NEW INDIA ASSURANCE CO. LTD. JEEVAN BHARTI BUILDING, TOWER Vs. DR. GIRISH M. WAGHER R/O, B/4, AAROHI FLATS, BH. NEW YORK TRADING CENTRE, THALTEJ, AHMEDABAD

JUDGEMENT

(1.) This appeal is directed against the order of the State Commission Gujarat dated 30.11.2010 vide which the State Commission allowed the complaint preferred by the respondent complainant and directed the appellant insurance company to pay to the complainant a sum of Rs.5,00,000.00 within three months.

(2.) Briefly put, the facts relevant for the disposal of the revision petition are that complainant admittedly took a medical insurance policy valid for a period of one year w.e.f. 17.06.2000 to 16.06.2001. The sum insured was Rs.5,00,000.00. According to the respondent complainant he had been suffering from unbearable stomache ache for which he consulted several doctors as also surgeon of Lilawati hospital. On the medical advice, the complainant got admitted in Shree Ortho Surgical Clinic on 20.07.2000 and discharged on 21.07.2000. During the admission period, several diagnostic tests were conducted and complainant was having right Iliac Abscess. The complainant was thus prescribed medicine for tuberculosis and he took domiciliary treatment at home. The respondent complainant filed insurance claim for reimbursement of expenses incurred for tests conducted during hospitalization from 20.07.2000 to 21.07.2000. The medical claim was repudiated by the insurance company on the plea that as per clause 4.10 of the insurance contract, the claim of the complainant was not payable. Being aggrieved of the repudiation of claim, the respondent filed consumer complaint.

(3.) The opposite party on being served with the notice of the complaint justified repudiation of claim submitted by the complainant on the plea that complainant was investigated at Lilavati Hospital, Bombay on 05.07.2000. He was investigated for Typhoid amongst other investigative suggestive of fever and weight loss. Thereafter, sonography was carried out on 10.07.2000, which showed a mass of 5 to 4.0" in all dimensions. It is submitted that C T Scan was carried out on 12.7.2000 which confirmed the presence of the mass and he was advised FNAC. He was advised Barrium Mill and C T Guided Aspiration. This was carried out on 20.7.2000 and were suggestive of T.B. treatment which was subsequently started on 21.7.2000 but present complainant was hospitalized only on 20.7.2000 for the purpose of investigation only and no treatment was given on that date and therefore, present complainant cannot be considered for the payment of his mediclaim. It was also pleaded that claim file was referred to Panel Doctor Kiran Vadaliya, M.S., FCPC, FIAMS, LLB who opined as under: