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MILIND S. SONAWANE, NAGESH C. KUMBRE
Oriental Insurance Co. Ltd. – Appellant
Versus
Sanjog Vinodlal Mutha – Respondent
JUDGMENT
Milind S. Sonawane, Presiding Member.—This is an appeal challenging correctness and legality of the judgment and order passed by the learned District Consumer Disputes Redressal Commission, Ahmadnagar (the ‘District Commission’ for short) in C.C. No. 204/2015, whereby the District Commission allowed the complaint filed by the respondents directing the appellant to pay to them sum of Rs.4,57,755/- towards the insurance claim along with Rs.20,000/- for the mental and physical harassment and Rs.5,000/- as the costs of the proceedings.
2. The brief facts of the appeal are that, the respondents in 2005 took the medi-claim policy from the appellant. It was renewed over the number of years till 2013. On 31.07.2013, the son of respondent no.2 i.e. respondent no.1 upgraded the policy by taking ‘family floater basic cover’ of Rs.7 Lakh and personal accident cover of Rs.35 Lakh under the ‘gold plan’. In this manner the entire family of the respondents was covered under the policy. When the policy cover was available from 31.07.2014 to 30.07.2015, respondent no.2 was admitted on 19.01.2015, firstly in Noble Hospital, Ahmadnagar. He was diagnosed to have heart attack. He was admitted i
(1) Significance of Policy Documentation – Policy documents issued by the appellant contained a “dash” in the column for pre-existing diseases. This serves as an admission by the insurer that no such....
Waiting period – Since the waiting period of 48 months had not elapsed after the sum insured was enhanced by the complainant under the subject policy, the concerned claim has rightly been denied by t....
Medically examined - insurance company has not submitted any such document of any such doctor, who has ever medically examined the insured and prescribed the medicine of diabetic disease during such ....
Existence of Disease – There is no reason for the insurance company to connect the existence of diabetes with the disease for which treatment has been taken.
(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.
Insurance Policy must be read holistically so as to give effect to reasonable expectations of all parties including insured & beneficiaries.
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