Details		DD MM	YY
Date of Judgment	25	11	2022
Date of filing	03	03	2022
Duration	22	08	00

IN THE CONSUMER DISPUTES REDRESSAL COMMISSION GUJARAT STATE, AHMADABAD First Appeal No. 176 of 2022 Court No. 1

1. NATIONAL INSURANCE COMPANY LIMITED

3^rd floor, Middletone street, Kolkata- 700071 ..Appellant Vs

1. SHARMILA BARUN ASHISH MUNSHI

3/B/10, Shree Balaji Agora Residency, Sardar Pate Ring Road, Sugad, gujarat- 382424 ....Respondant Coram :Hon’ble Mr. Justice V. P. Patel, President Ms. A.C.Raval, Presiding Member APPERANCE : Learned Advocate R. P. Raval for the Appellants V. M. Pancholi for the Respondent Order: (By Ms. A.C. Raval, Member)

1.Appellant has filed this appeal under section 15 of the Consumer Protection Act 1986, being aggrieved and feeling dissatisfied with the judgment and order dated 01.01.2022 Passed by the Consumer Disputes Redressal Commission, Ahmedabad (Addl.) (for short Learned District Commission ) in consumer Case no. 413 of 2015

2.Heard Ld. Advocate for Mr. R. P. Raval for the appellant. Mr. V. M. Pancoli for the respondent. Perused The record of the case and judgment and order passed by the Id. District commission.

3. The appellant herein is the original opponent and the respondent is original complainant. (Herein after the appellants and respondents will be referred as per their original status)

4. Facts of the case of the complaint:

“Complainant has obtained overseas travel Insurance Policy no.251100/48/13/0570000001/805082888 from the National Insurance Company Limited for the period between 28/02/2014 to 22/02/2015 through opponent no.2. Complainant has obtained the insurance policy of the opponent through Karvat Travel Service Private Limited and paid the premium for the said policy at Ahmadabad to Lovely Insurance Service on 17/01/2014. Complainant has paid Rs.11,656=00 as premium. Opponent has issued the policy for the above said period in favour of complainant for 50000 US $.”

During the said overseas visit to Australia the complainant was having the complaint of abdominal pain and low grace fever on 21/04/2014. got admitted in Mercy Hospital between 21/04/2014 to 23/04/2014 thereafter complainant went to Palmers Medical Centre and checked herself with Dr. Anil Kumar Cheeti on 02/06/2014. She took the treatment and presented the claim for amount of $3704.10 and $1139.60 from the opponent. The opponent rejected the claim of the complainant vide letter dated 23/12/2014, where the reason was given that because of the pre-existing medical condition, the claim was not maintainable. Hence, the complainant approached the Learned District Commission Ahmadabad (Additional) by filing CC No.413 of 2016 which was allowed by the Learned District Commission.

5. Argument of the Appellant:

Learned Advocate appearing for the appellant argued that Opponent TPA has examined the claim papers and treatment papers of complainant and found that the treatment taken at overseas under the policy is for the pre-existing disease. The medical treatment papers of overseas doctor clearly suggest that complainant has history of Hypertension, the MIA radiology report dated 23rd April, 2014. These reports clearly suggest that complainant has history of Cholecystectomy and opine that mild inflammatory change noted in the left parabolic gutter, in close association with the descending colon. Further noted that this is related to recent episode of diverticulitis or recent colonoscopy. The finding also suggests that inflammatory change adjacent to descending colon. The episode and claim at overseas treatment is related to the pre-existing disease of complainant. So not covered under the policy issued and falls under clause 10 (c) of the policy conditions.

Opponent has rightly rejected the claim after scrutiny of medical reports and as the insured had a history of pre-existing disease which falls under the policy exclusion. Hence the repudiation of the claim of the complainant is just and proper therefore order passed by the ld. Distri

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