IMPORTANT POINT
If a person does not disclose any factum of his having been hospitalized for treatment or having undergone operation in the near proximity say a year or two before obtaining the insurance policy he cannot be accused
of suppressing the factum of pre-existing disease.

J.D. Kapoor, President— Vide impugned order dated 17.8.2005 passed by the District Forum the appellant has been directed to pay Rs. 50,000 towards hospital bills and other medical expenses and Rs. 10,000 as compensation for mental agony and harassment besides Rs.1,000 as cast of litigation for having wrongfully repudiated the claim of the respondent.

2. Feeling aggrieved the appellant has preferred this appeal.

3. Case of the respondent in brief is that the respondent obtained a medi-claim policy No. 48/2001/00303 dated 8.5.2000 from the appellant in respect of himself and his family members including his minor son and paid its premium for Rs. 8,316 for a period from 12.5.2000 to 11.5.2001. During the subsistence of the policy, the child felt some health problem and on the advice of various doctors, he admitted in Sir Ganga Ram Hospital where he was operated for Hernia and paid a sum of Rs.22,300 vide cash bill No.5737 dated 4.8.2000 besides Rs.27,700 for medicines etc. After that the respondent lodged his son’s medi-claim to the appellant with all medical records but the appellant repudiated the claim on the ground that the problem “Hernia” is a pre-existing disease by birth and hence fall under the exclusion clause No.8 of the policy vide its letter doted 10.11.2002. The respondent obtained the opinion of the expert doctor and submitted it to the appellant but no use, despite promised for consideration of his claim. He also issued a legal notice to the appellant and the same was not rebutted and thus the appellant had wrongly repudiated the claim of the respondent. He claimed Rs. 50,000 which he has spent for the treatment of his son in Ganga Ram Hospital and Rs.50,000 as damages for mental agony, pain and harassment and Rs.5,000 for cost of litigation.

4. Appellant resisted the complaint firstly on the ground that the Forum has no jurisdiction to entertain and determine the complaint and that the complaint is misconceived, false, frivolous and vague and has no cause of action and thirdly because it was not maintainable because it was covered under exclusion clause of the insurance policy and lastly that the hospital records were verified by its panel doctors, who opined that since the disease existed by birth and congenital external is disorder by birth and the claim is not admissible.

5. All the aforesaid contentions raised by the appellant did not find favour with the District Forum and rightly so. It is well settled law that the parties are governed by the terms of contract and every beneficial legislation or beneficial contract has to be provided and receive beneficial interpretation and consideration. Contract of insurance is for th6 benefit of the consumer and therefore has to be provided the interpretation that should serve the interest of the consumer and promote its object and not with a view as to how to defeat the rightful claim of a consumer. It was a policy obtained for a child and the appellant company took the plea that the father of the child was aware of the existence of the disease by birth and relying upon the opinion of the panel doctor and the appellant rightly repudiated the claim.

6. We have perused the impugned order as well as the report of the panel doctor of the appellant. The panel doctor has opined that B/L Ingina Hernia does not mean that the patient had suffered from the disease by birth or had any pre-existing knowledge about his son’s precise medical condition and find ourselves in agreement with the view of the District Forum that B/L Ingina Hernia does mean that the patient had suffered from the disease by birth.

7. Medical science says that human body bears the germs of every disease and when it is exposed it becomes a disease. Thus germs of disease in human body are chronic in one form or sense or the other and it cannot be called chronic disease unless it is exposed.

8. We have taken a view that unless and until a person is hospitalized for treatment of a particular disea