- (1.) The instant appeal filed under Clause 10 of the Letters Patent challenges judgment dated 4.5.2011 rendered by the learned Single Judge dismissing the writ petition of the petitioner-appellant M/s IFFCO TOKIO General Insurance Company Ltd. (for brevity, 'the Insurance Company').
(2.) Brief facts of the case are that Shri Naresh Aggarwal-respondent No. 2 had taken an individual medi-claim policy for himself and his wife from the Insurance Company, which was valid from 6.6.2007 to 5.6.2008 (P-2). In the terms and conditions of the policy there was a specific exclusion clause No. 1 under the heading 'What is not covered', which reads as under: "What is not covered: 1. All Diseases/injuries which are in pre-existing condition when the cover incepts with us for the first time. However, this exclusion shall cease to apply for such Pre-existing Condition if You/Insured Person have maintained an Individual Medishield Insurance Policy with us for a consecutive 3-years period prior to the present policy coverage and no claim, care, treatment or advice has been recommended by or received from a Medical Practitioner in relation to such Pre-Existing Condition during that 3-year period."
(3.) The said policy was renewed from 6.6.2008 to 5.6.2009 and again from 6.6.2009 to 5.6.2010. Respondent No. 2 was hospitalised from 10.3.2010 to 12.3.2010 for treatment of 'Coronary Artery Disease' in Medicity, Sector 38, Gurgaon. He approached the Insurance Company through third party administrator under the policy i.e. M/s Paramount Health-respondent No. 3 with the request to provide cashless facility for treatment. On 11.3.2010, respondent No. 3 declined the request of Shri Naresh Aggarwal-respondent No. 2 on the ground that he was seeking treatment for the heart disease which he had been suffering for the last eight years. It was found to be a case of preexisting disease covered under aforementioned exclusion clause of the policy (P-6). Respondent No. 2 thereafter raised a claim for reimbursement of medical expenses incurred by him on his treatment (P-7). On 16.4.2010, his claim for payment was denied on the ground that his was a known case of coronary artery disease since 2002 (P-11). It is stated that the treatment of disease taken by respondent No. 2 in the year 2010 was not covered under the medi-shield policy as he was suffering from this disease prior to taking the policy. Feeling aggrieved, respondent No. 2 approached the Permanent Lok Adalat (Public Utility Services) Gurgaon (for brevity, 'the Lok Adalat') by filing an application under Section 22-C of the Legal Services Authority Act, 1987, claiming a sum of Rs. 2,33,000- with interest @ 24% per annum from the date of claim application till payment with costs (P-17). On 8.12.2010, the Lok Adalat passed an order directing the petitioner-appellant to pay to respondent No. 2 a sum of Rs. 2,20,000/- along with interest @ 9% per annum from the date of institution of the claim till payment (P-1).;