Meghalaya
StateCommission
FA 02/2003
National Insurance Co. Ltd - Complainant(s)
Versus
Shri R.N.D.Purkayastha - Opp.Party(s)
Mrs. P.D.B.Baruah
16 Jul 2010
ORDER
| First Appeal No. FA 02/2003 (Arisen out of order dated in Case No. of District ) | ||||||||||||||
1. National Insurance Co. Ltd Shillong ....Appellant 1. Shri R.N.D.Purkayastha Shillong ....Respondent | ||||||||||||||
*JUDGEMENT/ORDER Heard Mrs PDB Baruah the learned counsel for the appellant, and also heard Mr K. Khan the learned counsel for the respondent. The case in brief is that the respondent is a holder of medi-claim insurance policy dt. 14.8.2000 issued by the appellant covering the period from 14.8.2008 to 13.8.2001. The sum covered by the policy was for Rs 50,000 (Fifty Thousand). In the month of December .2000 the respondent was diagnosed of having a polip in his left vocal cord and was advised for operation by the doctor. On coming to know of this the respondent informed the appellant vide letter dt. 14.2.2001 that the respondent is undergoing a medical operation at the Appollo Hospital at Chennai. Accordingly the respondent was operated on 25.2.2001 in the said hospital and there after the respondent on 23.3.2001 submitted a claimed of Rs 23,572.22 to the appellant for refund of the medical expenditure incurred by the respondent. The respondent did not receive any information from the appellant on the above claim and he issued a reminder on 4.10.2001,but even then the respondent did not get any response to his claim and he had to issue a legal notice on 11.1.2002. However, on 15.2.2002 the respondent receive a letter from the appellant informing him that his claim is closed as “No Claim.” The appellant in their show cause have denied the claim of the respondent on the ground that the respondent had prior knowledge of his ailment and that under condition 4.1 of the policy the appellant are not liable to reimburse the claim of the respondent in the said policy. On perusal of records it is clear that the ailment of respondent occurred when the policy was still valid as a policy covers the period from 14.8.2000 to 13.8.2001. The only point for consideration is that weather the respondent has prior knowledge of his ailment and weather the ailment was pre existing before the policy was issued by the appellant. In order to appreciate the above views we may go inside the facts and circumstances as available from the records. It is not disputed that the policy was accepted by the appellant with out any objection and that the objection was raised only after the respondent had under gone the medical operation. The evidence of Shri Phinso Dorji administrative officer of the insurance is clear that the respondent did not have adverse medical history and as such the medical certificates was not required and the declaration made by the respondent in the proposal form was totally accepted. This shows that the appellant had accepted the proposal with out any objection. In the evidence of Dr Saikia he opined that the polip was benign the pre existing of the ailment could have been by mere interference. From the evidence of the witnesses there is no conclusion that the ailment of respondent was pre existing. We have also perused the order passed by the Learned District Forum and we are of the opinion that the policy was accepted in toto by the appellant and that the appellant repudiated the claims of the respondent by raising flimsy and vague grounds when the claims is made by the respondent. For the aforesaid reason we find no reason to interfere with the order passed by the learned District Forum and the name is upheld. In the result there is no merit in the appeal and accordingly it is dismissed. Pronounced Dated the 16 July 2010
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