State Consumer Disputes Redressal Commission
New India Assurance Co.Ltd. vs Master Garv Goel on 11 January, 2017
Daily Order IN THE STATE COMMISSION: DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision: 11.01.2017 First Appeal No. 990/2012 (Arising out of the order dated 10.09.2012 passed in Complaint Case No. 1040/2008 by the District Consumer Disputes Redressal Forum (New Delhi) 'M' Block, Ist Floor, VikasBhawanI.P.Estate, New Delhi-110001) In the matter of: New India Assurance Co. Ltd. (through its Divisional Manager) E-9 Connaught House Connaught Place New Delhi-110001 .........Appellant Versus Master GarvGoel (Minor Aged About 6 Years) S/o Sh. Sanjay Kumar Goel R/o A-108B, Gali No. 3 Rama Garden, Karawal Nagar Delhi-110094 (Through his father, natural guardian & Next friend Sh. Sanjay Kumar Goel) ..........Respondent Raksha TPA Pvt. Ltd. 15/5, Mathura Road Faridabad Haryana-121003 .........Proforma Respondent CORAM N P KAUSHIK - Member (Judicial) 1. Whether reporters of local newspaper be allowed to see the judgment? Yes 2. To be referred to the reporter or not? Yes N P KAUSHIK - MEMBER (JUDICIAL) JUDGEMENT
Present appeal is directed against the orders dated 10.09.2012 passed by the Ld. District Forum VI VikasBhawan New Delhi. Vide impugned orders the appellant/OP therein, New India Assurance Co. Ltd. was directed to pay to the complainant an amount of Rs. 50,292/- alongwith interest @ 9% w.e.f. 01.08.2007 till the date of its realization andcompensation to the tune of Rs. 10,000/- was also awarded.
In brief, the complainant Sh. Karan Goel aged 2 years old was admittedly having a medi-claim policy. The same used to be renewed from time to time. Lastly it was valid for the period from 17.06.2007 to 16.06.2008. Sh. Karan Goel was operated upon for hernia in Deepak Memorial Hospital Delhi on 27.06.2007. He was discharged on 02.07.2007. Claim preferred by the complainant was dismissed by the appellant herein stating as under:
"PT. WAS ADMITTED AS A K/C/O B/L INGUINAL HERNIA WITH ECTOPIC ANUS WITH C/O B/L INGUINO SCROTAL SWELLING WITH CH. CONSTIPATION PREVIOUSLY OPERATED FOR TETROLOGY OF FALLOTS AT AIIMS (NO CLAIM PAID BY US FOR THAT) INVESTIGATED & DIAGNOSED AS A CASE OF B/L ING. HERNIA WITH ECTOPIC ANUS TREATED SURGICALLY AND DISCHARGED WITH FOLLOW UP ADVICE."
Appellant has relied upon exclusion clause No. 4.8 of the policy which reads as under:
"4.8 Convalescence general debility, "Run-down" condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, International self-injury and use of intoxicating drugs/alcohol."
Contention of the appellant is that the complainant was suffering from the congenital external disease or defect as envisaged under clause 4.8 policy which is reproduced above. He was not entitled to the expenditure claimed. Admittedly the child was having inguinal hernia with ectopic anus. Clearly the abnormality is more of an internal nature and less of external nature. It was the internal viscera that pushedthe anus to an abnormal position. Anomaly though was congenital, it was of internal origin. It is difficult to say that it was an external anomaly. In the circumstances, clause 4.8 of the policy relied by the appellant is not attracted. Appeal thus preferred is devoid of merits. The same is dismissed.
Copy of the orders be made available to the parties free of costs as per rules and thereafter the file be consigned to Records.
FDR, if any, deposited by the appellant be released as per rules.
(N P KAUSHIK) MEMBER (JUDICIAL)