NATIONAL INSURANCE COMPANY LIMITED Vs. VINAY KUMAR SEHGAL

JUDGEMENT

(1.) National Insurance Company Limited challenges order of District Forum, Jalandhar dated December 31, 1996 in this appeal whereby a direction was given to the appellant to pay Rs.87,200/- alongwith Rs.3,000/- damages and Rs.1,000/- as costs of litigation to the complainant Vinay Kumar Sehgal.

(2.) Vinay Kumar Sehgal, approached the District Forum claiming Rs.99,000/- (Rs.87,200/- as medical expenses and Rs.11,800/- special damages ). He was working as Divisional Manager of M/s. Northern India Sales Corporation at Jalandhar. The aforesaid Corporation is owned by M/s. Usha International Limited. Since 1986 he had been taking insurance cover (Mediclaim Insurance Policy) from the opposite party, National Insurance Company. The details of the policies taken were mentioned in para 2 of the complaint. Last of the policies taken was on May 19,1989. Thereafter the policy in dispute was taken on July 16,1980 for a year. On December 14,1990 he went to Escorts Heart Institute, Delhi for check up. On the following day surgery was advised, which was actually performed on December 2, 1990 (bye-pass surgery ). As per details given in para 3 of the complaint, he spent Rs.87,200/- on the surgery. Further details of Rs.86,500/- were given in para 4 of the complaint that for check-up Rs.1,500/-, for Angiography package Rs.10,000/- and for surgery Rs.75,000/- were spent. In fact he had felt pain while on tour on December 12,1990 and had to visit the Escorts Hearts Institute. Since the opposite party avoided making payment of the aforesaid amount, District Forum Was approached with the complaint. The Insurance Company submitted its reply denying its liability. It was alleged that the complainant was suffering from heart disease prior to the issuance of the insurance policy on July 16,1990. He concealed this fact from the Insurance Company before obtaining the policy. Since June 21,1990 he was a known case of heart disease. The complainant fully knew about the existence of this disease when he submitted proposal form for policy in dispute. Thus for valid reason aforesaid the mediclaim of the complainant was repudiated by the Insurance Company. From July 16,1990 to July 15,1991, the complainant was not under the cover of mediclaim policy. Thus, it would appear that on June21, 1990 when he suffered from heart ailment, he was not covered under the policy. Information of repudiation of the claim was given to the complainant on February 14, 1992. Since the claim was repudiated there was no deficiency in rendering service on the part of the Insurance Company. The complainant was playing hide and seek game with the Court. He had no other reason of concealing the fact that his claim already stood repudiated before filing the complaint. Because of the disputed facts and circumstances, the complaint should be relegated to his remedy in the Civil Court. In the complaint no allegations were made regarding repudiation of the claim. The complainant wanted to play fraud on the Insurance Company by obtaining policy concealing the factum of heart ailment. On merits also, similar pleas were taken.

(3.) The complainant produced his evidence by way of affidavit dated July 25,1996. On behalf of the Insurance Company affidavit of Joginder Singh, Divisional Manager and attorney of National Insurance Company was filed. These witnesses have reiterated the stand taken up in the pleadings referred to above. The District Forum on the material produced passed the impugned order.