National Consumer Disputes Redressal
National Insurance Co. Ltd. vs Arun Kumar Goyal on 4 February, 2011
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO.320 of 2007 (From the Order dated 3.11.2006 in First Appeal No.704/2006 of the State Consumer Disputes Redressal Commission, Delhi) National Insurance Co. Ltd. 11th Floor, Scope Minar (N) Laxmi Nagar Distt. Centre Delhi-92 (Thourgh its Principal Officer) Petitioner Versus Arun Kumar Goyal R/o B-252, Vivek Vihar, Phase-I, Delhi-110095 Respondent BEFORE: - HONBLE MR. JUSTICE ASHOK BHAN, PRESIDENT HONBLE MRS. VINEETA RAI, MEMBER For the Petitioner : Dr. Sushil Kr. Gupta, Advocate For the Respondent : Mr. Goutam Prasad Advocate PRONOUNCED ON : 04.02.2011 O R D E R
ASHOK BHAN J., PRESIDENT National Insurance Co. Ltd.
(Petitioner herein) which was Opposite Party before the District Consumer Disputes Redressal Forum (for short, the District Forum) has filed this Revision Petition against the order dated 3.11.2006 passed by the State Consumer Disputes Redressal Commission (for short, State Commission) Delhi, in First Appeal No.704/2006 confirming the Order passed by the District Forum in directing the Petitioner to pay Rs.50,000/- towards insurance policy to the Respondent-Complainant along with 7000/- towards compensation and 3000/-
as costs.
Facts:
Respondent took a Mediclaim Policy (Hospitalization and Domiciliary Hospitalization Benefit Policy) for himself and his family members including his wife, son, daughter and father namely, Sangeeta Goyal, Aman Goyal, Ashna Goyal and Satya Prakash Goyal respectively, bearing No. 351700/48/02/8501315 dated 18th July, 2002, for the period 18.7.2002 to 17.7.2003. As per policy, five members of the family were insured for a sum of Rs.50,000/- each. The insurance was granted subject to terms, conditions and stipulations as stated in the policy.
Wife of Respondent Smt. Sangeeta Goyal complained of breathlessness on exertion and for this she underwent comprehensive check-up at G.B. Pant Hospital on 7.8.2002. As per registration card dated 9.8.2002 it was mentioned that the wife of Respondent was having complaint of dysponea on exertion (breathlessness Grade II-III since last 1-1/2 months, her B.P. was 120/80 mm of Hg, Pulse was 80 per minute. After examination she was provisionally diagnosed as having a septal defect, pulmonary stenosis and anemia. She was advised to undergo ECG, ECHO, X-ray chest and other investigations.
ECHO findings confirmed the diagnosis of ostium secondum atrial septal defect, a congenital heart disease.
Later on she was advised to get herself admitted in the Hospital on 7.10.2002 for cath and pressure studies. The Respondent took his wife to Dharamvira Heart Centre, Sir Ganga Ram Hospital, Rajender Nagar, New Delhi to take a second opinion where she was advised to undergo open heart surgery which was performed on her on 4.6.2003 on which Respondent incurred an expenditure of Rs.1,45,000/-.
Respondent filed his claim with the Insurance Company on 24th July, 2003 which was repudiated by the Petitioner by letter dated 1.7.2003 on the ground that the claim was not payable as per clause 4.1 of the policy. It was also mentioned in the letter that it was the first year of the policy and the wife of the respondent was operated for a disease which was congenital i.e. having since birth.
Petitioner, being aggrieved filed the complaint before the District Forum. Petitioner, on being served, filed its written statement contending that the claim of the Petitioner fell under exclusion clause 4.1 and 4.3 of the policy.
District Forum overruling the objection of the Petitioner allowed the complaint and directed the Petitioner to pay Rs.50,000/- along with Rs.7000/- towards compensation and Rs.3000/- as costs. Petitioner being aggrieved filed the appeal before the State Commission, which has been dismissed by the impugned order.
The only point to be considered in this Revision Petition is whether the claim of the Respondent fell under exclusion clause 4.1 or 4.3. Exclusion clause 4.0 of the policy provides:
4. The Company shall not be liable to make any Payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:
4.1 All diseases/injuries, which are pre-existing when the cover incepts for the first time.
4.2.
4.3 During the first year of the operation of insurance cover, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or Fibromioma, Hernia, Hydrocele, Congenital, Internal diseases , Fistula in anus, Piles, Sinusitis and related disorders are not payable if these disease are pre-existing at the time of proposal, they will not be covered even during subsequent period of renewal too.
Present claim is a direct result of the expenses incurred for the operation of ASD, Acyanotic Congenital Heart Disease performed at Sir Ganga Ram Hospital. As per clause 4.3 of the policy, the Company is not liable to make the payment in respect of any of expenses whatsoever incurred by any insured person in connection with or in respect of treatment on diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhegia or Fibromioma, Hernia, Hydrocele, Congenital, Internal diseases, Fistula in anus, Piles, Sinusitis and related disorders during the first year of the operation of the insurance cover. As per discharge summary of Sir Ganga Ram Hospital diagnosis of the insured was Acyanotic congenital heart disease and was operated for Pericardial path closure of ASD. Congenital means from birth and heart disease would be internal disease which cannot be seen by naked eye. The insured was having internal heart disease right from birth and therefore, it would fall within the exclusion clause 4.3. The insured was suffering from acyanotic congenital heart disease which he came to know in the first year of the policy. Parties to the contract of insurance are bound by the terms and conditions of the policy. Since the claim filed by the Respondent fell in the exclusion clause, Insurance Company was not liable to make the payment in terms of the exclusion clause 4.3 of the policy. Fora below have eared in taking the view to the contrary. Accordingly, the Revision Petition is allowed, the Orders passed by the Fora below are set aside and complaint is dismissed.
Learned counsel for the Respondent after taking instructions from the Respondent who is present in Person, informed the Commission that the Respondent has already received the sum of Rs.50,000/- from the Petitioner in execution of the decree before the District Forum. If that be so, the amount already paid be not recovered from the Respondent.
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(ASHOK BHAN J.) PRESIDENT . . . .
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(VINEETA RAI) MEMBER