Oriental Insurance Company Ltd. v. Vijay Kumar Gupta
2019-11-21
ASHOK KUMAR GAUR
body2019
DigiLaw.ai
JUDGMENT : Ashok Kumar Gaur, J. 1. The present writ petition has been filed by the petitioner-Insurance Company challenging the order dt. 27th September, 2019, passed by the Permanent Lok Adalat, Alwar. 2. Counsel for the petitioner submitted that the petitioner-Company had issued a Mediclaim insurance policy for the period 5th May, 2016 to 4th May, 2017 covering a risk of Rs. 5 Lakhs and the said policy was subsequently renewed for a further period commencing from 5th May, 2017 to 4th May, 2018. 3. Counsel submitted that the wife of claimant is said to have suffered severe pain in stomach and initially she was taken to Solanki Hospital at Alwar and later on she was said to be admitted in Metromass Hospital, Jaipur and some ailment in her kidney was said to be detected and as per the averment made by the claimant, later his wife was taken to Santokba Durlabji Hospital, Jaipur and after admission, she was operated on 28th March, 2018, however, no stone was detected in the kidney of the claimant. 4. Counsel for the petitioner has drawn attention of this Court towards discharge summary ticket of Santokba Durlabji Hospital, Jaipur. Counsel for the petitioner submitted that the claim, which was made against the petitioner-company was replied by letter dt. 31st May, 2018, repudiating the claim on the ground of violation of the conditions contained in Clause 4.1 and 4.2 of the Mediclaim Policy. It was informed to the claimant that the condition, which was specifically inserted in the policy, was that the treatment of Kidney was not permissible in the second year of the Insurance policy. 5. Counsel submitted that the Permanent Lok Adalat, Alwar while passing the award has in fact not considered the exclusion clause, which was provided in the Mediclaim Insurance Policy at Serial No. 4 and as per clause 4.1 & 4.2 of the Policy, certain diseases, which were pre-existing, at the time of proposal and their exclusion was specifically mentioned. As per Clause (xix) 'Calculus disease' it was also specifically mentioned that for a period of two years, the same disease will not be covered. 6.
As per Clause (xix) 'Calculus disease' it was also specifically mentioned that for a period of two years, the same disease will not be covered. 6. Counsel for the petitioner submitted that the Permanent Lok Adalat has not looked into the various clauses of Mediclaim Policy, which did not entitle the claimant to get any reimbursement for treatment of her Kidney and moreover as per the policy, the claimant was not entitled for reimbursement, as the same was specifically excluded. 7. Learned counsel further submitted that the Medical procedure, which was adopted in treatment of wife of the claimant did not fall under the definition of operation and as such the claim of the claimant was not required to be covered under the clause of the Policy. 8. This Court has gone through the order passed by the Permanent Lok Adalat and perused the material available on record. 9. The Court below has recorded a finding that there was no operation performed on the wife of the claimant, in respect of her kidney and only procedure was adopted, whereby the Lower Calyceal Puncture was done and as such the Pus, which is said to be around the kidney of the wife of claimant was taken out by undertaking the procedure. 10. This Court finds that the reasoning given by the Permanent Lok Adalat is after considering the entire procedure, which was undergone by the wife of claimant and the Lok Adalat has also considered the clauses of the Mediclaim policy. 11. This Court finds that the Insurance Company cannot be permitted to take such a plea, wherein the exclusion clause is made applicable to deny genuine claim of the person. This Court also finds that if the wife of claimant has undergone the treatment from Doctors for her disease and there was no question of concealment of disease at the time of taking the policy, the Insurance Company cannot deny from its liability to pay genuine claim to the claimant. 12. This Court is not inclined to exercise writ jurisdiction and interfere in the order passed by the Permanent Lok Adalat and accordingly, the present writ petition stands dismissed.