NATIONAL INSURANCE COMPANY LTD Vs. SARDAR KULBIR SINGH

JUDGEMENT

(1.) Complainant/respondent obtained a Mediclaim (Hospitalisation and Domicilary Hospitalisation Benefit) Policy from the petitioner-Insurance Company for the first time on 6.9.1994 for Rs. 1,00,000 which was effective till 5.9.1995. Thereafter, respondent kept on subscribing to the said Mediclaim Policy and the last spell of the Policy was for the period 24.9.1997 to 23.9.1998 and the insured amount was enhanced to Rs. 2,00,000. The respondent suffered from some Cardiac problem and was admitted to Escorts Heart Institute and Research Centre, Okhla on 15.7.1998 and, after necessary tests, had undergone three Artery By-pass Grafting on 15.7.1998 where he incurred an expense of Rs. 1,73,850 regarding which respondent filed a claim with the petitioner-Insurance Company. Petitioner repudiated the claim on twin grounds, firstly, that the last Policy was obtained after a gap of 17 days as the earlier Policy had expired on 7.9.1997 and the same was renewed on 24.9.1997 and, secondly, that the respondent had suppressed the fact that he was suffering from Heart problem while obtaining the Mediclaim Policy and, as such, the case of the respondent falls squarely within the ambit of Exclusion Clause 4 of the Terms and Conditions of the Policy. Being aggrieved, complainant/respondent filed the cfomplaint before the District Consumer Disputes Redressal Forum (Central), Maharana Pratap Bus Terminal, Mezzanine Floor, Kashmere Gate, Delhi (for short the District Forum ).

(2.) On being served, petitioner filed its Written Statement stating that the rejection of the claim of the respondent was made after thorough investigation of the case after due application of mind. That while obtaining the Mediclaim Policy, the respondent deliberately concealed the facts about his illness and fully knowing about his Heart problem, respondent increased the insured amount from Rs. 1,00,000 to Rs. 2,00,000 surreptitiously. That it was on the detailed Report of their Panel Doctor, Dr. Vinod Gandotra that the claim of the respondent was repudiated. Thus, denying the allegation made in the complaint, petitioner prayed for dismissal of the complaint.

(3.) District Forum, after taking into consideration, the pleadings and the evidence led by the parties, allowed the complaint, holding petitioner-Insurance Company guilty of deficiency in service. The petitioner was directed to pay the sum of Rs. 1,73,000 to the respondent along with interest @ 9% p.a. within 3 months of the filing of the claim till the date of payment. Rs. 1,000 were awarded as litigation expenses.