NATIONAL INSURANCE COMPANY LTD Vs. SUKLA DUTTA

JUDGEMENT

(1.) This appeal arises out of the order of the District Forum, Kolkata, Unit-1, whereby the appellant (National Insurance Company Ltd.) has been directed to pay Rs.76,406.85/- for medical expenses incurred by the respondent along with interest at the rate of 18% with effect from 25.8.1998, being the date of submission of her claim till the date of actual payment. The appellant has been further directed to pay a sum of Rs.10,000/- by way of compensation to the respondent. The relevant facts necessary to be set out here are that the respondent took a mediclaim policy with the appellant-company. The respondent suffered a back pain which had turned in Lumber Canal Stenosis due to inter-vertebral disc leading to low back pain. The respondent incurred expenses for the disease. Afterwards she lodged the claim for a sum of Rs.76,406.85/- before the Company. But the company repudiated her claim on the ground that her ailment was a pre-existing one and it was not disclosed in the proposal Form. After repudiation she filed the case before the Forum and prayed for a direction upon the Company to pay an amount of Rs.76,406.85/- along with interest and other relief.

(2.) Being dissatisfied with the above order the company preferred this appeal. Learned Counsel for the appellant submits that the disease in question was pre-existing one and the respondent had undergone a laminectomy in the same region in 1993 and the current surgery in 1998 is a sequel to her earlier illness involving lumber spine which is excluded as per specific restriction imposed on the policy. So the claim is not payable under the clause of the terms and condition of the revised medi-claim policy. For these reasons the Company repudiated her claim. According to the appellant such bona fide repudiation is not deficiency in service on the part of the Company. So the order is erroneous, illegal and liable to be set aside.

(3.) On careful perusal of all the papers we notice that the respondent was a policy holder in respect of a revised mediclaim policy for the period from 1.3.1998 to 28.2.1999 for Rs.1,50,000/- under the National Insurance Company. In November, 1997 the respondent was investigated for his low back pain and diagnosed as a case of Spondylotesthesis (instability of L4 and L5 Vertebra) and one operation was done on 20.4.1998. After her recovery from the ailment she lodged her claim with the Insurance Company on 25.8.1998 in connection with her medical expenses for a sum of Rs.76,406.85/-. After preferring the claim the respondent was kept waiting without any intimation or without any settlement of the claim from the part of the Insurance Company. She made various correspondences through letters dated 27.11.1998, 15.12.1998, and 25.1.1999 in the name of the Senior Branch Manager, requesting him to settle the claim. On 23.2.1999 through a letter the Insurance Company repudiated the claim on the ground that the disease in question was pre-existing and at the time of taking the policy.