National Consumer Disputes Redressal
United India Insurance Co. Ltd. & Anr. vs S.K. Gandhi on 5 January, 2015
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO.2907 OF 2010 (From the order dated 23-04-2010 in FA No.831 of 2007 of the Delhi State Consumer Disputes Redressal Commission at New Delhi) 1. United India Insurance Co. Ltd. Divisional Office XII, 42 C, 3rd Floor Moolchand Commercial Complex New Delhi Through its Deputy Manager At Regional Office 1 Kanchanjangha Building 18-Barakhambha Road New Delhi 110001 2. Family Health Plan Ltd. TPA, Ashok Estate, 4th Floor Barakhambha Road, New Delhi ..Petitioners Versus S.K. Gandhi Flat No.502, Nanda Tower Kaushambi Opposite ISBT Anand Vihar Ghaziabad (U.P.) ..Respondent BEFORE: HONBLE MR. JUSTICE V.K. JAIN, PRESIDING MEMBER HONBLE DR. B.C. GUPTA, MEMBER For the petitioners : Mr. Rajesh Dwivedi, Adv. with Mr. A.K. De, Advocate For the respondent : Mr. Manoj Yadav, Advocate 05-01-2015 ORDER
JUSTICE V.K. JAIN, PRESIDING MEMBER (ORAL)
1. The respondent/complainant as well as his wife obtained a mediclaim policy from the petitioner-company for the period from 11-09-2004 to 10-09-2005. The respondent/complainant was taken to Minakshi Hospital, Ghaziabad when he complained of chest pain in the night intervening 4/5-01-2005. From Minakshi Hospital he was referred to Kailash Heart Institute at Noida, since the doctor in Minakshi Hospital was of the opinion that he had a mild heart attack. He remained hospitalized at Kailash Hospital, Noida from 05-01-2005 to 11-01-2005 and underwent angioplasty. The complainant submitted a claim of Rs.3,28,862/- to the petitioner company. The said claim was, however rejected on the ground that the hospitalization was for the management of an ailment which was a pre-existing disease. Aggrieved from the rejection of the claim, the complainant approached the concerned District Forum by way of a complaint.
2. The complaint was resisted by the petitioner-company primarily on the ground that the complainant had history of acute hypertension and CAD which are main factors for heart ailment but the aforesaid ailment was not disclosed by him to the insurance company at the time of taking the policy.
3. The District Forum vide its order dated 02-08-2007 allowed the complaint and directed the insurance company to pay the amount of Rs.3,28,862/- along with compensation amounting to Rs.50,000/- and cost of litigation amounting to Rs.5,000/-.
4. Being aggrieved from the order of the District Forum the insurance company approached the concerned State Commission by way of an appeal. Since there was some delay in filing the appeal an application for condonation of delay was filed. The said application, however, was dismissed. Consequently, the appeal filed by the petitioner company was dismissed as barred by limitation. Being aggrieved from the dismissal of its appeal the insurance company is before us by way of this revision petition.
5. The learned counsel for the petitioner company has drawn our attention to clauses 12 and 13 of the proposal form submitted by the complainant. The said form to the extent it is relevant reads as under:
12.
Medical History to be completed by the proposer/insured person PLEASE ANSWER THE FOLLOWING QUESTIONS IN YES OR NO (A DASH IS NOT SUFFICIENT) AND GIVE FULL DETAILS IF ANSWER IS YES.
12.1 Are you in good health and free from physical and mental disease or infirmly or medical complaints? Yes 12.2 If not in good health give full details
13. Have you ever suffered from any of the diseases/illness? No If yes, give details:
(a) Any nervous mental or psychiatric disease No
(b) slipped disc or other spinal disorder or (fainting episode, blackout, fit) paralysis of any kind. No
(c) high blood pressure, heart disease, including ischaemic heart disease, other circulatory disorder, etc. (rheumatic fever) No
(d) fistula, piles hernia varicose veins. No ****
(o) any other illness or disease or accident on operation sustained by you. No
6. It would thus be seen that while obtaining the policy the complainant clearly stated that he was in good health and free from any physical ailment including high blood pressure. The learned counsel for the petitioner has also drawn our attention to certificate dated 30-11-2005 purporting to be issued by Family Health Plan Ltd. stating therein that the complainant was admitted in Kailash Hospital and the duration of hypertension was mentioned as 8 to 9 years. It is further stated in the said certificate that hypertension is a major risk for CAD and, therefore, the claim was rejected on the ground that the claim in respect of such an ailment would be covered only from the fourth year of the policy. The petitioner-company has not placed on record either the discharge summary of the complainant or any medical document signed by the doctors who treated him in Kailash Hospital, to show that the complainant, when he was admitted to the said hospital had himself stated that he was suffering from hypertension from last 8-9 years. In fact there is no document from Kailash Hospital, Noida stating therein that at the time of admission the complainant had stated that he was suffering from hypertension from the last 8-9 years. It is quite possible that the complainant, despite suffering from hypertension was not actually aware of the same. In that case, he cannot be accused of misstatement or concealment. The onus was upon the insurance company to prove that he had made a misrepresentation while obtaining the insurance policy. In order to succeed the insurance company was required to produce evidence either from Kailash Hospital or from the doctor who treated the complainant to prove that the complainant at the time of admission in this hospital had himself stated that he was suffering from high blood pressure from last 8-9 years. The certificate purporting to be issued by a third party administrator such as Family Health Plan Ltd. cannot be a substitute for such medical evidence. In any case even the third party administrator does not show in the aforesaid certificate that Mr. S.K. Gandhi had himself stated at the time of admission in the hospital that he was suffering from high blood pressure from last 8 to 9 years.
7. For the reasons stated herein above we are of the view that the insurance company was liable to pay to the complainant to the extent of the sum insured by it which in the case before us was Rs.1,50,000/- as far as the complainant is concerned. Considering the sum insured in respect of the complainant was only Rs.1,50,000/- the District Forum was not justified in directing the insurance company to pay a sum of Rs.3,28,862/- to the complainant. Also, there is no medical evidence to show that at the time of obtaining the policy the complainant was suffering from hypertension.
8. For the reasons stated hereinabove we dispose of the revision petition with a direction to the insurance company to pay a sum of Rs.1,50,000/- to the complainant along with interest on that amount at the rate of 9% per annum from the date of rejection of the claim till the time the FDR of Rs.1,91,931/- was deposited by the complainant with this Commission. The order passed by the District Forum and the State Commission stand modified to this extent. The Registry is directed to release the amount of the FDR along with interest which may have accrued on it to the complainant within two weeks from today. The balance amount shall be paid by the insurance company within four weeks from today.
The revision petition stands disposed of.
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(V.K. JAIN, J.) PRESIDING MEMBER ..
(DR. B.C. GUPTA) MEMBER rk.1