NATIONAL INSURANCE CO LTD Vs. GIRIN R SHAH

JUDGEMENT

(1.) This revision petition has been filed by the insurance company, which was OP before the District Forum in the complaint lodged by the respondent Girin R. Shah. Sh.Ramesh P. Shah, who was father of the complainant, had taken a Mediclaim Insurance Policy of the OP-insurance company for Rs.2 lakh in the year 1998, which was renewed every year and the last renewal was for the period from 01.09.2003 to 31.08.2004. Since the father of the complainant had suffered from urinary infection, he was admitted in the Rahul Nursing Home on 03.05.2004 and was given treatment for five days as an indoor patient. He had developed an abscess inside the anus and also had infection. He was operated upon on 07.05.2004 and was given treatment for the urinary infection as an indoor patient upto 24.05.2004 and thereafter he was discharged and continued the treatment as an outdoor patient. According to the complainant, his father was admitted again on 04.06.2004 since the urinary infection increased but because of improvement in his health he was discharged from the hospital on 15.06.2004. Later on, on 08.08.2004, when his father had blood vomit he was taken to the Jivraj Hospital where he expired. The complainant had spent Rs.1,10,000/- for the operation of the anal abscess and for the urinary infection and hence he submitted the claim along with necessary documents to the insurance company on 15.09.2004. This claim was, however, repudiated by the insurance company on 19.10.2004 on the ground that the father of the complainant had pre-existing disease and since his insurance policy contained exclusion clause in respect of certain diseases the claim was rejected. Alleging that the rejection of his claim by the insurance company was illegal and improper and hence there was deficiency in service on the part of the insurance company, the complainant lodged a complaint with the District Forum seeking relief for payment of Rs.1,09,895/- with interest and compensation.

(2.) The insurance company filed its reply to the complaint before the District Forum and resisted the claim made therein denying all allegations as false. It was submitted that based on the declaration made by the father of the complainant at the time of taking the policy about the pre-existing disease, hypertension, IHD, cataract and diabetes were put under the exclusion clause in the insurance policy. According to the insurance company, since the deceased insured was suffering from high blood pressure, IHD and diabetes, he was not entitled to get the mediclaim expenses under the exclusion clause because he was given treatment for diabetes, blood pressure and perinal abscess etc. and also had hypoglemia which had led to further complications. In view of this, according to the insurance company, the insured had died on account of his pre-existing disease, which had been excluded under the insurance policy and hence the claim put forth by the complainant had to be repudiated since the insurance company is not liable to pay the amount of expenses in respect of such diseases.

(3.) On appraisal of the pleadings and evidence adduced by the parties before it, the District Forum dismissed the complaint vide its order dated 31.01.2008.