State Consumer Disputes Redressal Commission
Icici Lombard General Insurance ... vs Jasbir Singh on 31 October, 2013
H.P. STATE CONSUMER DISPUTES REDRESSAL
COMMISSION, SHIMLA.
First Appeal No: 162/2013.
Date of presentation: 28.06.2013.
Date of Decision: 31.10.2013.
.................................................................................
ICICI Lombard General Insurance Company Ltd.,
Branch Office Sahib Complex, Seri Bazar,
Mandi Town, District Mandi, H.P.,
Through its Manager (Legal),
ICICI Lombard General Insurance Company,
SCO 501, Sector 70, Mohali,
District Mohali, Punjab - 160059.
... Appellant
Versus
Jasbir Singh, S/o Harjeet Singh,
R/o House No.140/12, Ram Nagar,
Mandi Town, District Mandi, H.P.
... Respondent
......................................................................................................
Coram
Hon'ble Mr. Justice (Retd.) Surjit Singh, President
Hon'ble Mr. Chander Shekhar Sharma, Member
Hon'ble Mrs. Prem Chauhan, Member.
Whether approved for reporting?1
For the Appellant: Mr. Jagdish Thakur, Advocate.
For the Respondent: Mr. Digvijay Singh, Advocate.
.........................................................................................................
O R D E R:
Justice (Retd.) Surjit Singh, President (Oral) This appeal, under Section 15 of the Consumer Protection Act, 1986, is directed against the order dated 08.05.2013, of learned District 1 Whether reporters of the local papers may be allowed to see the order?
ICICI Lombard General Insurance Co. FA No.162/2013
Versus DOD:31.10.2013
Jasbir Singh
Consumer Disputes Redressal Forum, Mandi,
whereby a complaint, under Section 12 of the Consumer Protection Act, 1986, filed by respondent- Jasbir Singh against the present appellant, has been allowed and a direction is given to the appellant to pay a sum of `2,37,830/- on account of insurance money, with interest at the rate of 9% per annum, from the date of filing of the complaint, to the date of its payment and also to pay `3,000/- on account of compensation and `2,500/- as litigation expenses.
2. Admitted facts are that respondent-Jasbir Singh purchased a health policy from the appellant for his parents, for the period from 20.12.2010 to 19.12.2011. The policy was renewed from 20.12.2011 to 19.12.2012. After the purchase of the policy, father of respondent had some medical problem. He was got medically checked up and it was found that he had heart coronary disease. He was operated upon at National Heart Institute, New Delhi on 15.12.2011. A sum of `2,24,330/- was spent on the treatment at National Heart Institute and another sum of `13,500/- was spent on Angiography at Metro Hospital and Heart Institute, New Delhi. Claim was 2 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh lodged with the appellant for reimbursement of the expenses incurred on the treatment and Angiography, as per terms and conditions of the policy. Appellant initially sanctioned a sum of `1.50 lacs, but later on refused to pay even the said amount of money and repudiated the claim on the ground that father of the appellant had been suffering from Hypertension for the last seven years, which fact he had suppressed while submitting the proposal form. It was stated that suppression of this fact disentitled the respondent to reimbursement in view of clause-1 of Part-III of the Schedule to the policy, as also exclusion clause 3.1 of the Schedule.
3. Appellant then filed a complaint, under Section 12 of the Consumer Protection Act, 1986, seeking a direction to the appellant to pay the insurance money with interest and also to pay compensation and litigation expenses.
4. Complaint was contested by the appellant. It was stated that the District Forum did not have the jurisdiction to entertain the complaint, as the policy was issued at Bombay. On merits, it was stated that the appellant was guilty of suppression of material 3 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh facts, which disentitled him to seek indemnification in view of clause-1 of Part-III of the Schedule to the policy and exclusion clause 3.1 of Part-II of the same schedule. Learned District Forum, vide impugned order, has allowed the complaint and directed the appellant to reimburse `2,37,830/-.
5. We have heard learned counsel for the parties and gone through the record.
6. Clause-1 of Part-III of the Schedule to the policy as also clause 3.1 of Part-II of the Schedule, relying upon which the claim has been repudiated, are reproduced below for ready reference:
"PART III OF THE SCHEDULE Standard Terms and Conditions
1. Incontestability and Duty of Disclosure The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or on non-disclosure in any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or a claim being fraudulent or any fraudulent means or devices being used by the insured or any one acting on 4 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh his behalf to obtain any benefit under this policy.
PART II OF THE SCHEDULE
3. Exclusions 3.1 Any pre-existing illness. The claims arising on account of or in connection with any Pre-existing illness shall be excluded from the scope of cover under the policy. This exclusion shall cease to apply subject to the exclusions mentioned in sub-clause 3.4 herein below, if the Insured has taken a Healthcare Policy from the Company and has been covered under the Policy, without a break, for a period of four consecutive years immediately preceding the Period of Insurance. Notwithstanding the foregoing, Permanent Exclusions as mentioned under sub-clause 3.4 herein below shall not be covered under this Policy in any case."
7. Case of the appellant is that father of the respondent/complainant was suffering from Hypertension for the last seven years and this fact he did not disclose in the proposal form, Annexure R3. In the proposal form, it is mentioned that the policy was under 'B' plan. Below the column pertaining to name of pre-existing diseases, surgery/symptoms, letters 'N.A.' denoting 'Not Applicable' are written. Learned 5 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh counsel representing the appellant submits that by writing letters 'N.A.', respondent conveyed that his father was not suffering from any pre-existing disease etc. Submission may not be correct. Age of the father of the appellant was 56 years. Policy was purchased under plan 'B'. Literature of plan 'B' is not available on record. Respondent very categorically stated that since the policy was under plan 'B', medical examination of his parents was got done by the Insurance Company, i.e. the appellant, and in the case of his father, he was found to be suffering from diabetes as also Hypertension in the course of such medical examination. It is in the background of this plea of the respondent that letters 'N.A.' are to be read and construed. When so read and construed, they would mean that since the subject of the policy was to be medically examined, there was no need for detailing the pre-existing medical condition in the proposal form.
8. It is made out from the insurance policy itself that father of the respondent had been got medically examined because in the policy, copy Annexure C-1, it is mentioned that father of the 6 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh respondent was suffering from diabetes. In the proposal form, Annexure R3, there is no reference even to the disease of diabetes. The fact that this disease finds mention in the policy, Annexure C-1, suggests that that disease was noted down in the policy from the record of the medical examination. That record has been withheld by the appellant for the reasons best known to it. It is quite likely that the said record has some statements/declarations by the respondent or his father with regard to his state of health and medical condition and even to the disease of Hypertension.
9. Appellant is liable to an adverse inference for withholding the said record. Above stated position apart, Hypertension has been held to be a life style disease and easily controllable with conservative medicines, by the Hon'ble National Consumer Disputes Redressal Commission in Bajaj Allianz General Insurance Co. Ltd. vs. Valsa Jose, IV (2012) CPJ 839 (NC). In the said precedent, claim was repudiated on the ground that the fact of the person, whose health was insured, being a patient of Hypertension, had been suppressed. The Hon'ble National Commission 7 ICICI Lombard General Insurance Co. FA No.162/2013 Versus DOD:31.10.2013 Jasbir Singh held that repudiation was not justifiable as Hypertension is a life style disease easily controllable by conservative medication.
10. In view of the above stated position, appeal is dismissed.
11. A copy of this order be sent to each of the parties, free of cost, as per Rules.
(Justice Surjit Singh) President (Chander Shekhar Sharma) Member (Prem Chauhan) Member October 31, 2013.
DC Dhiman) 8