State Consumer Disputes Redressal Commission
Paramjit Singh Dhingra vs Oic Ltd. on 25 March, 2010
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
S.C.O. NO. 3009-10, SECTOR 22-D, CHANDIGARH.
First Appeal No. 1052 of 2004
Date of institution : 25.8.2004
Date of decision : 25 .3.2010
Paramjit Singh Dhingra, R/o 16, Mall Avenue, Near Ram Ashram School,
Amritsar.
.......Appellant
Versus
Oriental Insurance Company Limited, Branch Office No.III, 26 Kennedy Avenue
(Court Road), Amritsar through its Senior Branch Manager.
......Respondents
First Appeal against the order dated 14.7.2004 of
the District Consumer Disputes Redressal Forum,
Amritsar.
Before :-
Hon'ble Mr. Justice S.N. Aggarwal President
Mrs.Amarpreet Sharma, Member
Present :-
For the appellant : Shri Vikas Sagar, Advocate. For the respondents : Shri Vinod Chaudhary, Advocate. JUSTICE S.N. AGGARWAL, PRESIDENT:
Paramjit Singh Dhingra appellant had taken the medi-claim insurance policy from the respondents. It was valid for the period from 10.6.2002 to 9.6.2003. Ms. Gurdarchan Kaur wife of the appellant was also covered in this medi-claim policy.
2. It was further pleaded that on 9.9.2002 the appellant felt palpitation and he consulted Dr. R.K. Tuli. The appellant was advised to consult either the Escorts Hospital at New Delhi or Fortis Heart Centre, SAS Nagar, Mohali. The appellant consulted Fortis Heart Centre, SAS Nagar, Mohali. He was admitted in the Hospital on 27.9.2002 and was operated on 4.10.2002 for Aortic Valve First Appeal No.1052 of 2004. 2 replacement and Mitral Valve repair. He was discharged from the Hospital on 11.10.2002. He was not having any medical problem prior to 9.9.2002.
3. It was further pleaded that the son of the appellant had given due intimation to the respondents about the admission of the appellant vide letters dated 8.10.2002 and 30.10.2002. The appellant had incurred a sum of Rs.3,26,450/-. Insurance claim was lodged with the respondents. It was repudiated.
4. Alleging deficiency in service on the part of the respondents, the appellant filed the complaint in the District Consumer Disputes Redressal Forum, Amritsar (in short "District Forum") for recovery of Rs.3,00,000/- towards the medi-claim policy. Compensation, interest and costs were also prayed.
5. The respondents filed the written reply. It was admitted that the appellant had taken the medi-claim policy for an amount of Rs.3,00,000/- which was valid for the period from 10.6.2002 to 9.6.2003. The parties, however, are bound by the terms and conditions of the insurance policy.
6. It was further pleaded that the appellant was suffering from the heart disease prior to the taking of the mediclaim insurance policy but this fact was kept concealed by him while filling the proposal form. Therefore the repudiation of the insurance claim was legal and valid. Dismissal of the complaint was prayed.
7. Paramjit Singh Dhingra appellant filed his affidavit as Ex.C-1. He also proved documents Ex.C-2 to Ex.C-14. On the other hand, the respondents filed the affidavit of R.K. Dhupper, Divisional Manager as Ex.R-1 and the affidavit of Dr. P.S. Chhabra as Ex.R-2. They also proved documents Ex.R-3 to Ex.R-7 and Ex.R-9. They also filed the affidavit of Dr. Ved Kumar Gupta Ex.R-8.
8. After considering the pleadings of the parties and the affidavits/documents placed on file by them, the learned District Forum dismissed the complaint vide impugned judgment dated 14.7.2004.
9. Hence the appeal.
10. The submission of the learned counsel for the appellant was that the appeal be accepted and the impugned judgment dated 14.7.2004 be set aside. First Appeal No.1052 of 2004. 3
11. On the other hand, the submission of the learned counsel for the respondents was that there was no merit in the present appeal and the same be dismissed.
12. Record has been perused. Submissions have been considered.
13. The undisputed facts are that the appellant had taken the medi-claim policy for an amount of Rs.3,00,000/- from the respondents which was valid for the period from 10.6.2002 to 9.6.2003.
14. It was also not disputed that the appellant was admitted in Fortis Heart Institute & Multi-Speciality Hospital, SAS Nagar, Mohali (in short "the Hospital") on 27.9.2002 and he was operated upon on 4.10.2002 for Aortic Valve replacement and Mitral Valve repair. He was discharged on 11.10.2002.
15. The version of the respondents is that the appellant was suffering from heart disease prior to the taking of the mediclaim policy and this fact was kept concealed by him while filling the proposal form.
16. The appellant has placed on the file the certificate dated 23.9.2003 Ex.C-7 issued by the Fortis Hospital to the effect that Shri P.S. Dhingra had undergone AVR (Aortic Valve Replacement) on 4.10.2003. He was admitted on 27.9.2002 and was discharged on 11.10.2002. It was further certified by the doctor in the said certificate dated 23.9.2003 Ex.C7 that the patient had severe aortic regurgitation with endocarditis and it could have happened to any patient without any prior knowledge of the person concerned.
17. The appellant also placed on the file the discharge summary dated 11.10.2002 Ex.C-14 in which the present and past clinical history of the appellant was given as under:-
"PRESENT CLINICAL HISTORY:
61 YRS pleasant male from Amritsar not a known case of HTN/DM/CAD presented with complaints of few episode of brief syncol attack on 9th Sept. He also complaints of palpitations for same period. Than onward symptoms were on First Appeal No.1052 of 2004. 4 and off. No history of fever, CHF, hemoptysis, bleeding disorders. No history of fatigue/dyspnoea. No history of any other medical ailments. On examination he was conscious oriented, Hemodynamically stable but in AF with irregular pulse and BP of 110/70 mm hg. Cvs exam revealed diastolic murmur in aortic area. Echo showed RHD with bicuspid aortic valve with severe AR and he was advised for valve replacement surgery.
PAST HISTORY:
H/o drug allergy with brufen and sulpha medication present."
18. On the other hand, the respondents have filed the affidavit of Dr. P.S. Chhabra, Proprietor, Chhabra Nursing Home as Ex.R-2. This witness has also examined Paramjit Singh Dhingra appellant and has also examined the medical record of the appellant from the Hospital. He deposed that the disease of the appellant was pre-existing.
19. However the respondents have not placed on the file any document of prior date than the date of proposal form to show if the disease of the appellant was pre-
existing or if the appellant had got medical treatment prior to the filling of the proposal form on 10.6.2002. No document of the Hospital was filed according to which the disease of the appellant existed prior to 10.6.2002.
20. It may be that the appellant has manipulated with the hospital authorities and concealed the past history of his disease but this Commission cannot deliver the judgment on the basis of assumptions and presumptions. The respondents were legally bound to prove that the disease was existed prior to the filling of the proposal form on 10.6.2002 and this fact was kept concealed by the appellant while filling the proposal form. The respondents have miserably failed to produce any plausible document on the file to show if the appellant was suffering from First Appeal No.1052 of 2004. 5 heart ailment prior to the filling of the proposal form or if he had taken any medical treatment prior to that.
21. In view of the discussion held above, this appeal is accepted and the impugned judgment dated 14.7.2004 is set aside. The respondents are directed to pay the insurance amount of Rs.3,00,000/- to the appellant. In the facts and circumstances of the case interest is declined. Compliance of this order shall be made by the respondents within a period of two months from the date of receipt of a copy of this order failing which this amount shall be payable by the respondents to the appellant with interest at the rate of 7.5% per annum with effect from today till the date of payment.
22. The arguments were heard in this case on 11.3.2010 and the order was reserved. Now, the order be communicated to the parties.
23. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE S.N. AGGARWAL)
PRESIDENT
( MRS.AMARPREET SHARMA )
March 25, 2010 MEMBER
Bansal