SHYAMA NANDA JALAN vs National Insurance Co. Ltd.

BOTH sides are present through their respective Counsels. At the beginning of the hearing learned Counsel for the respondent submits that the appeal is barred by limitation having not been filed within the statutory period of limitation. On scrutiny of records, it appears that the judgment was passed on 9.12.1996 and the appeal was filed on 7.1.1997. There was, however, a petition for condonation of delay. Learned Counsel for appellant submits that since the appeal was filed within the statutory period there was no necessity of filing such an application for condonation of delay. Learned Counsel for the respondent submits that the appeal has not yet been admitted and as such further proceeding cannot continue. Since the appeal was filed within the period of limitation, the appeal be admitted. Parties are directed to come ready for final hearing at once.

HEARD learned Lawyers for both sides at length. It appears that the claim of the complainant was repudiated on the ground that it is not entertainable in view of Exclusion Clause 2.1.7. The basis of rejection of the claim of the complainant was the report of Dr. K.K. Arora said to be the panel Doctor of the Insurance Company. It is admitted that the complainant took admission at B.M. Birla Heart Research Centre at Calcutta for Coronary Artery Disease on 7.8.1994 and on the next date Angiography was done. He claimed reimbursement of expenses for this Angiography. The total claim thus made is Rs. 33,344/- for the said purpose. The Forum relied upon Clause 2.1.7 of the Medi-claim Policy and came to the conclusion that no claim for reimbursement could be entertained. We have considered the clause and we cannot persuade ourselves to agree to the interpretation of the said clause given by the Forum. The complainant immediately after his admission to the hospital had undergone Angiography Test on the next day and the present claim is for reimbursement of the expenses incurred therefore. In that view of the matter, the judgment appealed against cannot be sustained. It is hereby set aside and the claim of the complainant is allowed. The Insurance Company is directed to make payment to the complainant as per the Chart provided in the Medi-claim Policy within a period of 3 months from this date and on such failure of the payment the complainant would be at liberty to realise it by way of execution. The appeal be disposed of. Appeal allowed.