PRAMOD SINGH Vs. ORIENTAL INSURANCE COMPANY LTD

JUDGEMENT

(1.) In this writ petition, petitioner is aggrieved by the denial of payment of Mediclaim pursuant to Mediclaim Insurance Policy bearing No. 48 of the year 2003 for the period 14.5.2002 to 13.5.2003 issued by the Respondent-Oriental Insurance Company Ltd. vide Annexure-1.

(2.) In short, the relevant facts are that on 14.5.2002 petitioner took a Mediclaim policy from Branch office of the Respondent-Company situated at Sudama Palace, Kankarbagh, Patna, for the sum of Rs. two lacs insured for self and Rs. fifty thousand for his wife, namely, Smt. Manju Singh after deposit of Rs. 4915/-towards premium service charge and stamp duty. The Insurance Company issued certificate to the petitioner, a photostat copy whereof has been annexed as Annexure-1. The petitioner, who is a practising Advocate, claims that he was quite alright and physically fit to undertake his daily professional work and, in fact, attended the Court till 22nd May, 2002. However, he desired to get himself thoroughly examined by the expert Doctors at Delhi as he was being treated for simple Hypothyroid since. January, 2002 by Dr. A.K. Singh, M.B.B.S. (Gold Medalist) M.D., Nalanda Medical College, Patna, who referred him for check up to AIIMS, New Delhi on 22.5.2002. The photostat copy of the prescription of Dr. Singh has been annexed as Annexure-2. The petitioner consulted eminent doctors at Delhi and he was advised for Angiography, which was conducted in Escorts Heart Institute and Research Centre, New Delhi on 5.6.2002. Thereafter, the petitioner was advised for undergoing bypass surgery and he was hospitalised on 28.6.2002. Surgery was performed on 2.7.2002 and he was discharged on 9.7.2002. Thereafter, he applied for Mediclaim on 31.10.2002, which was received in the office of the Respondent on 15.11.2002. The petitioner has asserted that he was found fit and there was no question of pre- existing heart disease as per advice of Dr. Singh. It is stated by the petitioner that AGM of the Company (Respondent No. 3) came to him with letter dated 18.12.2002 (Annexure-4) and obtained authority letter so as to verify the bills submitted by him. The petitioner authorised the Company for verification of the Bills and since thereafter his wife visited the local office of the Respondents about half a dozen time and all the time she was assured for favourable action. It is alleged that at times they gave indication for giving some percentage of the claim amount so as to facilitate the payment Which was seriously objected to by the petitioner. As a result he received a letter dated 14.2.2003 issued by Respondent No. 3 refusing to entertain the claim of the petitioner on the ground that he had taken Mediclaim policy for the first time on 14.5.2002 (vide Annexure-5) whereas he was suffering from 'angina on exertion' since December, 2001, which he did not reveal in the proposal form. The said letter further mentioned that "Exclusion No. 4.1 of our Mediclaim policy excludes all diseases/injuries which are pre-existing when the cover incepts for the first time". Petitioner has asserted that he was confident that there was no question of pre-existing heart disease as per the advice of Dr. A.K. Singh.

(3.) A counter affidavit has been filed on behalf of the Respondent-Company and its officials (Respondent Nos. 1 to 3) in which it is not disputed that the petitioner went through bypass surgery at Escorts Heart Institute, New Delhi. However, the Respondents raised technical objections that Clause 4.2 makes it clear that a new policy comes into effect after 30 days of the taking of the policy; and, that as per the requirements the policy was issued on his self declaration that he was not suffering from any ailment, and, further, that a notice of a claim is to be given within 7 days of the Hospitalisation and Domiciliary Hospitalisation which the petitioner did not give. It is further stated that as per law the case was referred to Dr. Vinod Gandotra, New Delhi for survey and investigation, who in his report reported that it is not tenable under the purview of the policy on the ground of (a) pre-existing disease (b) concealment of the facts. According to the Respondents, they have acted according to the report of the Surveyor, which is binding on them under the law and if the petitioner is aggrieved by the decision of the Respondents based on survey report, he should have moved the Insurance Regulatory Authority, whose decision is final and binding on the Respondents.