RADHEY SHYAM GOYAL vs National Insurance Co Ltd

THIS appeal has been filed by the complainant appellant against the order dated 9. 6. 2003 passed by the District Forum-I, Jaipur in Complaint Case No. 294/2002, by which the complaint of the appellant was dismissed.

IT arises in the following circumstances: That the complainant appellant had filed a complaint against the respondent Insurance Company before the District Forum-I, Jaipur on 8. 10. 2002 inter alia stating that he had taken a mediclaim policy from the respondent for the period 7. 10. 1998 to 6. 10. 1999 for a sum of Rs. 1 lac. It was further stated in the complaint that the said policy was renewed for the period 7. 10. 1999 to 6. 10. 2000 and the amount insured was also increased from Rs. 1 lac to Rs. 1. 50 lac and that policy is marked as Annexure B at page 2 of the complaint. It was further stated in the complaint that during the relevant period the complainant appellant had got the operation of cataract in his right eye in the month of April 2000 and for which information was given to the respondent Insurance Company claiming Rs. 36,319. 28 which were incurred for getting the operation of the eye. But that claim was repudiated by the respondent Insurance Company through letter dated 13. 6. 2001 on the ground that the complainant appellant was having pre-existing disease, therefore, on that ground no amount was payable and file was closed and thereafter the present complaint was filed claimaing Rs. 36,319. 28.

A reply was filed by the respondent Insurance Company on 29. 11. 2002 and in the reply the fact that the policy was renewed for the period 7. 10. 1999 to 6. 10. 2000 and it was also admitted that through letter dated 13. 6. 2001 the claim was repudiated. It was further replied that as per report of Mr. Suraj Mal Meel, Surveyor Annexure R4 that the complainant appellant had taken medi-claim insurance policy for the same period from the Oriental Insurance Company and in that policy, there was an endorsement that the deceased was having problem relating to eye, therefore, the case of the respondent Insurance Company was that the complainant appellant was having pre-existing disease in respect of eye. It was further replied that no doubt the complainant appellant had entered into a compromise with the Oriental Insurance Company on 27. 3. 2002 and it was admitted by the OIC that entry of eye related problem which was found mentioned in the policy was deleted later on on the ground that it was wrongly mentioned but since this fact was not mentioned by the complainant appellant in his claim, therefore, the claim was rightly repudiated and complaint be dismissed.

THE District Forum after hearing both the parties through the impugned order had dismissed the complaint inter alia holding that since for the same period, the complainant appellant had taken medical insurance policy from two Insurance Companies and in the policy which was taken from the Oriental Insurance Company it was mentioned that he was having some eye problem, therefore, on that ground if the claim was repudiated by the respondent Insurance Company no mistake was committed and thus the present case was a case of suppression of material facts. Aggrieved from that order, this appeal has been filed by the complainant appellant and in this appeal the main contention of the learned Counsel for the appellant is that since the fact of eye problem which was found mentioned in the policy taken from the Oriental Insurance Company had been later on deleted and thus the repudiation of the claim of the complainant appellant on that ground by the respondent Insurance Company could not be justified and the findings recorded by the District Forum are erroneous one and could not be sustained and appeal be allowed. On the other hand, the learned Counsel for the respondent has supported the impugned order. We have heard the learned Counsel for the parties. In this case, there is no dispute on the point that the complainant appellant had taken a mediclaim policy from the respondent National Insurance Company for the period 7. 10. 1998 to 6. 10. 1999 and the same was renewed again for the period 7. 10. 1999 to 6. 10. 2000 and there is no dispute on the point that the complainant appellant had preferred this claim in respect of the operation of cataract which was conducted in the month of April, 2000 and the amount which were incurred in that operation were claimed from the respondent Insurance Company. There is also no dispute on the point that the said claim was repudiated by the respondent Insurance Company through letter dated 13. 6. 2001 on the ground of pre-existing disease and for that the case of the complainant appellant was that this disease was found in the policy which was taken by the complainant appellant from the Oriental Insurance Company. There is also no dispute on the point that a compromise had taken place between the complainant appellant and Oriental Insurance Company on 27. 3. 2002 and as per terms of the compromise the fact which was found mentioned in the policy in respect of the eye disease was deleted. The question for consideration is in the facts and circumstances just mentioned above, whether the findings recorded by the District Forum could be sustained or not and whether the repudiation of the claim by the respondent Insurance Company could be justified or not.

IN our considered opinion, when the fact of pre-existing disease which was found in the policy of Oriental Insurance Company and the same was deleted later on the ground of wrong mentioning, therefore, the respondent Insurance Company could not take the benefit of that ground. Apart from that the position of law is very much clear that when a medi-claim policy is renewed and if any disease if found existing during the period of expiring policy and for that disease the claim could not be repudiated by the Insurance Company. From the point of view also refusal of the claim by the respondent Insurance Company could not be justified. For reasons mentioned above, it is held that the repudiation of the claim of the complainant appellant by the respondent Insurance Company through letter dated 13. 6. 2001 on ground of pre-existing disease could not be justified and similarly findings recorded by the District Forum by which the complaint was dismissed could not be sustained and are liable to be quashed and set aside and appeal deserves to be allowed. The result is that the appeal is allowed, impugned order dated 9. 6. 2003 passed by the District Forum-I, Jaipur is quashed and set aside and the complaint of the complainant appellant is allowed in the manner that the respondent Insurance Company would pay a sum of Rs. 36,319. 28 with interest @ 9% p. a. from the date of filing of the complaint till the payment is made along with Rs. 2,000 as amount of cost to the complainant appellant. Appeal allowed.