CORAM:

HON’BLE JUSTICE SANGITA DHINGRA SEHGAL PRESIDENT

HON’BLE MS. PINKI, MEMBER (JUDICIAL)

Present : Ms. Kriti Khokar, counsel for the Appellant.

None for the respondent.

PER : HON’BLE MS. PINKI, MEMBER (JUDICIAL)

JUDGMENT

1. By this judgment, we shall dispose of the appeal filed by the Appellant against the impugned order dated 10.06.2011, passed by Consumer Disputes Redressal Forum (East), Saini Enclave, Delhi 110092 (hereinafter referred to as District Forum), in Complaint Case no. CC-106/2011 titled as Mr. Babu Lal Yadav vs. Star Health and Allied Insurance Co. Ltd. inter-alia praying for setting aside the order passed by the District Forum.

2. While the Appellant was Opposite Party before the District Forum and the Respondent was Complainant before the District Forum.

3. The facts of the case as per the District Forum, record are as under:

“The brief facts are that the complainant and his wife obtain from Ops Family Health Optima Insurance Policy bearing No.P/161211/01/2010/000455 for the period 27.1.10 to 26.1.2011 and the insured amount was Rs.2 lacs of the policy in question. Thereafter the same was renewed on 5.1.2011 for the period 27.1.2011 to 26.1.2012. On 4.8.10 the complainant was admitted in The Anusman Hospital, Dwarka due to chest paid and the treating doctor of the said hospital referred to Max super specialty Hospital on 5.8.10 as in the case of Coronary Artery Disease. In respect of the treatment and hospitalization, the complainant submitted a claim of Rs.2,57,000/- on 21.8.10 to OP as per the terms and conditions of the policy. The complainant claims Rs.2 lacs, the amount of the policy, Rs. 50,000/- as compensation for mental agony, harassment and sheer suffering and Rs.20,000/- as litigation cost.”

4. The District Forum after taking into consideration the material available on record passed the judgment dated 10.06.2011, whereby it held as follows:

“In this case the OP has rejected the claim solely on the ground of pre-existing disease. It appears to us that the defence of the pre-existing disease by the OP is only to save its skin from the clutches of the law. Admittedly, the complainant was admitted on 22.9.08 in the Batra Hospital and remained under treatment up to 27.9.08 and the complainant has filed the various papers in support of this contention. It is not the case of the OP that during that period the patient was not insured with the O.P. Mild Concentric WH may be a normal condition for person and not very significant if asymptomatic and no other associated medical concerns for someone who have hypertension and use pills for high bloca pressure for a while now Hypertrophy in medical terms means, enlargement of the size and concentric means all round. In terms of heart, concentric LV hypertrophy means that the muscle of the left sided pumping chamber of the heart has increased in size and thickness. This usually occurs because of either high blood pressure or any obstruction to the outflow of blood from the left heart. Commonest example of latter is narrowing of the valve.

The OP has not filed any terms and conditions in support of the contention and even the copy of the terms and conditions cannot form the basis of the agreement and contract unless and until such terms and conditions are signed by the complainant. Further, the OP has not produce any record nor any evidence to establish that the complainant was specifically informed about the said terms and conditions. A law has been laid down by the Hon'ble Supreme Court in Modern Insulators Ltd. v/s Oriental Insurance Co. Ltd. AIR 2000 in Civil appeal No.6895 of 1997 page 1014-1016. Under these circumstances, tne complainant is entitled to a sum of Rs.2 lacs as insurance policy amount.

The complainant has claimed a compensation of Rs.50,000/- for mental agony harassment and sheer suffering and Rs.20,000/-as litigation cost. A person had heart surgery and operated, therefore and paid over Rs. 2 lacs after having a medi-claim policy, but this amou