SATINDER SINGH Vs. NATIONAL INSURANCE CO LTD

JUDGEMENT

(1.) The present revision petition has been filed by one Satinder Singh (hereinafter referred to as the 'Petitioner') being aggrieved by the order of State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the 'State Commission') in favour of National Insurance Co. Ltd. (hereinafter referred to as the 'Respondent').

(2.) The facts of the case according to the Petitioner are that he had purchased a medical claim policy from the Respondent Insurance Company for a period of one year from 29.03.2004 to 28.03.2005 and paid the required premium. At the time of taking the policy, he also made the necessary disclosures and nothing was concealed from the Insurance Company. Suddenly, in December, 2004 the complainant felt "exertion" and he was taken to Deep Day Care Health Centre, Amritsar where he was treated upto 05.01.2005 and thereafter advised to go to the Escorts Hospital in Delhi for Angiography and other tests. The Petitioner went to Batra Hospital, New Delhi which is an approved hospital of the National Insurance Company where Angiography and other tests were performed and was diagnosed with Coronary Artery disease and angina on exertion class-III. It was specifically stated in the report by Batra Hospital that he was non-diabetic, non-smoker with no family history of CAD and the disease was a recent development. The Petitioner was advised a bye-pass surgery by the said hospital. When the Petitioner lodged a claim with the Respondent for his medical treatment at Batra Hospital, he was advised to go to Sir Ganga Ram Hospital for further treatment and surgery where a bye-pass surgery was conducted on him. The Petitioner thereafter submitted a claim for the medical expenditure which included Rs. 1,52,047/- that was spent on his operation at Sir Ganga Ram and Rs. 23,545/- at Batra Hospital. However, to his utter surprise the Respondent repudiated the claim on the ground that the present hospitalization was for management of an ailment which was related to a pre-existing disease and therefore was not admissible as per the Condition 4.1 of the said Insurance policy.

(3.) Aggrieved by this, Petitioner filed a complaint before the District Forum seeking Rs. 1,74,582/- along with interest @ 12% per annum, compensation of Rs. 50,000/- for deficiency in service, mental tension etc. as well as litigation cost.