NATIONAL INSURANCE COMPANY LIMITED Vs. RAMESHWAR GOSWAMI

JUDGEMENT

(1.) HAVING felt aggrieved of the judgment dated 4.12.2006 of the District Consumer Forum -1, Bareilly passed in Complaint Case No. 322/2004 filed by the respondent/complainant, the National Insurance Company Limited has preferred the instant appeal reiterating its old version that the Medi claim policy holder Sri Rameshwar was guilty of material concealment by screening the fact of his pre -existing diseases of hyper tension, diabetes and coronary heart problem.

(2.) THERE is no dispute that the appellant Insurance Company issued a Mediclaim policy of Rs. 2,00,000 to the respondent/complainant on 19.12.2003. About three months after he suffered a heart attack following complaint of short breathing and when he was hospitalized on the night between 10/11.3.2004 his case was referred to Escorts Hospital, New Delhi where after his examination bypass surgery was conducted. After he recovered he preferred a claim of Rs. 4,19,950 but it was repudiated on the ground of material concealment of the pre -existing ailments prior to the date of purchasing the Medi claim policy and since he concealed the factum of all these ailments , his claim was liable to be rejected. We have heard Mr. Rajesh Nath, learned Counsel for the appellant and Mr. Ashok Sinha, learned Counsel for the respondent and perused the record.

(3.) A reference has been made by the appellant to discharge summary of the Dharamdutt City Hospital which was prepared on 11.3.2004 at the time of a reference being made to the Escorts Hospital. Learned Counsel for the appellant contended with reference to the summary that insulin was prescribed for treatment of diabetes from which the complainant was suffering and likewise the history recorded in the discharge summary of Escorts Heart Institute at page 81 appears to indicate that Rameshwar was hypertensive, diabetic and has a family history of ischaemic heart disease. With reference to these two documents learned Counsel for the appellant has pressed into service the plea of pre -existing ailments of the complainant and since the complainant was allegedly under an obligation to disclose these ailments at the time of the filling of the proposal form for his Medi claim policy and further since he did not come alive to his obligation, he was held to be not entitled to have his claim. In this context it is noteworthy that neither any pathological report nor any Doctor's prescription to prove the existence of the two ailments of hypertension and diabetes has been filed by the Insurance Company in support of its case. The Escorts discharge summary though refer to the hypertensive and diabetic condition of the complainant on 11.3.2004 yet clarifies further that the patient was apparently well till one day back when he developed sudden onset breathlessness and vomitings for which he was admitted to a local hospital. However, since ECG revealed ST elevation in VI to III leads he was referred to the Escorts Hospital. The recital about the complainant being absolutely healthy until a day before rules out the possibility of his having suffered from two problems in the month of Dec. 2003 i.e. at the time when he had purchased the Medi Claim Policy.