ORIENTAL INSURANCE CO LTD Vs. V K SHARMA

JUDGEMENT

(1.) The present appeal is directed against orders of the District Forum (New Delhi) dated 1.8.2001, passed in Complaint Case No.920/98 - entitled Mr. V. K. Sharma and Anr. V/s. The Oriental Insurance Company Limited.

(2.) The relevant facts, in brief, are that the respondent had obtained a Mediclaim Insurance Policy for himself and his family valid from 10.11.1995 to 9.11.1996, on payment of a premium of Rs.5,670/- by Cheque No.27946 dated 7th November, 1995. In the proposal Form the respondents had mentioned that on account of a fracture in the right thigh of respondent No.2 a nail was inserted by Dr. V. B. Bhasin, Orthopaedic Surgeon in Ganga Ram Hospital, New Delhi which was removed by surgical operation in October, 1995. A fitness certificate was duly obtained from the said doctor dated 8th November, 1995 whereby Dr. V. B. Bhasin had certified that after the removal of the nail from the right thigh of the respondent No.2 in 1995 she had no handicap or disability on account of the said operation. However, on 22nd January, 1996 the respondent No.2 fell down at home and in the process fractured her right thigh bone and had to undergo treatment and hospitalization for the same in Ganga Ram Hospital, which fact was duly intimated to the appellant Insurance Company on 22nd February, 1996. Thereafter the respondent also lodged his claim, for the reimbursement of the amount spent on the said treatment on 13th March, 1996. The said claim of the respondents was repudiated by the appellant vide letter dated 19th April, 1996 on the ground that the injury for which the calim had been preferred was pre-existing and, as such, the same was not covered under the terms and conditions of the policy. The respondents vide letter dated 4.7.1996 again requested the appellant to reconsider the claim but the appellant vide reply dated 11.7.1996 again reierrated their stand and therefore the respondents were constrained to file a complaint before the District Forum for the redressal of their grievances.

(3.) The appellant Insurance Company in its reply/written version filed before the District Forum stated that the claim of the respondents had been rightly repudiated on account of the fact that in terms of the case sheet of Ganga Ram Hospital, prepared just after respondent No.2 had undergone A. O. plate fixation and bone grafting on 24th January, 1996, there was no mention of any incident as mentioned by the respondents in their complaint regarding the fall and refrecturing of right thigh bone of respondent No.2. On the contrary the said summary disclosed that the complainant had been undergoing treatment for the said pre-existing injury since September, 1995. Furthermore, the matter was referred for opinion of Dr. Vinod Gandotra, Specialist for fracture and bone diseases, who opined that it was a case of pre-existing disease/injury and, as such, excluded from the policy coverage in terms of exclusion Clause No.2.1.15 of the insurance policy in question and, therefore, there was no deficiency in service on the part of the appellant in repudiating the claim of the respondents.