State Consumer Disputes Redressal Commission
Uiic vs Shashi on 18 October, 2010
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SCO NOS.3009-12, SECTOR 22-D, CHANDIGARH.
First Appeal No.1132 of 2005
Date of institution: 01.09.2005
Date of decision : 18.10.2010
United India Insurance Company Limited, 36 Feroze Gandhi Market, Ludhiana
through its Manager.
.....Appellants
Versus
1. Smt.Shashi w/o Ashwani Kumar;
2. Sh.Ashwani Kumar;
Both residents of 479-A, Model Town Extension, Ludhiana.
.....Respondents
First Appeal against the order dated 08.07.2005
passed by the District Consumer Disputes
Redressal Forum, Ludhiana.
Before:-
Hon'ble Mr.Justice S.N.Aggarwal, President
Lt.Col.Darshan Singh (Retd.), Member
Mrs.Amarpreet Sharma, Member Present:-
For the appellant : Shri Vinod Gupta, Advocate
For the respondents : None
JUSTICE S.N.AGGARWAL, PRESIDENT
The respondents had taken the mediclaim policy from the appellants with hospitalisation and domiciliary hospitalisation benefits. It was valid for the period from 4.5.2001 to 3.5.2002. The respondents were insured for an amount of Rs.3 lakhs each.
2. It was further pleaded that Mrs.Shashi respondent No.1 was having recurrent stomach pain. She was referred to Rajiv Gandhi Cancer Hospital, Institute & Research Centre, Rohini, New Delhi (in short "the Rajiv Gandhi Hospital"). She was admitted in this hospital on 16.02.2002. Her disease was diagnosed to be Recurrent Carcinoma Cervix in bladder. She was operated for First Appeal No.1132 of 2005 2 Anterior Exanteration with ILEAL Conduit on 18.02.2002. She was discharged from the Rajiv Gandhi Hospital on 4.3.2002.
3. It was further pleaded that the appellants were informed about the admission of respondent No.1 in the said hospital vide letters dated 5.3.2002 and 7.3.2002. Thereafter, the claim for Rs.2,14,681.60 was submitted vide letter dated 19.03.2002. It was received by the appellants on 22.03.2002.
4. It was further pleaded that respondent No.1 was again admitted in Rajiv Gandhi Hospital on 14.3.2002 and she was discharged on 19.03.2002 for the same disease. She spent an amount of Rs.28,120.65 for the treatment from 14.3.2002 to 19.03.2002. The additional claim for this amount of Rs.28,120.65 was submitted to the appellants vide letter dated 9.4.2002. The said claim was repudiated by the appellants vide letter dated 14.5.2002 on the plea that the disease of respondent No.1 was pre-existing. Hence, the complaint for recovery of the mediclaim expenditure. Compensation, interest and costs were also prayed.
5. The appellants filed the written reply. It was denied if the respondents were taking the mediclaim policy from the appellants for the last 4-5 years. They were intentionally changing from one insurance company to another and from one office to another for getting the mediclaim policies. They had also obtained false claim under the mediclaim policy.
6. It was further pleaded that respondent No.1 was suffering from the disease for the last more than 14 years. The mediclaim record revealed that she had remained under medical treatment of various hospitals. The disease of respondent No.1 was pre-existing and she had taken the mediclaim policy by concealing these facts. The Discharge Summary dated 4.3.2002 and 19.3.2002 issued by Rajiv Gandhi Hospital revealed that respondent No.1 was hypertensive and non-diabetic lady. She was a known case of hypothyroid on Eltroxin and on antidepressants for 14 years. She had gone to the Rajiv Gandhi Hospital with the complaint of post coital bleeding. She was subjected to 45 gy of EBRT in 20 frs from 2.6.2000 to 28.6.2000. The discharge summary displayed that the admission First Appeal No.1132 of 2005 3 took place on different dates such as 10.7.2000 to 11.7.2000, 13.7.2000 to 14.7.2000, 19.7.2000 to 20.7.2000 and 31.7.2000 to 1.9.2000.
7. It was further pleaded that on receiving the information from the respondents, the appellants had deputed Dr.Pankaj Bhalla for medical opinion who vide his report dated 30.4.2002 reported that the disease of respondent No.1 was pre-existing in May, 2000 and therefore, it was not payable under the exclusion Clause 4.1. Accordingly, it was repudiated by the appellants vide letter dated 14.5.2002. The repudiation was legal and valid. Dismissal of the complaint was prayed.
8. Shashi respondent No.1 filed her affidavit dated 5.11.2003. She also proved documents Ex.C1 to Ex.C23. Ashwani Kumar respondent No.2 also filed his affidavit dated 4.11.2003. On the other hand, the appellants filed the affidavit of Dinesh Sekhri, Senior Divisional Manager as Ex.RW1/A and the affidavit of Dr.Pankaj Bhalla as Ex.RW2/A. The appellants also proved documents Ex.R1 to Ex.R8.
9. The learned District Forum accepted the complaint vide impugned order dated 8.7.2005 and the appellants were directed to adjudicate the claim of respondent No.1 in accordance with the terms and conditions of the mediclaim policy.
10. Hence, the appeal.
11. The submission of the learned counsel for the appellants was that the appeal be accepted and the impugned judgment dated 8.7.2005 be set aside.
12. Record has been perused. Submissions have been considered.
13. Admittedly, the respondents had taken the mediclaim insurance policy from the appellants for the period from 4.5.2001 to 3.5.2002 for an amount of Rs.3 lakhs. This fact is not denied by the appellants in the written statement.
14. It was, however, denied by the appellants if the respondents had been taking the mediclaim policy from the appellants for the last more than 4-5 years. The respondents have also not placed on the file any document to show if First Appeal No.1132 of 2005 4 they had been taking the mediclaim insurance policy from the appellants for that period. However, the documents placed on the file by the respondents revealed that the mediclaim policy for the period from 4.5.2000 to 3.5.2001 was taken by them from the appellants prior to the mediclaim insurance policy for the period from 4.5.2001 to 3.5.2002.
15. The appellants have placed on the file the affidavit of Dr.Pankaj Bhalla as Ex.RW2/A and his report Ex.R1. In his report Ex.R1, Dr.Pankaj Bhalla has reported that the disease of respondent No.1 was pre-existing. However, there is no evidence if respondent No.1 had taken any medical treatment from Dr.Pankaj Bhalla. His report is based only on the documents. Therefore, no reliance can be placed on the report and the affidavit of Dr.Pankaj Bhalla.
16. The appellants have also placed on the file the discharge summary of respondent No.1 from Rajiv Gandhi Hospital dated 4.3.2002 as Ex.R7. They have also produced the other discharge summary dated 19.3.2002 as Ex.R8. The brief summary of this case has been given by the Rajiv Gandhi Hospital as under : -
"BRIEF SUMMARY OF THE CASE :
Patient Shashi, is a 39 years old lady, hypertensive and nondiabetic. She is a known case of hypothyroidism and on regular treatment with Eltroxin. For the last 14 years and is on antidepressants for depressive illness. She presented first at this institute with RT in May, 2000 with complaint of post coital bleeding. She was subjected to 45 Gy of EBRT in 20 frs from 2/6/2000 to 28/6/2000 and also received two sessions of ICRT. Along with RT she also received 3cycles of chemotherapy.
Patient was apparently alright after that till December, 2001 when she started with haematuria, cystoscopy done on 8/2/2002 revealed features suggestive of First Appeal No.1132 of 2005 5 radiation cystitis. Biopsy taken from suspicious areas, during the procedure revealed features of metastatic squamous cell carcinoma with infiltration of the wall of the bladder.
Patient was optimized for surgery. She underwent anterior exenteration with ileal conduit formation on 18/2/2002. Postoperative stay of the patient in hospital was uneventful and she made a smooth recovery. Her condition at the time of discharge is satisfactory. The HP Report of the excised specimen is mentioned at the end of the summary.
PLAN- Regular follow up."
17. As per this document, Shashi respondent No.1 had taken 3 cycles of Chemotherapy when she remained admitted in Rajiv Gandhi Hospital for the period from 2.6.2000 to 28.6.2000. She had gone to Rajiv Gandhi Hospital in May, 2000 but the specific date of the month of May is not mentioned. Therefore, it cannot be held if the disease of respondent No.1 was existing even prior to 4.5.2000. The words, 'May, 2000' would mean either after 4th of May, 2000 or even before May, 2000.
18. The settled law is that if two interpretations are possible, the one in favour of the consumer should be taken. In these circumstances, we hold that the appellants have not proved if the disease of respondent No.1 was pre-existing i.e. prior to 4.5.2000 when the mediclaim policy was taken by the respondents for the first time.
19. Moreover, if respondent No.1 had taken the mediclaim for an amount of Rs.1,51,056/- from the appellants during the insurance period from 4.5.2000 to 3.5.2001, then the appellants could have refused to renew the mediclaim policy for the period from 4.5.2001 to 3.5.2002 but knowing well that the respondents had taken a huge amount by way of mediclaim, the appellants First Appeal No.1132 of 2005 6 have issued the insurance policy. Therefore, now they cannot allege that the disease of respondent No.1 was pre-existing.
20. In view of the above discussions, we find no merit in the present appeal and the same is dismissed.
21. The appellants had deposited an amount of Rs.25,000/- with this Commission at the time of filing of the appeal on 1.9.2005. The refund order of this amount would be passed after the appellants decide the mediclaim of the respondents.
22. The arguments in this appeal were heard on 14.10.2010 and the order was reserved. Now the order be communicated to the parties.
23. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(JUSTICE S.N.AGGARWAL) PRESIDENT (LT.COL.DARSHAN SINGH(RETD.) MEMBER (AMARPREET SHARMA) MEMBER October 18f, 2010.
Paritosh