MAHENDRA PRASAD Vs. GENERAL MANAGER

JUDGEMENT

(1.) HEARD .

(2.) THE petitioner had taken a Mediclaim Insurance Policy from the respondent -New India Assurance Company Limited, in the year 2001. This policy was thereafter renewed for the next year. It was thereafter renewed for 2003 -2004 as well. In 2004 she was taken seriously ill and had to be admitted in All India Institute of Medical Sciences, New Delhi where she underwent an open heart surgery. Claims were accordingly made on basis of Mediclaim Insurance Policy, which ultimately came to be rejected. The rejection was primarily based on the report of a surveyor, as contained in Annexure A being the report of Dr. Arun Agrawal. The tenor of the report is that the petitioner had been suffering from Rheumatic heart disease from before and had been hospitalized way back in 1991 also. This report also indicates that the said medical surveyor could not take copy of medical report from All India Institute of Medical Sciences, New Delhi and could meet "some persons at a separate place and settled the issue". This clearly discloses that he could not receive officially any document to support his report. Insurance Company then consulted a local doctor, who opined that the disease might have started in early age with gradual progression. In his opinion the disease starts at the age of 5 -15 years. On basis of the aforesaid in view of clause 4.1 of the prospectus to the policy the claim was rejected as a case of suppression and non -disclosure of pre -existing disease, which was material to the policy. The stand of the Insurance Company apart from above disclosure is that the report of the surveyor is binding on them and once the surveyor reported pre - existing disease they had no option but to repudiate the insurance claim.

(3.) IN the present case, though there is a finding of disease being from before, there is no material to support it. No report of All India Institute of Medical Sciences, New Delhi has been filed or brought on record and admittedly none is available to the insurance company. Further there is no finding nor any material to justify the finding that the petitioner was aware of Rheumatic heart disease from before and had concealed the same knowingly. In that view of the matter the decision to revoke the policy or repudiate the claim cannot be sustained. The decision impugned not to honour the Mediclaim Policy is thus set aside.