ORIENTAL INSURANCE CO LTD Vs. CHANDULAL KANJIBHAI PATEL

JUDGEMENT

(1.) This appeal by the Insurance Company is directed against the judgment and order dated October 22, 1993 passed by the District Consumer Disputes Redressal Forum, Mehsana (District Forum for short) allowing the respondent's complaint and directing the appellant to pay to the respondent Rs.25,501.83.

(2.) The respondent had taken mediclaim insurance policy from the appellant which was valid for the period from October 18, 1991 to March 17, 1992. This policy was renewed for further period from March 18, 1992 to March 17, 1993. This policy was further renewed for a period of one year from March 18, 1993 to March 17, 1994. The respondent developed urinary problem in 1992 and he was admitted to Muljibhai Patel Urological Hospital at Nadiad for medical treatment on May 17, 1992. He was advised to undergo operation for removal of stone. The respondent informed the appellant about his admission to the hospital and that he had to undergo operation. The respondent incurred total expenditure of Rs.28,531/- for the medical treatment. He made claim for payment of the said amount before the appellant. The appellant, however, refused to make payment of the amount claimed by the respondent relying on Condition No.3.8 of the insurance policy. According to the appellant, the respondent had produced bill of Rs.799.32 which was false and fabricated. Under the aforesaid Condition No.3.8 the appellant was not liable to make payment under the policy if claim made by the appellant was in any manner fraudulent or supported by any fraudulent means or device. The appellant refunded the prorata premium and cancelled the respondent's policy for the remaining period. In the background of the above facts, the respondent approached the District Forum by way of Complaint No.317 of 1993 for recovery of Rs.28,531/- together with interest and cost.

(3.) The appellant resisted the respondent's complaint and reiterated the same contentions which were raised while repudiating the respondent's claim. It was contended that respondent had produced false bill of Rs.799.32 and, therefore, he was not entitled to reimbursement of the medical expenses incurred by him. It was also stated that the appellant had cancelled the policy as provided in Condition No.3.11. The appellant, therefore, prayed for dismissal of the respondent's complaint.