State Consumer Disputes Redressal Commission
United India Insurance Company Ltd. ... vs 1.Kuldip Kumar Son Of Shri Sawan Ram, R/O ... on 20 July, 2012
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA First Appeal No.423 of 2011 Date of Institution: 24.03.2011 Date of Decision: 20.07.2012 United India Insurance Company Ltd. Regional Office, SCO 123-124, Sector 17-B, Chandigarh through its duly constituted attorney Sh. Anil Kakkar, Dy. Manager. Appellant (OP-1) Versus 1. Kuldip Kumar son of Shri Sawan Ram, R/o 166/1, Subhash Gali, Do Khamba Chowk, Ambala City. Respondent (Complainant) 2. Family Health Plan Ltd., SCO 58-59, Sector 34-A, Chandigarh through its Manager. Respondent (OP-2) BEFORE: Honble Mr. Justice R.S. Madan, President. Dr. Rekha Sharma, Member. For the Parties: Shri P.S. Saini, Advocate for appellant. Shri Sharad Aggarwal, Advocate for respondent No.1. Respondent No.2 exparte. O R D E R
Justice R.S. Madan, President:
This appeal has been preferred against the order dated 04.02.2011 passed by District Consumer Forum, Ambala whereby complaint filed by complainant (respondent No.1 herein) against the appellant-opposite parties seeking direction to pay the insurable benefits in respect of medi-claim policy was accepted by granting following relief:-
..the Ops are hereby directed to comply with the following directions within a period of 30 days from the receipt of this order:
i) To pay the claim of the complainant.
ii) To pay Rs.3000/- as litigation charges.
If the order is not complied within the stipulated period then the complainant will be entitled to interest @ 7.5% P.A. w.e.f. the date of filing of complaint till its actual realization.
The case of the complainant before the District Consumer Forum was that he had taken medi-claim Insurance Policy from the opposite parties w.e.f. 31.03.2007 to 31.03.2007 for Rs.1,00,000/- and thereafter the policy was renewed w.e.f. 31.3.2007. After getting the renewal of the policy, the complainant suffered from disease CAD USA and remained in NHPIMER, Chandigarh and he was discharged on 21.05.2007. According to the complainant he incurred Rs.3 lacs on his treatment. However, the claim submitted by the complainant was repudiated on the ground that the complainant was suffering from pre-existing disease and therefore the claim of the complainant falls under exclusion clause.
Challenging the repudiation of his claim, the complainant invoked the jurisdiction of the District Forum by filing complaint which on having been contested by the opposite parties on the above stated ground, was accepted by the District Forum by granting relief as noticed in the opening para of this order.
Aggrieved against the order of the District Forum, the appellant- United India Insurance Co.Ltd. has come up in appeal.
We have heard learned counsel for the parties and perused the case file.
On behalf of the appellant it is contended that as per the discharge summary prepared by the concerned treating doctor, the complainant was suffering Cronic Unstable Angina with past history of Hypertension since three years, diabetes mellitus Type-II since 4-5 years on regular treatment with a positive history of Coronary Artery Disease which are primary risk factors for the present condition of the complainant. In support of his argument learned counsel for the appellant has drawn our attention towards the Discharge Summary issued by PGI, Chandigarh (Annexure A-1).
The perusal of the Discharge Summary Annexure A-1, shows that the patient was diagnosed as a case of Coronary Artery Disease, Unstable Angina with Positive TMT, PTCA+A-Proxima LAD done on 19.05.2007. This document proved that the patient was a case of Chronic Unstable Angina with past history of Hypertension for the last three years, Diabetes Mellitus Type-II for the last 4-5 years on regular treatment with a positive family history of Coronary Artery Disease. The above said diseases are primary risk factors for the heart disease. However, the complainant had not disclosed the above stated fact in the proposal form while taking the policy.
It is further contended by the learned counsel for the appellant that as per Clause 4.1 of the Insurance Policy, the claim of the complainant was repudiated vide letter dated 07.09.2007 on the ground that the disease for which the patient had taken treatment, was a pre-existing disease and as such fell outside the scope of the Insurance Policy. In support of his argument learned counsel for the appellant has referred to the Exclusion Clause of the policy, which is reproduced as under:-
4. EXCLUSIONS 4.0 The company shall not be liable to make any payment under this policy in respect on any expenses whatsoever incurred by any insured Person in connection with or in respect of:
4.1 All diseases/injuries which are pre-existing when the cover incepts for the first time.
4.2 x x x x x x 4.3 x x x x x x The perusal of the above mentioned exclusion clause 4.1 clearly shows that the claim of the complainant does not fall within the ambit of the Insurance Policy which was issued to the complainant. Annexure A/1 Discharge Summary of the patient clearly depicts that he was suffering from different diseases prior to the date of obtaining the policy but this fact was not disclosed by him in the proposal form. It is well settled law that contract of insurance is based on good faith and the insured is under an obligation to disclose each and every fact with respect to his/her state of health at the time of submitting the proposal form. It is also well settled law that Treatment Record of hospital is sufficient evidence to prove that the patient was treated by the said doctor/hospital and the same cannot be denied. Reference in this regard is made to case law cited as SATWANT KAUR SANDHU Versus NEW INDIA ASSURANCE COMPANY LIMITED, (2009) 8 Supreme Court Cases 316 wherein the Honble Supreme Court has held that:-
We do not find any substance in the contention of learned counsel for the appellant that reliance could not be placed on the certificate obtained by the respondent from the hospital, where the insured was treated.
The instant case is fully covered by SATWANT KAUR SANDHUs case (Supra). Annexure A-7 Discharge Summary issued from PGIMS, Chandigarh clearly depicts that the patient was suffering from Hypertension since three years, diabetes mellitus Type-II since 4-5 years on regular treatment with a positive history of Coronary Artery Disease which are primary risk factors for the present condition of the complainant. District Consumer Forum has failed to appreciate the above stated evidence and erred in allowing the complaint because no relief can be granted to the complainant beyond the terms and conditions of the Insurance Policy and as per condition No.4.1, complainants claim was not covered under the policy. Hence, the impugned order cannot be allowed to sustain.
For the reasons recorded above, this appeal is accepted, the impugned order is set aside and the complaint is dismissed.
The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal and revision, if any filed in this case.
Announced: (Justice R.S. Madan) 20.07.2012 President (Dr. Rekha Sharma) Member