DILIP Vs. NEW INDIA ASSURANCE CO LTD

JUDGEMENT

(1.) This is a complainant's appeal against the order dated 16th July, 1999 passed in Case No.261/1998 by the District Consumer Disputes Redressal Forum, Indore (for short the 'district Forum' ).

(2.) Facts giving rise to this appeal are thus : M/s. Gokuldas Hospital Limited, Indore obtained a Group Mediclaim Insurance Policy No.4845130006917 covering the risk from 17.9.1996 of which the appellant was one of the beneficiary. On or about 2.10.1996 the appellant suffered from acute congestive glaucoma and was admitted in the Gokuldas Hospital for the treatment where he was treated medically for reducing the tension. He was operated for Glaucoma on 4.10.1996 and was discharged on 7.10.1996. However, the appellant developed secondary complications Cataract and the swelling of the lens in the right eye, hence, was referred to Dr. Kulin Kothari of Bombay for advice and treatment, where Dr. Kulin Kothari performed surgery basically for Glaucoma and to give relief permanently to the appellant. The appellant lodged a mediclaim of Rs.17,994/-. The Insurance Company vide letter dated 27.2.1997 did not make the payment as during the first year of the operation of the insurance cover the expenses incurred were excluded from the scope of the policy cover in view of Exclusion No.4.2 of the policy. After correspondence and notice when the claim was not paid, the appellant filed the complaint before the District Forum, which was resisted. The District Forum after appreciation of evidence held that the appellant suffered the disease Glaucoma, which was not an accidental causing an injury due to accident, therefore, in view of exclusion Clause No.4.2, the Insurance Company rightly did not make the payment.

(3.) Mr. V. K. Jain, learned Counsel for the appellant submitted that the Insurance Company erred firstly in treating the claim as of Cataract while the appellant suffered from Glaucoma, an unexpected event as the Glaucoma is sudden and is not known before hand. Besides, a disease which develops slowly without showing any symptom is also covered within the meaning of accident. The Insurance Company illegally applied exclusion Clause 4.2 and did not make the payment on the basis of the technical opinions obtained by the Insurance Company which were not produced before the District Forum, hence, the District Forum ought to have drawn adverse inference against the Insurance Company. The Insurance Company by mis-interpreting the words 'accident' and 'injury' applied exclusion Clause 4.2 to repudiate the claim.