NATIONAL INSURANCE CO. LTD. Vs. AJAY RAJORA

JUDGEMENT

(1.) This revision petition has been filed under section 21(b) of the Consumer Protection Act, 1986 against the impugned order dated 12.03.2008, passed by the Delhi State Consumer Disputes Redressal Commission (hereinafter referred to as 'the State Commission') in First Appeal No. FA-08/95, "National Insurance Company Ltd. versus Ajay Rajora", vide which, while dismissing the appeal, the order dated 19.11.2007, passed by the District Forum in consumer complaint No. 484/2006, filed by the present respondent/complainant, allowing the said complaint, was upheld.

(2.) The respondent/complainant had obtained a medi-claim insurance policy for the period from 14.07.2005 to 13.07.2006 from the petitioner / opposite party (OP) for an insured sum of 1,50,000/-. It is stated in the consumer complaint that at the time of obtaining the said policy, he was in good health and without any medical complaint of any kind. He met with an accident on 22.09.2005, when he slipped down from the staircase in his house, causing injuries to his back and spinal cord. He took rest for 5 days under the impression that the injury will heal itself, but when his condition became unbearable, he consulted Dr. Harsh Bhargava of Indraprastha Apollo Hospital on 27.09.2005. On the same day, MRI scan was done at the Mahajan Imaging Centre, after which he was put on medication. Since his condition did not improve, he again approached the said Doctor on 05.10.2005 and was advised admission in the Hospital for surgery. However, the complainant continued on conservative line of treatment, but when his condition did not improve, he consulted a super-speciality hospital on 14.02.2006, where also, he was advised immediate surgery. Thereafter, he again approached Dr. Bhargava and was advised that surgery was the only viable alternative. The complainant was operated at the Apollo Hospital on 21.03.2006 and incurred a sum of 1,43,310/- on his treatment. The surgery is commonly known as Diaminplant 12mm Metronics. The complainant informed the OP vide notice dated 03.04.2006 and asked them to make payment of 1,43,310/-, being the actual expenses on surgery and also demanded 1,01,000/- as liquidated damages. On the failure of the OPs to make such payment, the consumer complaint in question was filed, seeking directions to the OPs to pay actual expenses of 1,43,310/-, 1,01,000/- as liquidated damages and 25,000/- as litigation expenses.

(3.) The complaint was resisted by the OP insurance company by filing a reply before the District Forum in which they stated that at the time of obtaining the insurance policy, the complainant had concealed his pre-existing disease of 'aging process' from the company. Under clause 4.1 of the Policy, the pre-existing condition of disease was to be reported to the insurance company before taking the policy. The company was, therefore, not liable to pay the claim in question. Further, the complainant had made a false story that he met with an accident on 22.09.2005, when he slipped down from the staircase in his house. In fact, when the complainant met Dr. Harsh Bhargava of 27.09.2005 for the first time, he did not disclose about any fall from the staircase. The certificate issued later by Dr. Harsh Bhargava on 23.03.2006 mentions about the said fall, but the said certificate was false. The OP insurance company, further stated that as per the MRI scan report of Mahajan Imaging Centre, the findings were suggestive of primary lumber canal stenosis with a broad-based posteriorcentral disprotrusion at L-4-5 level which shows that the above process is a result of aging process. The condition stated in the MRI scan could not have been due to fall in the staircase.