NATIONAL INSURANCE COMPANY LTD vs USHA PURI

RESPONDENT had taken a group medical insurance policy from the appellant which covered the benefit till 30. 9. 1999 i. e. till the respondent attained the age of 70 years. In the year 1993 the respondent and her husband got themselves insured under the mediclaim policy of the appellant. In the same year respondent had fallen twice in her house and suffered injury and pain in both her knees. She was examined by Dr. Ashok Raj Pal who advised replacement of both the knees joint in June 2000. The operation was carried out at Sita Ram Bhartia Institute of Science and Research on 26. 6. 2000. The respondent paid a sum of Rs. 3,03,150. She also paid post-operated treatment.

THE appellant repudiated the claim of the respondent on the ground of non-disclosure of pre-existing disease by the respondent which in terms of exclusion Clause 4. 1 disentitles the respondent from reimbursement of medical expenses. Consequently the respondent filed the instant complaint before the District Forum. Vide impugned order dated 20. 7. 2007 which is not at all a happily worded order nor has even referred to the contentions of the appellant averred in the reply, the complaint was allowed with the following directions: (i) Appellant will pay Rs. 3,32,961 to the respondent inclusive of post operation medical expenses. (ii) Appellant will pay Rs. 40,000 to the respondent for causing mental agony, harassment and deficiency in service by wrongfully rejecting the claim. (iii) Appellant will pay Rs. 3,000 towards cost of litigation.

We feel constrained to reproduce the entire order which on the face of it suffers from inherent infirmity inasmuch as it is not at all a reasoned order nor the contentions and pleas taken and referred to have not been dealt with nor even the ground of repudiation is referred to and discussed nor the contentions of the parties have been discussed and dealt with. The order is as under: order complainant has taken group medical insurance policy from the OP which continued to cover untill 30. 9. 1999 till the complainant attains the age of 70 years. In year 1993 the complainant and her husband Sh. C. S. Puri got themselves to insure (in addition to the said group medical insurance) under the mediclaim policy of OP. In the same year the complainant had fallen twice in her house and suffered injury and pain in both her knees. The complainant was examined by Sh. Ashok Raj Pal, who advised replacement of both the knees joint in June, 2000. The operation was carried out at Sita Ram Bharita Institute of Science and Research on 26. 6. 2000. The complainant paid sum of Rs. 3,03,150 to the institute as treatment charges. The complainant also paid post-operated treatment and premium and issue the policy and why the necessity of getting the test conducted and taking the operation of the panel of doctor was not done before issuing the policy. The OP has wrongly disallowed the claim on lame excuses. This Forum order as under: 1. OP will pay Rs. 3,32,961 to the complainant inclusive of post operation medical expenses. 2. OP will pay Rs. 40,000 to the complainant for causing mental agony, harassment and deficiency in service by wrongfully rejecting the claim. 3. OP will pay Rs. 3,000 towards cost of litigation. This order will be complied with within 30 days. "

IN our view aforesaid order is not an order in the eyes of law being wholly unreasoned, highly laconic, cryptic and sketchy order. It is principle of natural justice that every aggrieved party should know the reasons for the rejection of his claim or disposal of his complaint and grounds for allowing the complaint or rejection of the complaint filed by a consumer before the District Forum so as to allow him to file an appeal assailing the finding of the adjudicatory authority. Any breach of this principle results in miscarriage of justice.

FOR the foregoing reasons we have no other option than to allow the appeal at the very outset, set aside the impugned order and send back the matter to the District Forum for deciding it afresh by way of a reasoned order by discussing and dealing with all the contentions and pleas raised by the appellant in support of repudiation of the claim. Appellant shall appear before the District Forum on 15. 2. 2008 for the aforesaid purpose. Appeal is allowed and disposed of in aforesaid terms.

A copy of the order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record Room. Appeal allowed.