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SANGITA DHINGRA SEHGAL, PINKI
Dinesh Kumar Jain – Appellant
Versus
Oriental Insurance Co. Ltd. – Respondent
JUDGMENT
Sangita Dhingra Sehgal, President—The facts of the case as per the District Commission record are:—
“The complainant’s son Late Vibhor Jain had purchased a happy family floater policy from the OP on 15.12.2010. The policy was valid for one year for an assured value of Rs. 6,00,000/-. The policy was further renewed for another year ending on 14.12.2012. Late vibhor Jain had expired on 11.3.2012 at Fortis Malar Hospital, Chennai. The complainant had submitted a claim for a sum of Rs 1,50,000/- under the policy which was, however, repudiated on the ground that the deceased was suffering from a pre-existing disease and as such the claim was not payable under the exclusion clause of the policy purchased by the deceased. The complainant has alleged that the repudiation of the claim was uncalled-for and an act of deficiency on the part of OP.”
2. The District Commission after taking into consideration the material available on record passed the order dated 14.09.2015, whereby it held as under:—
“The learned counsel for the OP has drawn our attention to the death summary prepared at Fortis Malar Hospital, Chennai which clearly records that the deceased had a history of hyperte
(1) Proof of delivery - In the absence of proof of delivery, therefore, Commission cannot rely solely on the Respondent’s statement before the District Commission that it had duly supplied the terms ....
Medical Examination – Insurance company is responsible for conducting a medical examination of the policyholder in advance.
(1) Health Insurance Policy [Mediclaim Policy] – Repudiation based on exclusion clause which was not communicated to insured can never be pressed into service to deprive insured from claiming relief.....
There should be nexus with pre-existing disease & disease for which claim has been made.
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