State Consumer Disputes Redressal Commission
Sr.Manager Health Insurance Lic vs Gurdeep Singh Bhatiya on 27 October, 2015
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR (C.G).
Appeal No.FA/15/396
Instituted on : 30.07.2015
Senior Manager (Health Insurance),
Divisional Office, Raipur
Life Insurance Corporation of India, Jeevan Prakash,
Jeevan Beema Marg, Pandri, Raipur (C.G.).
Authorized on his behalf.
Through : Manager (L & HPF), Divisional Office,
Jeevan Prakash, Jeevan Beema Marg, Pandri,
Raipur (C.G.) ... Appellant.
Vs.
Gurdeep Singh Bhatia, S/o Shri Ravail Singh,
R/o : Sandeep Sadan, Pulgaon Naka, Ganjpara,
Durg, Tehsil and District Durg (C.G.) ... Respondent.
PRESENT: -
HON'BLE JUSTICE SHRI R.S.SHARMA, PRESIDENT
HON'BLE MISS HEENA THAKKAR, MEMBER
HON'BLE SHRI D.K. PODDAR, MEMBER
HON'BLE SHRI NARENDRA GUPTA, MEMBER
COUNSEL FOR THE PARTIES: -
Shri N.K. Shrivastava, for the appellant.
Shri Champleshwar Sinha, for the respondent.
ORDER
Dated : 27/10/2015 PER :- HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT.
This appeal is directed against the order dated 03.07.2015, passed by the District Consumer Disputes Redressal Forum, Durg (C.G.) (henceforth "District Forum") in Complaint Case No.C.C./14/368. By the impugned order, learned District Forum, has // 2 // allowed the complaint and directed the appellant (O.P.) to pay within a period of one month from the date of order a sum of Rs.3,82,000/- i.e. claim amount. The District Forum has further directed that if the above amount is not paid within the stipulated period to the respondent (complainant), then same will be payable along with interest @ 9% p.a. from the date of order. The appellant (O.P.) has further been directed to pay a sum of Rs.5,000/- towards compensation for mental agony and Rs.5,000/- towards cost of litigation to the respondent (complainant).
2. Briefly stated the facts of the case are that the respondent (complainant) has purchased Jivan Arogya Policy of the Life Insurance Corporation of India. The Policy No. is 386766007 and has been issued for the period from 08.08.2011 to 08.08.2014. When the health of the respondent (complainant) deteriorated, he was admitted in Central India Institute of Medical Sciences (AIIMS), Nagpur from 28.06.2013 to 30.07.2013 and took treatment. During this period, he was admitted in the ICU from 28.06.2013 to 06.07.2013 where a sum of Rs.3,82,000/- was spent in his treatment and the respondent (complainant) paid the above amount to the Manager of the CIIMS, Nagpur. The respondent (complainant) health policy No.386766007, therefore, on 26.03.2014, the respondent (complainant) submitted claim before the appellant (O.P.) for payment of the amount spent by him in his treatment, which was repudiated by the appellant (O.P.) on the ground that the respondent // 3 // (complainant) did not mention regarding his previous diseases. When the respondent (complainant) purchased insurance policy from the appellant (O.P.) at that time he was not suffering from any disease and he did not suffer from headache or any incurable disease. In the year 2011 when the respondent (complainant) purchased the insurance policy, he was fully healthy, therefore, the appellant (O.P.) did not conduct examination regarding his health and on 08.08.2011 insurance policy was issued in his favour, therefore, his claim would have been accepted by the appellant (O.P.). The appellant (O.P.) repudiated the claim of the respondent (complainant) on the ground that the respondent (complainant) was suffering from Headache, Chronic Siriusitis, Vertigo since 3-4 years, which comes in the category of deficiency in service, because the respondent (complainant) did not violate any terms and conditions of the insurance policy. The respondent (complainant) suddenly suffered from the disease and the same is not related to any incurable disease from which the respondent (complainant) was suffering, therefore, the appellant (O.P.) is liable to pay a sum of Rs.3,82,000/- under Health Policy to the respondent (complainant). The respondent (complainant) requested to the appellant (O.P.) several times orally to pay the amount, but the appellant (O.P.) did not pay the amount and the appellant (O.P.) inspite of receiving application on 26.03.2014, did not pay the amount to the respondent (complainant) and thus committed deficiency in // 4 // service. Hence, the respondent (complainant) filed consumer complaint before the District Forum and prayed for granting reliefs, as mentioned in the relief clause of the complaint.
3. The appellant (O.P.) filed its written statement and averred that the respondent (complainant) was admitted in Central India Institute of Medical Sciences, Nagpur for the period from 28.06.2013 to 30.07.2013 and as per hospital discharge summary the diagnosis/treatment of the respondent (complainant) done was Left ACOM Aneurysm (op) with Pyogenic Meningitis. The respondent (complainant) was admitted in ICU from 28.06.2013 to 06.07.2013. In the claim form, the respondent (complainant) demanded a sum of Rs.2,95,612/- in respect of the expenditure incurred in his treatment. M.D. India vide their claim rejection letter dated 15.04.2014, informed the respondent (complainant) that he was suffering from pre-existing disease. M.D. India has made clear that the respondent (complainant) was suffering from Headache, Chronic Sinusitis and Vertigo since 3-4 years, which was made clear by the CIIMS in brief history of the discharge summary. The respondent (complainant) met with a road accident and his surgery was performed. The respondent (complainant) was suffering from Headache (On & off) and vertigo since 3-4 years (History of Chronic Sinusitis with Nasal Congestion), History of RSA (Road Side Accident) 28 years back, left frontal bone operated for that and KC/C/O (Known case o) HTN (Hypertension) // 5 // since 1 ½ years on regular t/t (treatment). Thus, on the basis of the information given by the respondent (complainant) in the proposal form at the time of filling proposal form in respect to the question no.10 regarding health details and medical information, his proposal was accepted and insurance policy was issued. The appellant (O.P.) issued Health Policy - Jeevan Arogya on life of the respondent (complainant) and Smt. Balbir Kaur after giving consent by them that they understood all the facts and terms and conditions of the policy. As per Jeevan Arogya Policy, hospital cash benefit for 8 days @ Rs.2,100/- i.e. double Rs.33,600/- and for 23 days @ Rs.2,100/- i.e. Rs.48,300/- and total amount of Rs.81,900/- is payable to him and the appellant (O.P.) is ready to pay the same to the respondent (complainant). In the proposal form, the respondent (complainant) demanded a sum of Rs.2,95,612/- and in the complaint he is demanding Rs.3,82,000/- whereas the respondent (complainant) is only entitled to get a sum of Rs.81,900/- from the appellant (O.P.). The complaint filed by the respondent (complainant) on false ground is liable to be dismissed with cost.
4. Learned District Forum, after having considered the material placed before it by the parties, has allowed the complaint and directed the appellant (O.P.) to pay compensation to the respondent (complainant), as mentioned in para 1 of this judgment.
// 6 //
5. The respondent (complainant) has filed documents. Ex. 1 is letter dated 26.03.2014 sent by the respondent (complainant) to Senior Divisional Manager, L.I.C. of India, Divisional Office, Raipur, Ex-2, is letter dated 19.04.2014 sent by Manager (Health Insurance), Divisional Health Unit, Divisional Office, Pandri, Raipur (C.G.), Ex. 3 is Claim Rejection Letter dated 15.04.2014 sent by M.D. India to the respondent (complainant), Ex.4 is LIC's Jeevan Arogya Insurance Policy, Ex. 5 is LIC's Jeevan Arogya Insurance Policy Conditions and Privileges, Ex. 6 is Claim Intimation Form, Ex. 7 is Hospital Treatment Forum, Ex. 8 is Discharge Summary of Central India Institute of Medical Sciences, Nagpur, Ex. 9 is Test Report dated 28.06.2013 regarding MDCT Angiography of Intracranial Vessels, issued by Spandan Diagnostics, Nagpur, Ex. 10 is Report dated 01.07.2013 of Central India Institute of Medical Sciences, Nagpur, Ex. 11 is Report dated 30.06.2013 of Central India Institute of Medical Sciences, Nagpur, Ex. 12 to 19 are Reports of various dates of Central India Institute of Medical Sciences, Nagpur, Ex. 20 to Ex. 26 are Report on Microbiology of various dates of Su-Vishwas Diagnostic Lab, Nagpur.
6. The appellant (O.P.) has also filed documents. Annexure D-1 is Discharge Summary of Central India Institute of Medical Sciences, Nagpur dated 30.07.2013, Annexure D-2 is Form for Claiming HCB/MSB/DCPB/OSB/Quick Cash under Health Insurance Policy, Hospital Treatment Form, PAN Card, Bill No.322664 dated 26.08.2013 // 7 // issued by Central India Institute of Medical Sciences, Nagpur, Annexure D-3 is Claim Rejection Letter dated 15.04.2014 sent by M.D. India to the respondent (complainant), Annexure D-4 is Draft Circular issued by the Life Insurance Corporation of India, Central Office regarding introduction of LIC's Jeevan Arogya (Plan No.903), Annexure D-5 is HCB Calculation of Gurdeep Singh Bhatia, Annexure D-6 is LIC's Jeevan Arogya Insurance Policy (Table 903) and LIC's Jeevan Argoya Insurance Policy Conditions and Privileges, Annexure D-7 is Proposal Form for Health Insurance Policy, Annexure D-8 is Agent's Confidential Report / Moral Hazard Report.
7. Shri N.K. Shrivastava, learned counsel appearing for the appellant (O.P.) has argued that the impugned order passed by the District Forum, is contrary to the facts mentioned in the written statement of the appellant (O.P.) (Insurance Corporation) as well as documents available in the record of the District Forum, hence the impugned order is liable to be set aside. He further argued that the impugned order passed by the District Forum, is contrary to law. The District Forum, has not properly analysed the documents filed by the appellant (O.P.) (Insurance Corporation). He further argued that the respondent (complainant) was having history of Headache (On and Off) and Vertigo since 3-4 years prior to obtaining insurance policy , and he had history of Road Side Accident (RSA) 28 years back, left frontal bone operated for that. It appears that the respondent // 8 // (complainant) suppressed regarding his pre-existing illness and he obtained insurance policy after suppressing material facts, therefore, the appellant (O.P.) (Insurance Corporation) has rightly repudiated the claim of the respondent (complainant). He further argued that if this Commission reaches to the conclusion that the respondent (complainant) is entitled to get compensation under the insurance policy, then the respondent (complainant) is only entitled for Rs.81,900/-. He further argued that in the claim form, the respondent (complainant) demanded a sum of Rs.2,95,612 towards total benefits claimed and in the complaint he prayed for granting a sum of Rs.3,82,000/- under the Health Policy. There is no evidence that the respondent (complainant) incurred expenditure of Rs.3,82,000/- in his treatment, therefore, the impugned order passed by the District Forum, is liable to be set aside.
8. Shri Champleshwar Sinha, learned counsel appearing for the respondent (complainant) has supported the impugned order passed by the District Forum and argued that the respondent (complainant) never suppressed any material facts to the appellant (O.P.) prior to obtaining insurance policy. Merely mentioning that respondent (complainant) was suffering from Headache, Chronic Sinusitis and Vertigo since 3-4 years or the respondent (complainant) met with a road accident 28 years back, it cannot be held that the respondent (complainant) suppressed material facts or was suffering from pre-
// 9 // existing illness. In the medical report merely mentioning that respondent (complainant) has history of headache and vertigo since 3- 4 years and history of Road Side Accident (RSA) 28 years back, left frontal bone operated for that, is not sufficient to repudiate the claim of the respondent (complainant), therefore, the appeal is liable to be dismissed.
9. We have heard the learned counsels for the parties at length and have also perused the record of the District Forum minutely.
10. The appellant (O.P.) repudiated the claim of the respondent (complainant) on the ground that insured Gurdeep Singh Bhatia was suffering from headache, chronic sinusitis, vertigo since 3-4 years and the above fact is mentioned in the Claim Rejection Letter (Ex. - 3).
11. The appellant (O.P.) has filed Discharge Summary of Central India Institute of Medical Sciences, Nagpur (M.H.) which is marked as Annexure D-1 in which it is mentioned that Bhatia Gurdeep Singh was admitted in the hospital on 28.06.2013 and was discharged on 30.07.2013. In the above Discharge Summary, under the head Brief History - Complaints and Duration / Clinical Examination, it is mentioned thus :-
"This patient came with c/o sudden LOC (for ½ hr) at 12.30 a.m. on 27.6.2013. H/o vomiting 10-12 episodes. C/o severe headache since evening 27.6.2013. C/o irrelevant talk (on and off), confused since morning.
// 10 // H/o headache (on and off) and vertigo since 3-4 yrs. (h/o chronic sinusitis with nasal congestion). H/o RSA 28 yrs. back, left frontal bone # (operated for that) K/c/o HTN since 1 ½ year on regular t/t. No h/o DM, IHD, asthma.
O/E: Pt. conscious respond to v.c, moving all 4 limbs with gr V P-84/min BP 140/80 mm of Hg SPo2 100% RS/CVS - NAD P/A soft."
12. In the above Discharge Summary, it is mentioned that patient came with complaint of sudden LOC (for ½ hr) at 12.30 a.m. on 27.06.2013, H/o vomiting 10-12 episodes and c/o severe headache since evening 27.06.2013.
13. From the bare perusal of the above discharge summary Annexure D-1, it appears that the respondent (complainant) suffered sudden severe headache and vomiting. Merely mentioning in the Discharge Summary that the respondent (complainant) was suffering from Vertigo since 3-4 years is not sufficient to hold that the respondent (complainant) suppressed material facts prior to obtaining insurance policy.
14. The burden to prove that the insured had suppressed facts regarding previous illness or diseases, is on insurer and mere production of the discharge summary was held to be insufficient to prove sickness and suppression of material facts. The burden of proof establishing pre-existing disease and the insured was having knowledge regarding the disease, is on insurer. The documents filed // 11 // by the appellant (O.P.) are not sufficient to prove that insured has knowledge regarding his pre-existing disease. Therefore, merely filing Discharge summary, is not sufficient to prove pre-existing disease of the insured and it is also not sufficient to prove that the insured has knowledge regarding his pre-existing diseases and he malafidely suppressed the above facts from the appellant (O.P.) at the time of making proposal for the insurance policy.
15. In the instant case, the appellant (O.P.) (Insurance Corporation) pleaded that the respondent (complainant) is legally entitled for Rs.81,900/- as per terms and conditions of the insurance policy. It appears that the appellant (O.P.) (Insurance Corporation) itself admitted that the respondent (complainant) is entitled to get amount under the Health Policy. According to the appellant (O.P.) (Insurance Corporation), no benefit will be payable for the first 24 hours of hospitalization. The amount of Daily benefit due to hospitalization as specified in the policy schedule would be the Initial Daily Benefit amount. Initial Daily benefit would be the applicable daily benefit amount which will be payable per day of each eligible hospitalization day. For each policy year commencing at a policy anniversary on or after the first anniversary the applicable daily benefit shall increase 5% of the Initial Daily benefit and the amount of daily benefit in case of admission to the Intensive Care Unit shall be two times the applicable daily benefit.
// 12 //
16. On above basis, the appellant (O.P.) pleaded that the respondent (complainant) is entitled for Rs.81,900/-, but the respondent (complainant) himself submitted claim form before the appellant (O.P.) which is marked as Annexure D-2, in which he prayed for making payment of Rs.2,95,612/- towards total benefit. According to Discharge Summary of Central India Institute of Medical Sciences, Nagpur (Document Annexure D-1), the respondent (complainant) was admitted in the above hospital on 28.06.2013 and was discharged on 30.07.2013. He was admitted in the above hospital for near about 1 month and 2 days and X-ray, USG and CT Scan were conducted there. Therefore, looking to the treatment taken by the respondent (complainant) in Central India Institute of Medical Science, Nagpur, we hold that the respondent (complainant) is entitled to get a sum of Rs.2,95,612/- from the appellant (O.P.) as prayed by him in the claim form (Annexure D-2).
17. Learned District Forum, has awarded a sum of Rs.3,82,000/- to the respondent (complainant), which is excessive. We find that District Forum, has not given any cogent reason for awarding the said amount in favour of the respondent (complainant). The respondent (complainant) himself demanded a sum of Rs.2,95,612/- from the appellant (O.P.) towards total benefits claim in the claim form, // 13 // therefore, the respondent (complainant), is entitled to get a sum of Rs.2,95,612/- from the appellant (O.P.) towards compensation.
18. Therefore, the appeal filed by the appellant (O.P.) is partly allowed and it is directed that the appellant (O.P.) will pay within a period of one month from the date of order a sum of Rs.2,95,612/- (Rupees Two Lakhs Ninety Five Thousand and Six Hundred Twelve Only) to the respondent (complainant) instead of Rs.3,82,000/-, as directed by the District Forum, along with interest @ 9% p.a. from the date of order till realisation. The remaining part of the impugned order, will remain unaltered and is affirmed. No order as to the cost of this appeal.
(Justice R.S. Sharma) (Ms. Heena Thakkar) (D.K. Poddar) (Narendra Gupta) President Member Member Member /10/2015 /10/2015 /10/2015 /10/2015