towards cost of litigation.