S. RAVINDRA BHAT, J.

( 1 ) THE petitioner seeks appropriate directions to the respondent (hereinafter called "the insurer" close) to reimburse the expenses incurred by him for his medical treatment, in accordance with the policy of insurance (hereinafter called "mediclaim" ).

( 2 ) THE respondent is in the business of Insurance. The petitioner is a chartered accountant by profession. He was retained for the job carrying auditing the respondent's Division Office No. 7, Delhi. At that time, i. e May 2001 the insurer's agents/employees allegedly represented to petitioner that he should take an Individual Mediclaim Policy to cover his health. On a pointed query from petitioner that, if he could be insured, as he was a diabetic, a hypertensive and had undergone a cataract operation of an eye, he was assured by respondent's representative that he would be eligible for such a policy and that he had to furnish complete details of the medication being undergone by him at that point of time.

( 3 ) THE petitioner filled up the proposal form, underwent the necessary medical tests suggested by the respondent and fully disclosured his existing medical condition. An ECG was also conducted, as required, on 3. 5. 2001 and supplied to the respondent. The said ECG showed 'nad' in the heart condition. After satisfying itself as to the insurable interest of the petitioner, individual Mediclaim Policy No. 2002/34 was issued to him effective from 10th May, 2001. No claim was under the said Policy; it was renewed with effect from 10th May, 2002 through Policy No. 2003/31. No Claim was preferred against the said Policy also. Again the cover was renewed effective 10th May 2003 through Policy No. 2004/17. Yet again it was extended w. e. f. 10th May, 2004 by Policy No. 2005/30. No Claim was made against this policy too. Finally the Policy was extended for the period 10th May, 2005 to 9th May, 2006 through Policy No. 2006/44. This Policy carried a cumulative bonus of 15% due to 'no claim' against for the previous four years. The sum insured against the said policy was Rs. 2,30,000/- inclusive of the bonus.

( 4 ) THE petitioner, on 22. 8. 2005, visited Dr. N. C. Krishnamani for a check up. He was diagnosed of suspected heart function disorder. An angiography was perfomed at Metro Golden Heard Institute by Dr. J. C. Mohan on 8. 9. 2005 and 'triple vessel disease' was diagnosed. The petitioner was advised "cabg" which was performed on 29. 11. 2005 at Delhi Heart and lung Hospital by Dr. Ganesh K. Mani. The total charges for surgery and medical expenses on pre-operation and post operation was Rs. 2,31,330/ -. The petitioner after fully recovering submitted his claim papers for process of claim on 30. 3. 2006/31. 3. 2006.

( 5 ) IT is aleged that M/s. Genins India Ltd, the insurer's agent did not approve for "cashless" treatment, (ie. the procedure whereby the insured is permitted treatment and the insurer directly pays the medical bills) by letter dated 19. 11. 2005. He was advised to file the claim in due course. The petitioner later submitted his bills, and claimed full reimbursement. The petitioner's insurance cover had in the meanwhile been renewed, through policy No. 211700/48/2007/67 effective from 10th May, 2006. He claims that at the time of renewal, he was again assured that his pending claim made by letter dated 30. 3. 2006 would be settled.

( 6 ) AFTER some correspondence, the respondent insurer repudiated its liability on 31. 10. 2006. The impugned letter is in the following terms:

"deptt:misc DATE: 31/10/2006 (WITHOUT PREJUDICE)SH. HARI OM AGARWAL 4320/3, ANSARI ROAD darya GANJ new DELHI - 110002 re: MEDICLAIM UNDER POLICY NO. 211700/48/2006/44 claim NO. 211700/48/2006/000133a/c SH. HARI OM agarwal this has reference to the above mentioned subject. We have sent your claim file to our TPA and as per their opinion the claim is not payable due to claim falls out of the scope of coverage under the terms and conditions of policy as per under excl

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