IMPORTANT POINT
In a case of medi-claim policy where Insurance Company repudiated claim that disease claimant suffered was pre-existing but failed to produce any document from any hospital Consumer complaint allowed by Fora could not be interfered with.

Dr. P.D. Shenoy, Presiding Member— In this case Shri Raj Narain had obtained a medi-claim policy from the National Insurance Company for one year from 2007 June, 1999. While he was in Bareilly, Uttar Pradesh, after three days of taking the policy he fell sick and he consulted Dr O.P. Aggarwal and on his advise he under went comprehensive medical check-up. In the third week of June, 1999 he consulted Dr Vijay Kumar Kohli who referred him to Malhotra Heart Institute wherein he was admitted on 22nd June, 1999 and under went a heart surgery on 24th June, 1999. He was discharged on 5th July, 1999. He submitted a claim form, claiming Rs.1,61,612 through his letter dated 22nd July, 1999. The Insurance Company rejected the claim of the petitioner by taking a plea that it was a pre-existing disease. They had appointed Dr A K Batra for investigation into the case. Dr Batra opined that the petitioner had a pre-existing disease which was not revealed by him while taking the insurance policy. As the Insurance Company had repudiated the claim he filed a complaint before the District Forum claiming Rs.1,82,968 along with interest @ 24% per annum and compensation of Rs.5,000.

2. The District Forum after hearing the parties and going through the records of the case held that the complainant was neither aware of any exclusion clause nor he was supplied with the terms and conditions of the policy at the time of issuing cover note. Secondly, the Insurance Company had failed to establish that the complainant was having a heart disease prior to taking the policy. Lastly, the Insurance Company was deficient in service for not settling the claim of the complainant. Accordingly, the Insurance Company was directed to settle the medi-claim of the complainant within 60 days from the receipt of the order and pay interest at the rate of 10% per annum on the claimed amount with effect from 90 days after filing of the complaint till its realization.

3. Dissatisfied by the order of the District Forum, the Insurance Company had filed an appeal before the State Commission. The State Commission after hearing the Counsel for the parties dismissed the appeal.

4. Aggrieved by the order of the State Commission, the Insurance Company has filed this revision petition. Learned Counsel for the petitioner submitted that within three days of taking the policy, the complainant felt pain in his chest and went for a check-up and three weeks later he under went a heart surgery and hence, it is a clear case of concealing the pre-existing disease. The terms of the policy clearly stipulates that if the insured person undergoes treatment including hospitalization and surgical treatment for a pre-existing disease, the Insurance Company is not liable to pay compensation according to the learned Counsel. The Investigator Dr A K Batra has given a clear report in support of his contention that it was a pre-existing disease. On the other hand, the learned Counsel who is appearing for the Cavetor has submitted that there was a delay of 75 days in filing this revision petition for which no convincing reasons has been given. He also submitted that the insured was neither aware of the medical problem when the policy was taken nor was he aware of the terms and conditions of the policy.

5. Though Dr Batra has given his report as an investigator he has not filed any affidavit. Further no affidavit of Dr O.P. Aggarwal who has initially treated the insured prior to the hospitalization has been filed before us. It is also not disputed that the policy document which includes the terms and conditions of the policy was not given to the insured prior to the surgery .That there is a delay of 75 days is not disputed. Condonation application indicates that the order of the State Commission was passed on 29th march, 2007 and the certified copy of order, was received by them only on 8th May, 2007. Para 22 of the State Commission’s order reads as follows:

“A copy of this order as per the statutory