NATIONAL INSURANCE COMPANY LTD Vs. PANGULURI RAMA RAO

JUDGEMENT

(1.) THIS is an appeal preferred by opposite party Insurance Company against the order of the Dist. Forum directing it to pay Rs. 25,802 under mediclaim policy together with interest and costs.

(2.) THE case of the complainant in brief is that he was a Vijaya Bank Credit Card holder taken medical claim insurance policy under Vijaya Bank Credit Card Holders Group Insurance Coverage. He sustained pain on the lower back bone. An operation was performed on 1.3.2005 wherein he spent about Rs. 50,000 towards medical expenses, however, bills to a tune of Rs. 25,802 were only issued. When he sent the claim form along with certificate on 18.3.2005 the appellant did not choose to settle the claim, on the other hand repudiated the claim on the ground that he incurred the expenses within 30 days of taking the policy. Therefore he claimed the said amount with interest @ 24% p.a., and compensation of Rs. 1 lakh together with costs of Rs. 2,000.

(3.) THE appellant Insurance Company resisted the case. While admitting issuance of policy it alleged that the claim was repudiated by letter dated 1.6.2005 by virtue of exclusion Clause 4.2 -the expenses incurred within 30 days of the policy were not covered'. When the complainant had been diagnosed for acute IVDP with sciatica @ LL on 21.1.2005 itself, and took treatment at Sanjivini Orthopaedic and Physiotherapy Centre, Guntur between 28.2.2005 and 12.3.2005 and the policy being effective from 1.1.2005 he having been contracted with the said disease within 30 days he was not entitled to any amount. Therefore it prayed for dismissal of the complaint with exemplary costs.