- (1.) THIS is insurer s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 11.01.2008 passed by the District Forum, Dehradun in consumer complaint No. 32 of 2005. By the order impugned, the District Forum has allowed the consumer complaint and directed the opposite parties insurance company to pay a sum of Rs. 2,00,000/ - to the complainant together with interest @9% p.a. from the date of filing of the consumer complaint till payment.
(2.) IN brief the facts of the case are that the complainant Sh. Ranjeet Kumar Gupta purchased a Hospitalisation and DomiciliaryHospitalisation Benefit Policy for himself; his wife and two children from National Insurance Company Limited. The said policy was valid for the period from 10.03.2004 to 09.03.2005. Under the said policy, the complainant was insured for sum of Rs. 2,00,000/ -. On 05.04.2004, the complainant felt some medical problem and he contacted Dr. Gilhotra, Heart Specialist, who referred him to Delhi. The complainant went to Escorts Heart Institute and Research Centre, New Delhi, where his Angiography was done and on 08.04.2004, the complainant was advised for surgical revascularization. On 10.04.2004, the complainant got himself admitted in Escorts Heart Institute and Research Centre, New Delhi and his bye pass surgery was done. The complainant has alleged that he had spent a sum of Rs. 2,08,505/ - on his treatment and Rs. 12,283/ - towards medical expenses. In all, sum of Rs. 2,36,088/ - was spent on his treatment. The complainant lodged a claim with the insurance company for the reimbursement of the mediclaim expenses. The claim of the complainant was repudiated by the insurance company. Thereafter, alleging deficiency in service on the part of the insurance company, the complainant filed a consumer complaint before the District Forum, Dehradun.
(3.) THE insurance company filed written statement before the District Forum and pleaded that the claim was not found payable under Clause 4.1 and 4.2 of the policy because the disease with which the complainant insured had suffered, was pre -existing at the time of obtaining the policy and that the expenses on Hospitalisation / Domiciliary Hospitalisation were incurred during first 30 days from the date of commencement of insurance cover. It was also pleaded that the claim of the complainant was rightly repudiated and no deficiency in service was made by the insurance company. 24. The District Forum, on an appreciation of the material on record, allowed the consumer complaint vide impugned order dated 11.01.2008 in the above terms. Aggrieved by the said order, the insurance company has filed this appeal. Xxx Xxx Xxx;