NEW INDIA ASSURANCE CO LTD Vs. LEELA RAMANI

JUDGEMENT

(1.) The opposite party in O. P. No.1105/98 on the file of the District Consumer Disputes Redressal Forum, Chennai (South) is the appellant herein. The case of the complainant was as follows : She had taken a mediclaim insurance policy with the appellant/opposite party for herself and her son for the period 24.10.1997 to 23.10.1998 having an insured limit of Rs.35,000 per head. The opposite party was bound to compensate any claim made after 30 days from the date of commencement of the insurance cover. The complainant's son developed acute pain in the lower back region. It was examined by Dr. Prakash, an Orthopaedic Surgeon who diagnosed the ailment to be an acute prolapsed intervertebral disc. After scanning, the surgeon decided to perform and actually performed an operation on 20.12.1997 at a cost of Rs.34,208.75. The complainant submitted a claim before the appellant/opposite party and it was rejected on the ground that their panel Doctor had opined that the patient would have been suffering from the disease for about 6 months prior to operation and, therefore, the claim was not payable as per the policy. Under these circumstances, the complaint came to be filed for the said sum of Rs.34,208.75 with compensation of Rs.10,000 and cost of Rs.5,000.

(2.) The opposite party resisted the complaint on the following grounds. The claim of the complainant had been rejected for good and valid reasons after obtaining opinion of a panel doctor of the opposite party. The alleged illness did not require an operation which could be cured by non-operative treatment. The claim was rejected as the complainant's son was having a pre-existing disease excluded under the mediclaim policy. The complainant had to approach the Civil Court for redressal in which case the parties would have adequate opportunities to reject and prove their respective claims.

(3.) On the side of the complainants Exs. A1 to A9 were marked and on the side of the opposite parties Exs. B1 was marked.