Decided on July 31,2006



J.D.KAPOOR,J - (1.) VIDE impugned order dated 5.10.2000, complaint of the appellant seeking compensation arising out of mediclaim policy was dismissed on the ground that appellant was not entitled to the claim as he had to undergo treatment for pre -existing disease about which he had not made a disclosure in the proposal form. Feeling aggrieved, the appellant has preferred this appeal.
(2.) BROAD facts are more or less admitted and are like this. Appellant had taken individual mediclaim policy bearing No. 48/2000/120 valid from 14.6.1999 to 13.6.2000 from the respondent by paying premium of Rs. 3,686. He at the time of taking the policy specifically mentioned in the proposal form about his medical history and the respondent accepted the proposal and accordingly issued a clean policy without any condition attached to it. Unfortunately he suffered shunt infection and consequently was admitted at Inderprastha Hospital on 12.7.1999. Respondent was informed about it on 13.7.1999 vide his letter dated 12.7.1999. Appellant received respondents letter dated 21.7.1999 on
(3.) 8.1999 whereby he was informed to complete certain formalities as mentioned in the said letter to enable the respondent to process his claim. After the discharge from the hospital on 5.8.1999, the complainant vide letter dated 13.8.1999, completed required formalities. The respondents vide their letter dated 17.9.1999, repudiated his claim by stating that it was not within the purview of the present policy on the ground of pre -existing disease as per their doctors opinion. 3. Is an admitted fact that the appellant underwent V.P. shunt operation in January 1999 i.e., before taking the said policy on 14.6.1999 and the fact of operation of shunt (Head) was mentioned in the proposal from of the policy. The appellant suffered infection in the shunt and was again admitted in the Inderprastha Hospital on 12.7.1999 for shunt operation. The case of the appellant was that he had already informed the respondent about the disease in the proposal form and the respondent took no objection to it and issued him a clean policy and now they have repudiated the claim without any basis whereas they are liable to pay him Rs. 316,672 spent on his treatment. It appears that the District Forum has mainly relied upon the report of panel doctor of the respondent, namely, Dr. Vipin Gupta and exclusion Clause 4.1 which is as under : 4.1 The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of '' Such diseases which have been in existence at the time of proposing this insurance, pre -existing conditions means any injury which existed prior to the effective date of this insurance. Pre -existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance, whether or not the insured person had knowledge that the symptoms were relating to the sickness. Complications arising from pre -existing diseases will be considered part of that pre -existing condition. ;

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