NATIONAL INSURANCE CO. LTD. Vs. ABDUL RAZAK

JUDGEMENT

(1.) This revision is directed against the order of the State Commission Delhi in FA No. 520/2012 dated 06.08.2013 whereby the State Commission confirmed the order of the District Forum-VI in complaint case no. 1590/2012 and dismissed the appeal preferred by the insurance company.

(2.) Briefly stated facts relevant for the disposal of the revision petition are that respondent complainant purchased a mediclaim policy from the petitioner insurance company effective w.e.f. 11.07.2008 till 10.07.2009. The sum insured under the above policy was Rs.1,00,000/-. In March 2009, the complainant developed problem of pain in his abdomen for which he took treatment as out patient at Singhal Medical Centre, Krishna Nagar, Delhi. When the complainant did not get relief from the treatment, he got himself admitted in hospital on 24.03.2009. It is the case of the complainant that on the basis of clinical examination, he was diagnosed as suffering from septicemia as well as worm in gall bladder. The complainant was, therefore, operated upon for empyema gall bladder and worm in gall bladder on 25.03.2009 and was discharged from the hospital on 28.03.2009. After his discharge from the hospital, the complainant submitted insurance claim for expenses of Rs.50, 056/- incurred by him on his treatment during the period for which he was admitted in the hospital. The insurance claim, however was repudiated on the ground that as per clause 4.3 of the insurance contract, the surgery of gall bladder and bile duct was not covered for first two years of the insurance cover.

(3.) The District Forum on consideration of the pleadings and the evidence came to the conclusion that repudiation of insurance claim in view of Exclusion Clause 4.3 of the insurance contract amounted to deficiency in service and allowed the complaint. Relevant observations of the District Forum are reproduced as under: