NATIONAL INSURANCE COMPANY LTD Vs. RAJ NARAIN

JUDGEMENT

(1.) -IN this case Shri Raj Narain had obtained a medi-claim policy from the National Insurance Company for one year from 7th June, 1999. While he was in Bareilly, Uttar Pradesh, after three days of taking the policy he fell sick and he consulted Dr. O. P. Aggarwal and on his advice he under went comprehensive medical check-up. In the third week of June, 1999 he consulted Dr. Vijay Kumar Kohli who referred him to Malhotra Heart Institute wherein he was admitted on 22nd June, 1999 and underwent a heart surgery on 24th June, 1999. He was discharged on 5th July, 1999. He submitted a claim form, claiming Rs. 1,61,612 through his letter dated 22nd July, 1999. The Insurance Company rejected the claim of the petitioner by taking a plea that it was a pre-existing disease. They had appointed Dr. A. K. Batra for investigation into the case. Dr. Batra opined that the petitioner had a pre-existing disease which was not revealed by him while taking the insurance policy. As the Insurance Company had repudiated the claim he filed a complaint before the District Forum claiming Rs. 1,82,968 along with interest @ 24% per annum and compensation of Rs. 5,000.

(2.) THE District Forum after hearing the parties and going through the records of the case held that the complainant was neither aware of any exclusion clause nor he was supplied with the terms and conditions of the policy at the time of issuing cover note. Secondly, the Insurance Company had failed to establish that the complainant was having a heart disease prior to taking the policy. Lastly, the Insurance Company was deficient in service for not settling the claim of the complainant. Accordingly, the Insurance Company was directed to settle the medi-claim of the complainant within 60 days from the receipt of the order and pay interest at the rate of 10% per annum on the claimed amount with effect from 90 days after filing of the complaint till its realization.

(3.) DISSATISFIED by the order of the District Forum, the Insurance Company had filed an appeal before the State Commission. The State Commission after hearing the Counsel for the parties dismissed the appeal.