National Consumer Disputes Redressal
United India Insurance Co. Ltd. vs Krishna Prakash Dubey on 29 July, 2011
OP 10/1998 NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 3026 OF 2010 [Against the order dated 22.05.2010 in Appeal No. 379/2010 of the M.P. State Consumer Disputes Redressal Commission] United India Insurance Co. Ltd. Regional Office, Paryavas Bhawan Arera Hills, Bhopal Through its Regional Office-I, Kanchanjunga Barakhamba Road New Delhi Petitioner Versus Krishna Prakash Dubey S/o Late Shri B.L. Dubey R/o Omkar 1369, Dayanagar Gadha Road Jabalpur (M.P.) Respondent BEFORE : HONBLE MR. JUSTICE R.C. JAIN, PRESIDING MEMBER HONBLE MR. S.K. NAIK, MEMBERS Appearance : For the Petitioner : Mr. Ravi Bakshi, Advocate For the Respondent : In person Pronounced on : 29th July, 2011 O R D E R
PER S.K. NAIK, MEMBER This revision petition arises in the backdrop of both the fora below i.e. the District Consumer Disputes Redressal Forum, Jabalpur, M.P. (for short the District Forum) and the M.P. State Consumer Disputes Redressal Commission (for short the State Commission) having delivered a concurrent finding and order admitting the insurance claim on account of the respondent-complainant having availed treatment at the Asian Heart Institute, Mumbai. United India Insurance Co. Ltd., the petitioner-opposite party, is aggrieved by these orders and have filed this revision petition to challenge their findings.
Briefly stated, the respondent-complainant obtained a mediclaim policy, which was valid from 23rd of July, 2007 to 22nd of July, 2008. He while on tour on 26th of July, 2007 to Mumbai suddenly developed pain in his chest and jaw and consulted one Dr. Anil K. Sharma, physician, who though prescribed Dispirin for the relief of his pain appears to have advised him to consult a cardiologist. On the 28th of July, 2007, he approached the Asian Heart Institute, Mumbai, where angiography was conducted, on the basis of which he was admitted in the said institute for coronary artery bypass surgery and was discharged on the 13th of August, 2007. On the strength of the mediclaim insurance policy, he preferred a claim for Rs.3,10,877/-, which was repudiated by the petitioner-Insurance Company under Exclusion Clause 4.2 of the terms and conditions of their policy. This forced the respondent to file a complaint before the District Forum, who, on appreciation of the evidence of the parties, rejected the contention of the petitioner-Insurance Company that the case of the complainant was covered under the Exclusion Clause 4.2 and directed them to pay the complainant the amount admissible under the terms and conditions of the policy and further awarded a sum of Rs.1000/- as compensation and another Rs.1000/- towards litigation expenses. Aggrieved thereupon, the petitioner-Insurance Company filed an appeal before the State Commission, who dismissed their appeal and affirmed the order of the District Forum. Yet dissatisfied with the orders so passed, the Insurance Company has preferred this revision petition.
We have heard Shri Ravi Bakshi, learned counsel appearing on behalf of the petitioner-United India Insurance Co. Ltd. and Shri Krishna Prakash Dubey, the respondent-complainant who has appeared in person. Shri Bakshi has submitted that respondent-complainant had obtained a policy on the 23rd of July, 2007 and within a few days thereafter on the 28th of July, 2007 was admitted to the Asian Heart Institute, Mumbai for a major surgery of coronary artery bypass. Contending that such a major medical problem would not have cropped up all of a sudden, he submits that the respondent-complainant must have been aware of the same at the time of obtaining the policy. In this regard, he has referred to the opinion of Dr. R.K. Bisarya, who is on the experts panel of the Insurance Company, to fortify his argument. Dr. Bisarya in his opinion has contended that the disease of the complainant had advanced so much that he needed bypass grafting to three arteries in the heart. According to him, it would have taken a long time to reach this stage and, therefore, it was a case of pre-existing disease. Learned counsel referring to Exclusion Clause 4.1 of the policy, therefore, forcefully argues that the medical problem was fully within the knowledge of the respondent-complainant at the time of taking the policy and the treatment having been obtained within 30 days of the taking of the policy, the claim had been rightly repudiated. He, therefore, prays for the setting aside the orders of fora below.
The respondent-complainant on the other hand has contended that both the fora below have arrived at the concurrent finding of facts and have held that he was fully covered under the mediclaim policy and is entitled to reimbursement of the medical expenses. The objective under the Consumer Protection Act, 1986 being better protection to the consumers and it being a piece of legislation for social benefit, this Commission should not interfere at the stage of revision. He prays for the dismissal of the revision petition.
Having heard the parties, we have given our thoughtful consideration to the matter. The main ground on which the learned counsel for the petitioner-Insurance Company seeks to assail the orders passed by the fora below hinges on close proximity of the disease with the commencement of the insurance cover as it was contracted within first 30 days of obtaining the policy. According to him, the case is fully covered under Exclusion Clause 4.2 of the policy. The said clause reads as under :-
4.2 Any disease other than those stated in clause 4.3 contracted by the Insured person during the first 30 days from the commencement date of the policy. This condition 4.2 shall not however, apply in case of the insured person having been covered under this Scheme or Group Insurance Scheme with any of the Indian Insurance Company for a continuous period of preceding 12 months without any break.
(Note :
These exclusions 4.1 and 4.2 shall not however apply if:
a. In the opinion of a Panel of Medical practitioner constituted by the Company for the purpose, the Insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company.
b. The insured had not taken any consultation, treatment or medication, in respect of the hospitalization for which claim has been lodged under the policy prior to taking the insurance.
No doubt, as per this clause a person would not be entitled to indemnification if he contracts the disease as stated during the first 30 days from the commencement of the date of the policy but the note which has the effect of a proviso; clearly states that the exclusion clause will not apply if in the opinion of a panel of medical practitioner constituted by the Company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company and further it would also not apply if the insured had not taken any consultation, treatment or medication in respect of the hospitalization for which claim has been lodged under the policy prior to the taking of the insurance policy. Learned counsel would have us believe that the opinion rendered by their panel doctor i.e. Dr. R.K. Bisarya was sufficient proof that the respondent-complainant was aware of the existence of the disease. Both the fora below have, in our view, rightly not given full credit to the said report of Dr. Bisarya, as it could be a self-serving report as the said doctor is on the panel of the petitioner-Insurance Company. There is no other independent opinion or evidence from the medical literature to corroborate his opinion.
The petitioner-Insurance Company has not been able to produce any evidence other than the opinion of their panel doctor to prove that the respondent-complainant was aware of his health problem prior to the taking of the policy and had consulted any doctor/hospital/nursing home in that regard. With the unlimited resources at their command it was not difficult for the petitioner/Insurance Company to have investigated the claim if really the respondent-complainant had undergone any test or treatment with regard to this ailment at Jabalpur prior to his visit to Mumbai. The plea of the respondent-complainant not having produced the prescription of Dr. Sharma too would not cut much ice as he appears to have only prescribed a painkiller for the ache in the chest and jaw of the respondent-complainant and advised him to consult a cardiologist. Nowhere it has been stated by the treating hospital that the respondent-complainant had prior history of any heart ailment. On the contrary, medical literature on cardiac arrest and sudden cardiac death on page 1709 of Harrisons Internal Medicine 17th Edition states that Approximately 50% of all cardiac deaths are sudden and unexpected. The plea of proximation of the incident to the date of the insurance cover, therefore, will give no support to the petitioner-Insurance Company. The burden to prove that the respondent-complainant had any prior knowledge about his medical problem was squarely on the petitioner-Insurance Company, who, in our view, have not been able to discharge the same satisfactorily.
Under the circumstances, we do not find that the fora below have committed any illegality, material irregularity or jurisdictional error in arriving at the findings that they have. The revision petition, accordingly, is dismissed with no order as to costs.
Sd/-
( R. C. JAIN, J. ) PRESIDING MEMBER Sd/-
(S.K. NAIK) (MEMBER) Mukesh