KANHAIYALAL AGHI Vs. NATIONAL INSURANCE CO. LTD

JUDGEMENT

(1.) This revision petition arises from repudiation of an insurance claim under a hospitalization benefit policy taken by the revision petitioner/Complainant from the respondent/National Insurance Co. The petition has been filed with delay of 43 days. We have perused the application for condonation of this delay. The application is vague and seeks to place the entire blame at the doorstep of the Advocate who was allegedly engaged to file the revision petition. The application itself is signed by another Advocate, who eventually filed this revision petition. In our view, no reasonable explanation comes out from this application. The revision petition is therefore, liable to be dismissed on the ground of delay alone.

(2.) The claim pertains to hospitalization of the insured/complainant with heart ailment, for nine days in June, 2007. Significantly, it is the admitted case of the respondent/National Insurance Co that the pre-existing heart condition of the insured was a known fact at the time of issuance of the policy. In this behalf, the Written Statement filed by the OPs before the District Forum makes the following categorical statements:-

(3.) The District Forum allowed the claim observing that it was an admitted fact that the policy was taken specifically mentioning that the complainant was having heart problem. Therefore, the respondent cannot be permitted to take shelter under 'revised policy' which sought to exclude 'all diseases/injuries, which are pre-existing when the cover incepts for the first time'. The District Forum also observed that the respondent insurance Co. could not even clarify the date and year of commencement of the 'revised policy'. In this behalf the District Forum has noted that the counsel for respondent/National Insurance Company placed reliance on Ex. R-2, which was the mediclaim insurance policy (revised). Clause 4.1 therein specifically excluded all diseases/injuries which were pre-existing on commencement of the insurance cover. It also observed that as these terms and conditions were revised conditions and as counsel for the respondent could not clarify the date or year of commencement thereof, their applicability to the case of the Complainant could not be ascertained. It was on this ground that the District Forum held that in case of any ambiguity or confusion in the rules, the benefit of doubt needs to be given to the consumer.