GURCHARAN SINGH FALAK vs NEW INDIA ASSURANCE CO.LTD

COMPLAINANT-Gurcharan Singh Falak has come up in appeal against the order dated 21st May, 1996 passed by the learned District Forum, Gurgaon, whereby his complaint against the New India Assurance Co. Ltd., claiming Rs. 3,65,881/- by way of reimbursement of the expense incurred by him on his treatment abroad has been dismissed by allowing only a sum of Rs. 17,181/- being the amount actually spent by him on his treatment in India.

ACCORDING to the appellant appearing in person, he had obtained a medi-claim insurance policy in November, 1990 and had disclosed at that time that he had already undergone the Coronary Artery By-pass Surgery in the year 1980 and had not experienced any problem thereafter. The insurance policy covering the risk commenced w.e.f. 15th November, 1990 by paying a sum of Rs. 2,340/- as premium and he got it renewed in 1991, 92, 93 and 94 onwards annually. ACCORDING to him in November, 1993 he consulted Doctors in the Escorts Heart Institution and Research Centre, New Delhi and was later on advised redo surgery. But somehow Doctors did not opt for the surgery, but during all these processes and for the Angiography test etc. he incurred an expense of Rs. 17,181/- at New Delhi. Thereafter he went to U.S.A. alongwith his wife and stayed with his son, who got him medically treated in various medical centres on 17th August, 1994 after by-pass surgery etc. On return to India on 27th November, 1994 he made a claim to the Assurance Company for a sum of Rs. 3,65,881/-against expense of about Rs. 14 lacs made by his son on his medical treatment. The details of the claim of Rs. 3,65,881/- are as under : (i) Expenses incurred At Escorts Heart =Rs. 17,181/- Institute and Research Centre,. New Delhi (ii) Expenses incurred on travelling by air from Delhi to =Rs. 98,700/- Sanfrancisco and back to Delhi for two tickets (iii) For the cost of redo surgery, had it been done in India though the complainant had incurred much higher amount in U.S.A. Rs. 2,50,000/- Rs. 3,65,881/- In their reply, the Assurance Company pleaded that firstly the complainant never disclosed at the time of the taking out the insurance in 1990 that he had already undergone by-pass surgery in 1980. Secondly, the medi-claim insurance policy taken out by the complainant did not cover the risk for the reimbursement of the expenses incurred in any Nursing Home or Hospital outside India. After going through the matter in detail and examining the terms and conditions of the policy and other evidence, the learned District Forum came to the conclusion that so far as the disclosure of information with regard to his earlier by-pass surgery in 1980 is concerned, the objection of the Assurance Company was unfounded. However, on the second question the learned District Forum found that the insurance policy of the complainant covered only the expenses incurred on his treatment within India and not outside. Since expense of Rs. 17,181/- had incurred by him on Escorts Hospital, New Delhi, the complaint had been allowed to that extent. In the appeal before us, the complainant appellant has vehemently contended that there is no such bar or exception expressly incorporated in the terms and conditions of the insurance policy in pursuance whereof his claim for the reimbursement of the expenses incurred by him in U.S.A. could be repudiated. After hearing the appellant in person we are of the considered view that the decision arrived at by the learned District Forum is wholly in accordance with the terms and conditions of the policy. Therefore, there is no legal infirmity in the order and according to the medi-claim policy taken out by the complainant he is entitled to the reimbursement of the expenses incurred by him anywhere in India but not abroad. Burden of proof lies on the complainant to prove that his case was covered under some specific term and condition or the operating clause of the insurance policy. Consequently, we have no hesitation in agreeing with the view taken by the learned District Forum; hence the appeal is dismissed with no order as to costs. However despite all this, if the complainant-appellant is not satisfied with the relief granted under the Consumer Protection Act, he is at liberty to claim the same by having resort to his remedy before the Civil Court. Appeal dismissed.