Decided on September 25,2006

KUSUM GUPTA Respondents


- (1.) RESPONDENT was admitted in the hospital on 24.4.1999 where she underwent minor surgery of hysterectomy Meaorrhgia and filed mediclaim of Rs. 45,588 towards the medical expenses incurred by her. The claim of the respondent was repudiated by the appellant by invoking the Exclusion Clause 4.3 providing the specific diseases which are not covered during the first year of the policy. Feeling aggrieved, the respondent has filed the instant complaint before the District Forum.
(2.) WHILE allowing the complaint of the respondent vide its order dated 31.1.2002, District Forum, directed the appellant to pay the expenses incurred by the respondent and also to pay Rs. 2,000 as compensation for mental agony and harassment including the cost of litigation.
(3.) LEARNED Counsel for the appellant has assailed the impugned order on the following premises : (a) that the respondent obtained the insurance policy subject to the terms and conditions and exceptions prescribed by the Insurance Company and after reading the prospectus containing all the terms and conditions, she accepted the policy and this fact is borne out from the proposal form itself which is to the following effect : "I hereby declare and warrant that the above statements are true and complete. I consent and authorise the insurers to seek medical information from any Hospital/Medical Practitioner who has at any time attended or may attend concerning any disease or illness which affects my physical or mental health. I agree that this proposal shall form the basis of the contract stated in the proposal form and if Questionnaires are incorrect and untrue in any respect, the Insurance Company shall incur no liability, under this insurance." (b) that condition No. 4.3 formed part and parcel of the contract arising from the proposal form and the insurance policy cover note and, therefore, the respondent/consumer was not entitled to the mediclaim for which she got the treatment as the claim for the treatment of the disease in question was not permissible in the first year of the policy. Said clause provides as under 4.3 During the first year of the operation of insurance cover, the expenses on treatment of Disease such as Cataract, Benign, Prostatic, Hypertrophy, Hysterectomy, for Meaorrhgia, or Fibromyoma, Hernia, Hydrocela, Congenital, Fistula in anus piles, Sinuistis and related disorders are not payable if these diseases are pre -existing at the time of proposal they will not be covered. Even during subsequent period of renewal too. The learned Counsel for the appellant has placed reliance on various judgments but the same cannot come to his rescue as the same are on different premise as in case the question of theft was involved and in another case, it was the question of burglary was involved. However, the judicial unanimity on this point is that terms of the contract have to be provided the meaning strictly in terms of the contract and no extra help should be summoned to provide another meaning.;

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