National Consumer Disputes Redressal
Arun Kumar vs New India Assurane Co. Ltd. & 2 Ors. on 23 September, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 3816 OF 2012 (Against the Order dated 19/07/2012 in Appeal No. 250/2003 of the State Commission Delhi) 1. ARUN KUMAR S/o Late Sh Sham Nath
R/o 12 Shan Nath Marg Civil Lines Delhi - 110054 ...........Petitioner(s) Versus 1. NEW INDIA ASSURANE CO. LTD. & 2 ORS. Divisional Office 712500
Allied Mounts Casa Blanca
No-260,2nd floor
Anna Salai Chennai - 6000002 2. The New India Assurence Co Ltd Head Office, New India Assurence Bldg 87 Mahatma Gandhi Road Fort Bombau - 400001 Maharastra 3. The New India Assurence CO Ltd 7255 Prem nagar Shakti Nagar Chowk Delhi ...........Respondent(s)
BEFORE: HON'BLE DR. B.C. GUPTA,PRESIDING MEMBER HON'BLE MR. PREM NARAIN,MEMBER
For the Petitioner : For the Respondent :
Dated : 23 Sep 2016 ORDER
APPEARED AT THE TIME OF ARGUMENTS
For the Petitioner
:
Ms. Vandana Sharma, Advocate
For the Respondents
:
Mr. P. K. Seth, Advocate
PRONOUNCED ON: 23rd SEPTEMBER 2016
ORDER
PER DR. B.C. GUPTA, PRESIDING MEMBER This revision petition has been filed under section 21(b) of the Consumer Protection Act, 1986, against the impugned order dated 19.07.2012, passed by the Delhi State Consumer Disputes Redressal Commission, (hereinafter referred to as "the State Commission") in Appeal No. A-250/2003, New India Assurance Co. Ltd. & Ors. vs. Arun Kumar, vide which, while allowing the appeal on the ground of suppression of pre-existing disease at the time of obtaining the insurance policy, the order passed by the District Consumer Disputes Redressal Forum on 18.02.2003, allowing the consumer complaint, filed by the present petitioner was set aside.
2. The facts of the case are that the petitioner/complainant has been obtaining the medi-claim policy from the respondent, New India Assurance Company since 1997 and he also subscribed to the Good Health Medi-claim Insurance Plan, offered to the holders of Citibank Credit Card. As stated by the complainant, he suffered from degenerative joint disease in both knees, which was first detected and diagnosed on 20.01.2001. The complainant was hospitalised at Sita Ram Bhartiya Institute of Science and Research, New Delhi on 29.04.2001 and discharged on 30.04.2001. He submitted a claim on 16.06.2001 alongwith relevant documents, giving details of the treatment taken at the hospital and submitted a medical bill of Rs. 38,240.50. However, the Insurance Company repudiated his claim vide letter dated 14.08.2001, saying that as per the medical report, he had been suffering from the said disease for the last 4 to 5 years atleast and hence, the claim was not payable. The complainant filed the consumer complaint in question, seeking directions to the Insurance Company to pay him the amount claimed i.e. Rs. 38,240.50 and litigation cost of Rs. 11,000/- alongwith interest @ 24% per annum till the date of payment of claim.
3. The complaint was contested by the respondent, Insurance Company by filing their written submissions before the District Forum, stating that the complaint was not maintainable at Delhi as the Regional Office of the Insurance Company did not have a branch at Delhi. It was also stated that a contract of insurance was one of uberrima fides, that is of utmost good faith and hence, the claimant should have disclosed true condition about his health at the time of filling the proposal form. There was, therefore, no deficiency in service on the part of the respondent.
4. The District Forum, after taking into account the averments of the parties, allowed the complaint vide their order dated 18.02.2003, in which they stated as follows:-
7. As per the discharge summary (Annexure-C) has been shown history of difficulty in walking for a long time and history of borderline hypertension but not on any medication. Non-disclosure of such problem in the Proposal Form by the complainant can not be blown out of proportion to throw out the case of complainant or to disentitle him to claim the amount from the respondent.
The District Forum directed payment of Rs. 38,240/- to the complainant for his treatment alongwith interest @ 9% per annum, payable from 01.10.2001 till realisation.
5. Being aggrieved against the said order, the Insurance Company challenged the same before the State Commission. The State Commission decided the appeal vide order dated 04.01.2007, which was challenged by the Insurance Company by way of revision petition before this Commission. The said revision petition was allowed vide orders of this Commission on 26.05.2011, and a direction was given to the State Commission to decide the case afresh, after discussing the merits of the case as per law. Vide impugned order dated 19.07.2012, passed in this case and other allied cases, the State Commission set aside the order of the District Forum, taking the plea that the complainant had not disclosed his pre-existing disease at the time of taking the insurance policy. Being aggrieved against the said order, the complainant is before this Commission by way of the present revision petition.
6. During arguments, the learned counsel for the petitioner/complainant stated that the medi-claim policy in question was being continuously taken by the complainant from the Insurance Company since 1997 and was being renewed from year to year. The claim had been wrongly repudiated by the Insurance Company, based on the report of their panel doctors that the nature of the ailment suggested that the complainant should have been suffering from degenerative joint disease for the last 4 to 5 years atleast. The learned counsel stated that the disease of the complainant led to osteoarthritis requiring surgery for which, he was hospitalised and operated upon in the year 2006. The respondents had paid the claim of Rs. 3 lakhs on account of said treatment and a copy of the necessary claim settlement advice dated 10.05.2006 had been placed on record. The Insurance Company should, therefore, have paid the previous claim as well. The learned counsel further stated that since the Insurance Company has been renewing the policy from year to year, they should have allowed the claim in question filed by him.
7. The learned counsel for the respondent Insurance Company, however, stated that the observation made by the District Forum, as reproduced in the preceding paragraphs, supported the version of the Insurance Company that the complainant had not truly disclosed about his state of health, while filing the proposal form. Moreover, vide impugned order, three different cases had been decided, but only in one case, the Revision Petition had been filed. The learned counsel has further drawn attention to the column no. 7 and 8 in the proposal form relating to the existing disease, saying that the same had been left blank, which showed that the complainant had not disclosed anything about the pre-existing disease. The learned counsel has drawn attention to an order passed by Hon'ble Supreme Court in Satwant Kaur Sandhu vs. New India Assurance Company Ltd., reported in 2009 8 SCC 316, stating that it was the duty of the insured to make true and full disclosure of the state of his health, failing which, the claim was not payable.
8. We have examined the entire material on record and given a thoughtful consideration to the arguments advanced before us.
9. The main point for consideration in the present case is whether there has been suppression of any material information on the part of the complainant, while filling up the proposal form submitted to the Insurance Company, which has led to a breach of terms and conditions of the insurance policy. It has been stated in the repudiation letter dated 14.08.2001, sent by the Insurance Company to the complainant as follows:-
"On referring the file to our Company's panel doctor, he has opined that the nature of the ailment suggests that you should have been suffering from the same for 4-5 years atleast."
10. From the above version, it is made out that the opinion given by the panel doctors is based on presumption only that the complainant would have been suffering from degenerative joint disease for the last 4 to 5 years atleast. The said presumption has not been supported by any medical evidence or record, which may indicate that the complainant withheld any material fact about his health condition from the knowledge of the Insurance Company, while making application for getting the policy. It is not denied that the complainant has been taking the insurance policy since the year 1997. It was the bound duty of the Insurance Company to have verified the information given in the proposal form by obtaining suitable expert opinion. In case certain columns in the proposal form were left blank, it was obligatory on the Insurance Company to ask him to fill the required information, before taking decision to issue the insurance policy. It is a matter of grave concern that the Insurance Companies, whether in the public sector or the private sector, do not make any effort to examine the proposal properly or get the necessary verification done, at the time of issuing the policies in question. However, when the claims are filed, minute scrutiny starts at that stage and the claims are repudiated, even for minor lapses on the part of the proposer. In the present case, the discharge summary of Sitaram Bhartiya Hospital stated that the complainant had difficulty in walking for a long time and history of borderline hyper tension, but not on any medication. The District Forum had rightly observed that non-disclosure of such conditions in the proposal form cannot be blown out of proportion, so as to disentitle the complainant from the claim amount from the Insurance Company. We have no reasons to differ with the conclusion arrived at by the State Commission, because the conditions so mentioned in the report of the hospital, do not imply that the complainant was suffering from any serious disease. It is held, therefore, that the claim has been wrongly repudiated by the Insurance Company on the ground of non-disclosure of information about the health conditions in the proposal form.
11. This revision petition is, therefore, ordered to be accepted and the impugned order passed by the State Commission is set aside. The order passed by the District Forum on 18.02.2003 is restored and the Insurance Company is directed to make payment to the complainant within four weeks from today. There shall be no order as to costs.
...................... DR. B.C. GUPTA PRESIDING MEMBER ...................... PREM NARAIN MEMBER