State Consumer Disputes Redressal Commission
United India Insurance Company Ltd. vs Dr. Anil Kumar Garg on 15 November, 2018
STATE CONSUMER DISPUTES REDRESSAL COMMISSION UTTARAKHAND, DEHRADUN
FIRST APPEAL NO. 106 / 2013
United India Insurance Company Ltd.
Regional Office, Ratan Palace, Kaulagarh Road, Dehradun
Through its Chief Regional Manager
......Appellant / Opposite Parties
Versus
Dr. Anil Kumar Garg S/o Sh. Ramesh Chand Garg
R/o Medical Officer, District Jail
Roshanabad, Haridwar, District Haridwar
.......Respondent / Complainant
Sh. Vaibhav Jain, Holding Brief of Sh. J.K. Jain, Advocate, Learned Counsel for
the Appellant
None for Respondent
Coram: Hon'ble Mr. Justice B.S. Verma, President
Mr. Balveer Prasad, H.J.S., Member
Mrs. Veena Sharma, Member
Dated: 15/11/2018
ORDER
(Per: Mr. Balveer Prasad, Member):
This appeal has been set in motion by the Insurer against the Judgment passed by the District Consumer Disputes Redressal Forum, Haridwar (hereinafter to be referred 'The District Forum') in C.C. No. 29 of 2012; Dr. Anil Kumar Garg vs. United India Insurance Co. Ltd. on 15.03.2013, whereby the complaint was allowed for Rs. 35,000/-, towards medical treatment and damages.
2. The facts relevant for disposal of the appeal, are that the complainant is the consumer of the appellant, having Medi-Claim Insurance Policy since 06.05.1999 and thereby paying the amount of premium regularly. Akash Garg, the son of the complainant, was admitted to Jolly Grant Hospital, as he sustained severe injuries in an accident, which took place on 2 28.09.2011. As a result thereof, the complainant fell down and suffered nervous shock, for which he was also admitted in that Hospital. He was discharged on 04.10.2011 and Rs. 6,391/- were incurred as medical expenses. Thereafter on passing blood in omitting, he contacted Fortis Hospital at New Delhi, got admitted there and had to incur expenses in the sum of Rs. 22,265/-. In this way, the total expenses incurred amounted to Rs. 28,656/-. No payment was made by the Insurance Company, despite requests, thereby causing deficiency in service.
3. By filing objections, the opposite parties stated that the claim is not maintainable. The answering opposite party, vide its letter dated 29.02.2012 conveyed to the complainant, repudiation of claim mentioning therein that only investigations were carried out during hospitalization, which was not followed by any active treatment, therefore, the claim stands non-payable. At Fortis Hospital, the patient was hospitalised as a diagnosed case of Pulmonary Koch's on 14.10.2011, investigated and treated conservatively and discharged on 15.10.2011 with a follow up advice. The brief history as disclosed in the discharged summary mentions him to be a chronic alcoholic and chronic smoker - admitted for Vertigo. Alchohol is the common cause for Vertigo, therefore, claim falls out of the scope of policy and is not payable under Clause 4.8 Vertigo.
4. The District Forum on consideration of the material on record, allowed the complaint in the terms mentioned in the Judgment. Feeling aggrieved, the appellant has come with, projecting the appeal mainly on the grounds that the District Forum overlooked this fact that there was violation of terms and conditions of the insurance policy issued to the complainant. The District Forum erred in holding that there is no nexus between the health policy issued to the complainant and him, being a chain smoker and habitual drinker. The provisions of the Consumer Protection Act have been overlooked in passing the order impugned.
35. Heard learned counsel for the appellant at length. No one did turn up, on behalf of the respondent. Learned counsel for the appellant submitted that the contract of insurance is based on the principle of utmost good faith and the complainant / respondent has violated the same and thus, the conduct of the complainant is not based on bonafide. It was also argued that the order in question is based on conjunctures and surmises and as such, cannot be treated in conformity with the principles of law. Attention of the Bench was invited on the Exclusion Clause 4.8, as given in the policy document and prayed that the matter falls, out of the scope of the policy.
6. Perusal of the record reveals that the fact as to the subsistence of the medi-claim policy is admitted to both the parties. The factum of expenses (amounting to Rs. 28,656/-) incurred is also not in dispute. It is worth to note that the complaint was filed on 31.01.2012 and the objections / written statement was filed on 16.04.2012. The order of repudiation was passed on 29.02.2012, after the institution of complaint case. The claim was repudiated on two grounds stated as under:-
Firstly, that Patient was diagnosed as a diagnosed case of Pulmonary Koch's on 14.10.2011, investigated and treated conservatively and discharged on 15.10.2011 with follow up advice. After going through the claim documents, it was observed that only the investigations were carried out during the hospitalization which was not followed by any active treatment, therefore, the claim is non-payable.
Secondly, that the patient is a chronic alcoholic and chronic smoker, he was admitted with Vertigo, Alchohol is the common cause of vertigo (withdrawal symptom), therefore, the claim falls out of the scope of the Policy and is non-payable under Clause 4.8.4
The Exclusion clause (as worded in Clause 4) contemplates that the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:
4.8 Charges incurred at Hospital or Nursing Home primarily for diagnosis x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home.
7. Dr. Anil Kumar Garg furnished the detailed affidavit, narrating all what is worded in the complaint. Documentary evidence has also been filed in support of the claim. Sh. Sanjay Joshi, Divisional Manager, United India Insurance Co. Ltd. filed affidavit, denying the factum stated by the complainant. No specific denial has been placed on record, questioning the genuineness of the medical records furnished by the complainant. It is worth to observe that the policy is in existence, since 1999 - no question mark has ever been placed on the conduct of the complainant.
8. It transpires from the perusal of the record that the proposal form of the medi-claim policy was filled by the agent of the Insurance Company and the complainant put his signature in good faith, reposing confidence in the agent of the Company. The factum is duly testified on oath by way of affidavit furnished by the complainant. No only this, the expenses incurred by the complainant towards treatment are also testified on oath. All these facts have not been controverted by the opposite parties in written statement, nor in the affidavit furnished on behalf of the Insurance Company. Para 5 of the affidavit given by the complainant pertains to the problem of Typhoid and weakness, for which Fortis Hospital was contacted by him. The Divisional Manager of the Insurance Company deposed "No Comment" on the said point in his affidavit, meaning 5 thereby this fact stands admitted to the opposite parties. In view of these circumstances, the facts as to taking liquor or smoking by the complainant, has no relevance with Typhoid. The ground was not sufficient to repudiate the claim. The Divisional Manager has nowhere stated specifically in his affidavit that the complainant was a chronic smoker or alchoholic.
Hence, for want of evidence, the alleged factum as shown in the photocopy of the discharge summary, cannot been taken as true. In view of these circumstances, we find that the Insurance Company repudiated the claim of the complainant on flimsy grounds in a technical manner.
9. Learned counsel for the appellant referred to the law laid down by Hon'ble National Commission in HDFC Standard Life Insurance Co. Ltd. vs. Smt. Jayalaxmi; 2011 (1) CPR 243 (NC), Revision Petition No. 1712 of 2014, National Insurance Co. Ltd. vs. Ganpatbhai Somabhai Kadia, decided on 19.05.2017, Pradeep Kriplani vs. New India Assurance Co. Ltd.; 2017 (4) CPR (NC) 78 and the law postulated by Hon'ble the Supreme Court of India in Satwant Kaur Sandhu vs. New India Assurance Co. Ltd.; 2009 (5) Supreme 523. We have gone through the rulings cited and placed before us. These rulings add to the volume, but not to the weight of the proposition that where the complainant is guilty of violating the terms and conditions of the policy and has suppressed the material facts, he is not entitled to any relief, whatsoever.
10. Law postulated by Hon'ble Supreme Court deserves special mention in this case. Oriental Ins. Co. Vs. Ozma Shipping Co.; (2009) 9 SCC 159. The Apex Court deprecated repudiation of claims on flimsy grounds and observed as follows:-
"Insurance companies in genuine and bonafide claims of the insured should not adopt the attitude of avoiding payments on one pretext or the other. This attitude puts a serious question mark on the credibility and trustworthiness of the insurance companies. Incidentally by adopting an honest 6 approach and attitude the insurance companies would be able to save enormous litigation costs and the interest liability."
11. Consumer Protection Act, 1986 is a beneficial legislation, manned for the better protection of consumers and the genuine claims should not be repudiated only on hyper-technical grounds and such repudiation on technical ground, is not in the line of the spirit of legislation. A rational approach and not a technical approach is the mandate of law. It is also worth to depict that the 'Soul of law is Equity, not facility for Inequity'. Accordingly, we find that the repudiation of claim by the Insurance Company, is not at all justified in law. The rulings cited on behalf of the appellant, are of no help for the appellant, in the light of the discussion made as above.
12. On careful consideration of the matter, we are of the definite view that the verdict passed by the District Forum, is well founded - No interference is called for and the same is confirmed.
13. Accordingly, appeal is dismissed, with no order as to costs.
(MRS. VEENA SHARMA) (BALVEER PRASAD) (JUSTICE B.S. VERMA)