NATIONAL INSURANCE CO LTD Vs. V L JAIN

JUDGEMENT

(1.) The complainant and his wife took a mediclaim policy from the petitioner-National Insurance Co.Ltd. for the period from 18-08-2004 to 17-08-2005. The case of the complainant is that the policy was purchased for the first time in the year 1998 and thereafter it was purchased continuously till the year 2004. On 09-12-2004 the wife of the complainant namely, Smt. Nirmal Jain who was the other policy holder along with the complainant was admitted in G.B. Pant Hospital with complaint of angina class II. It was recorded on the basis of the documents furnished by her that she was a known case of hypertension for last eight years. On clinical evaluation and investigations, she was diagnosed as a case of HTN, CAD AOE II. She was treated with PTCA and discharged on 14-12-2004. The claim submitted to the insurance company, however, was repudiated on the ground that it was inadmissible as per the exclusion clause 4.1 of the policy. Being aggrieved from the denial of the claim, the complainant, Shri V.L. Jain, approached the District Consumer Disputes Redressal Forum III, Delhi (for short, the District Forum) by way of a complaint. The District Forum vide its order dated 11-10-2007 directed the insurance company to pay the claim amount of Rs.1,41,126/- to the complainant along with compensation of Rs.5,000/- including cost.

(2.) Being aggrieved from the order of the District Forum the insurance company filed an appeal before the Delhi State Consumer Disputes Redressal Commission (for short, the State Commission). The appeal came to be partly allowed by reducing the quantum of claim from Rs.1,41,126/- to Rs.1,00,000/- which was the sum insured in respect of the wife of the complainant. Being still dissatisfied, the insurance company is before us by way of Revision Petition No.2648 of 2008. The complainant has also filed Revision Petition No.2660 of 2008, being aggrieved from the reduction of the claim amount from Rs.1,41,126/- to Rs.1,00,000/-.

(3.) Clause 4.1 of the policy on which reliance has been placed by the insurance company reads as under: