Repudiation of an insurance claim is not a deficiency in service if it is done in a bona fide manner after application of mind.

Mrs. Saroj Rajwade, Member—This is a complaint on the original side filed by the complainant alleging deficiency in service on the part of the opposite party. Complainant is resident of Indore. His son Jasdip Singh is residing in Maryland (USA) for last 10 years. Complainant and his family have obtained Medi-claim Policy from the opposite party since 1991 and renewed it in following years. However, no claim has ever been filed against this Medi-claim Policy by complainant or his family any time. In June, 1994 when the complainant wished to go to USA his Medi-claim Policy was effective but he was advised to obtain Overseas Medi-claim Policy. The complainant was advised to undergo medical checkup before issue of Overseas Medi-claim Policy. Accordingly checkup was done by Dr. D.K. Jain and Pathological test by Dr. P.S. Ajmani (Annex-B). Opposite party issued Medi-claim Policy, after satisfying themsevles, bearing No. 852/36064 (Annexure-C). The complainant proceeded to USA on or about 12.6.1994. After staying for 40 days, the complainant got some complaint and was immediately taken to Doctor. After examination complainant was admitted to University of Maryland, School of Medicine, Bathmore Maryland and was advised to undergo cardiovascular surgery. This development was reported to agent of opposite party and a claim for reimbursement of expenses was filed with opposite party. Opposite party referred the claim to its claim settling agent, i.e. Mercury International Assistance and Claims Ltd., England. Complainant has further stated that prior to this, complainant never had any complaint about hypertension, or heart disease or ischemic heart disease nor was ever treated for above diseases or hospitalised for this ailment. This, according to complainant, is proved by reports of medical check-ups done in past and the medical check-up done prior to departure for U.S.A. Further if he had received any treatment, he would have filed a claim under Medi-claim Policy.

2. Opposite party vide their letter dated 4.1.1995 repudiated this claim on the ground that records received from hospital show that complainant had a history of hypertension and he had positive stress test in 1993 resulting in medication for ischemic heart disease. Lot of correspondence was exchanged between the two parties but failing to get relief from the opposite party, the complainant filed a complaint on 31.12.1996 and prayed for directions to opposite party to pay Rs. 12,44,006/- (Twelve lakhs forty four thousand and six rupees) as per details in para 18 of the complaint.

3. Opposite party filed a reply to the complaint on 15.10.1997, in which they have raised preliminary objections, about adjudication of this case in Consumer Forum, on the grounds that this case will require expert scientific testimony and voluminous oral and documentary evidence. Opposite party, therefore, prayed for directions to pursue the case in Civil Court. Subject to above objection, the opposite party submitted a parawise reply in which all the allegations made in the complaint were denied generally and specifically opposite party further stated that report of Dr. Chopra attending surgeon in USA who performed the surgery, shows that complainant was a patient of hypertension and had undergone a positive stress test in 1993 and consequently was on medication for ischemic heart disease. A copy of the report has been filed as (Annexure R1) with the reply. It was further submitted on behalf of opposite party that there was no deficiency in service as the repudiation of claim was done by their agent as per terms of policy after careful consideration and proper application of mind. Opposite party, therefore, denied that they were liable to pay the amount claimed in the complaint and also prayed for dismissal of complaint.

4. An affidavit-cum-rejoinder was filed by the complainant to the above reply of the opposite party in which complainant alleged that repudiation of claim was made in a mala fide