ORAL ORDER
Per Hon’ble Mr.S.R.Khanzode, Presiding Judicial Member
Heard Mr.K.H.Gorvankol-Advocate for the appellant and Ms.Sushama Gor- Advocate proxy for Mrs.Kalpana Trivedi-Advocate for the respondent who also files letter of authority, which is taken on record. Appellant supplied the documents which were missing from the compilation of appeal as per the list. Taken on record.
This appeal takes an exception to an order dated 31/05/2004 passed in consumer complaint no.154/2001 by Central Mumbai District Consumer Disputes Redressal Forum. It is a case of alleged deficiency in service on the part of respondent –M/s.New India Assurance Co. Ltd. (herein after referred as ‘Insurance Company’) for arbitrarily repudiating the mediclaim insurance, which was lodged consequent to the hospitalization of the complainant/appellant at JaslokHospital, Mumbai during the period 20/07/2000 to 23/07/2000. Insurance Company repudiated the claim referring to the exclusion clause 4.10 in the policy stating that hospitalization mere for diagnostic purpose will not be covered. Not satisfied with the repudiation, consumer complaint was filed. It proceeded ex-parte against the Insurance Company. However, considering the evidence and material placed before it, the forum was not satisfied with the same and dismissed the consumer complaint. Feeling aggrieved thereby, complainant preferred this appeal.
Heard both the parties. Since the Insurance Company was ex-parte and led no evidence, we have to consider sufficiency of the material i.e. affidavit and documents including Discharge Card of the hospital produced by the complainant. Referring to the exclusion clause 4.10, to which the Insurance Company relied, it reads as under:-
“Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.”
(underline provided).
Referring to the Discharge Card of the hospital and the sworn statement of the complainant, we find that only after definite and conclusive diagnosis of Post menopausal osteoporosis, complainant was admitted for evaluation and for HRT treatment of her ailment and all the diagnostic tests were performed. Therefore exclusion clause to which a reference is made supra, is clearly not attracted in the instant case. Thus, finding the repudiation arbitrary, the deficiency on the part of Insurance Company is well established.
There is no reason to disbelieve the complainant about the expenses incurred in the hospital of `15,789.20ps (rounded off to `15,789/-). It is as per the final bill of JaslokHospital placed on record. We find it proper to award the compensation to that extent.
Forum did not read the evidence led before it properly and arrived at a wrong conclusion. We hold accordingly and pass the following order:-
ORDER
Appeal is allowed.
Impugned order dated 31/05/2004 is set aside.
Respondent/Insurance Company do pay compensation of `15,789/- to the appellant/complainant along with interest @ 9% p.a. from the date of filing of the complaint i.e.31/12/2001 till its realization.
Respondent to bear his own costs and pay `10,000/- as costs to the appellant.
Pronounced on 14th March, 2013.
