State Consumer Disputes Redressal Commission
National Insurance Co.Ltd. & Anr. vs Umesh Prasad Verma & Anr. on 2 December, 2015
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION,
PANDRI, RAIPUR (C.G).
Appeal No.FA/15/79
Instituted on : 25.04.2015
1. National Insurance Company Limited,
Through : It's Sr. Divisional Manager,
Divisional Office, Taha Complex, Ring Road - 2.
Vyapar Vihar Road,
Bilaspur District Bilaspur (C.G.) - 495001
2. National Insurance Company Limited,
Through : Its Regional Manager, Nagpur Regional
Office, Mangalam Arcade, IInd Floor,
179-B, Dharampet Extension, North Bazar Road,
Nagpur (Maharashtra)
3. National Insurance Company Limited,
Through : Its Chief Manager,
Chief Office, - 3 Middleton Street,
Kolkata Pin - 700071 ... Appellants.
Vs.
1. Umesh Prasad Verma,
S/o Late Shri Rameshwar Prasad Verma, Age 56 years.
2. J.K. Verma, S/o Umesh Prasad Verma, Aged 31 years,
Both are R/o : Prakash Shitut,
Nagdone Colony, Vyapar Vihar Road,
Bilaspur, District Bilaspur (C.G.) ... Respondents.
PRESENT: -
HON'BLE JUSTICE SHRI R.S.SHARMA, PRESIDENT
HON'BLE MS. HEENA THAKKAR, MEMBER
HON'BLE SHRI NARENDRA GUPTA, MEMBER
COUNSEL FOR THE PARTIES: -
Shri Dashrath Gupta, for the appellants.
Respondent No.2 appeared for the respondents.
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ORDER
Dated : 02/12/2015 PER :- HON'BLE SHRI JUSTICE R.S. SHARMA, PRESIDENT. This appeal is directed against the order dated 02.12.2014, passed by District Consumer Disputes Redressal Forum, Bilaspur (C.G.), (henceforth called "District Forum") in Complaint Case No.CC/102/2014. By the impugned order, the District Forum has allowed the complaint of the respondents (complainants) and directed the appellants (OPs) to pay within a period of one month from the date of order a sum of Rs.2,09,177/-, otherwise interest @ 9% would payable on the above amount till realisation. The respondents (OPs) have further been directed to pay a sum of Rs.20,000/- towards compensation and a sum of Rs.2,000/- as cost of litigation.
2. Briefly stated the facts of the complaint are that the respondent no.2 (complainant No.2) is employed by the appellant No.3 (O.P.No.3) in the appellants Insurance Company as Administrative Officer (Legal) on 25.07.2011, which was effective from 22.08.2011. After confirmation, under the Staff Insurance Scheme, the respondent No.2 (complainant No.2) got the Medi Claim Policy according to which risk up to Rs.2,50,000/- for each complainant was covered. On 05.03.2013, the respondent No.1 (complainant No.1) got admitted in Medica Super Speciality Hospital in Kolkata due to sudden arising heart disease. Respondent No.1 (complainant No.1) was operated on 11.03.2013 in // 3 // which expenses of Rs.2,24,000/- was incurred. Respondent No.2 (complainant No.2) for getting the above amount submitted claim form along with documents before appellant No.1 (O.P.No.1) which was repudiated by the appellant No.1 (O.P.No.1) vide letter dated 26.06.2013 on the ground that there was probability of pre-existing Heart Disease, therefore, the claim was not payable. Subsequently against the repudiation of the claim, the respondents (complainants) raised their objection before the Company Grievance Redressal Forum but the same has not yet been finally decided, therefore, the respondents (complainant) filed consumer complaint before the District Forum and prayed for granting reliefs, as mentioned in the relief clause of the complaint.
3. The appellants (OPs) filed their written statement and pleaded that the claim form submitted along with medical documents was got examined by Doctor Avijit Royzada, (M.D.), who in his report stated that the disease of respondent No.1 (complainant No.1) was "progressive in nature and most probably it can be pre-existing disease" and it was well known to the respondents (complainants). It has further been pleaded that as per terms and condition of the medi- claim Policy claim was repudiated. Appellant No.2 (O.P.No.2) also repudiated the claim of the respondents (complainants) after getting report from the Dr. Rajesh M. Ballal, on the ground of pre-existing // 4 // heart disease. The respondents (complainants) were very well aware about pre-existing disease and therefore, the appellant No.2 (O.P.No.2) reached to the conclusion that claim of the respondents (complainants) was rightly repudiated. The appellants (OPs) in view of their written statement and documents produced in support of their defense prayed for dismissal of the complaint filed by the respondents (complainants).
4. Learned District Forum, after having considered the material placed before it by the parties, allowed the complaint and directed the appellants (OPs) to pay compensation to the respondents (complainants), as mentioned in para 1 of this order.
5. The respondents (complainants) have filed documents. The documents are letter dated 25.07.2013 sent by National Insurance Company Limited to Mr. Jai Kishan Verma, letter datred 03.01.2013 sent by National Insurance Company Limited to Shri Jaikishan Verma regarding Confirmation, Enclosure to Letter dated 02.05.2013 - Annexure 'A' - Revised terms of Group Mediclaim Policy Covering Employees / Retired Employees of GIPSA Member Companies and GIR , Enclosure to Letter Dated 02.05.2013 - Annexure 'B' Revised terms of Group Mediclaim Policy covering the Employees / Retired Employees of GIPSA Member Companies and GIC, Enclosure to letter dated 02.05.2013 Annexure 'C' New Premium Rate Chart, Option Cum // 5 // Enrolment Form issued by National Insurance Company Limited, Nagpur Regional Office, letter dated 10.03.2013 sent by Jaikishan Verma to Shri N. Menmon and Shri Rajesh K. Gupta, bill dated 20.03.2013 issued by Medica Superspeciality Hospital, Kolkata and annexures, Discharge Summary of Medical Super speciality Hospital, Kolkata, operation note of Medica Super Speciality Hospital, Kolkata, Annexure II Claim Form, letter dated 24.06.2013 sent by Mr. Jai Kishan Verma to Mr. N. Menon and Mr. Rajesh K. Gupta, letter dated 26.06.2013 sent by Sr. Divisional Manager, Bilaspur Divisional Office, National Insurance Co. Ltd., letter dated 28.06.2013 sent by J.K. Verma A.O. (Legal) Bilaspur D.O. National Insurance Company Ltd. to Sr. Divisional Manager, Bilaspur D.O. , National Insurance Company Limited, Bilaspur, letter dated 30.07.2013 sent by Divisional Manager, Bilaspur Divisional Office, National Insurance Company Ltd. to Shri J.K. Verma, A.O., Bilaspur D.O., Representation for Grievance dated 29.08.2013 by J.K. Verma, Administrative Officer (Legal) , Acknowledgement, representation for grievance dated 29.10.2013 by J. Verma, Administrative Officer (Legal).
6. The appellants (OPs) have also filed documents. The documents are Departmental Circular No.H.O.PERS/01/2014 issued by National Insurance Co. Ltd., Registered and Head Office, Kolkata, Consolidated Revised terms of Group Mediclaim Policy covering // 6 // Employees / Retired Employees of GIPSA Member Companies and GIC - Re as on 29.11.2013, Terms and conditions of Mediclaim Insurance Policy, prescription slip dated 20.06.2013 of Dr. Avijit Royzada, Sai Baba Heart & Kidney Centre, Bilaspur, Opinion given by Dr. Rajesh M. Ballal on 21.07.2013.
7. In the instant case, the appellants (OPs) have filed an application under Order 41 Rule 27 CPC along with Circular No.PERS-MPL/HO/28/1997 dated 17.11.1997 issued by National Insurance Company Ltd. Calcutta and Circular No.CSPD/949-A6 dated 04.03.1998.
8. We have heard the parties on the application filed by the appellants (OPs) under Order 41 Rule 27 CPC.
9. The appellants (OPs) sought permission to file above documents at the appellate stage as additional evidence.
10. Looking to the facts and circumstances of the case , we find that the above documents which are sought to be filed by the appellants (OPs) at the appellate stage as additional evidence are essential for proper adjudication of the case and if the above documents are taken on record as additional evidence at the appellate stage, it will not cause any prejudice to the respondents (complainants).
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11. Therefore, we allow the application filed by the appellants (OPs) under Order 41 Rule 27 CPC subject t and the above documents are taken on record as additional evidence at the appellate stage.
12. So far as merits of the case is concerned, Shri Dashrath Gupta, learned counsel appearing for the appellants (OPs) has argued that the impugned order of the District Forum, is contrary to the facts mentioned in the written statement of the appellants (OPs) as well as documents available in the record of the District Forum, hence the impugned order is liable to be set aside. He further argued that the impugned order is contrary to law. The District Forum has not properly analyzed the documents filed by the appellants (OPs). He further argued that at the time obtaining insurance policy, the respondent No.1 (complainant No.1) was suffering from disease and he suppressed the material facts. According to the opinion given by Dr. Avijit Royzada, it appears that that pre-existing disease was present, but the respondent No.1 (complainant) did not disclose the above fact in the proposal form and the above facts were suppressed by the insured at the time of making proposal for the insurance, therefore, the respondents (complainants) are not entitled for getting any benefit in respect of the insurance policy in question. The impugned order passed by the District Forum, is erroneous and is liable to be set aside.
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13. The respondent No.2 (complainant No.2) Jaikishan Verma, appearing on behalf of both the respondents has argued that the impugned order passed by the learned District Forum, does not suffer from any infirmity, irregularity or illegality. He further argued that the respondent No.1 (complainant No1) was not suffering from any pre-existing disease prior to submitting proposal form and the insured did not suppress any material facts at the time of making proposal for the insurance. He further argued that the opinion of Dr. Avijit Royzada, is not sufficient to hold that the respondent No.1/ insured was suffering from pre-existing disease. The appellants (OPs) have wrongly repudiated the claim of the respondents (OPs), hence the appeal is liable to be dismissed. He placed reliance on National Insurance Company Limited vs. Raj Narain, 2008 (1) CPR 342 (NC) and Union of India v. Ibrahim Uddin and Anr., 2013 AIR SCW 2752.
14. We have heard learned counsel for both the parties and have also perused the record of the District Forum.
15. The appellants (OPs) repudiated the claim of the respondents (complainant) on the ground that the respondent No.1 (complainant No.1) was having pre-existing disease and he suppressed material facts at the time of obtained insurance policy.
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16. The appellants (OPs) filed documents before the District Forum i.e. opinion given by Dr. Rajesh M. Ballal and report of Dr. Avijit Royzada.
17. In the Circular No.PERS-MPL/HO/28/1997 dated 17.11.1997 issued by National Insurance Company Limited, Calcutta, which has been filed by the appellants (OPs) before us at appellate stage, in which is mentioned thus :-
"4. All pre-existing diseases are to be excluded, when any family member of the insured employee is to be included for the first time. Please refer to our Circular No. PERS/MPL : HO : 22/97 dated 29/07/97."
18. Dr. Rajesh M. Ballal in his opinion dated 21.07.2013 mentioned that "Patient diagnosed as Rheumatic Aortic Stenosis on 17/12/2012. Admitted on 5/3/2013 and Aortic Valve Replacement done on 11/3/2013."
19. According to the respondents (complainants), the Mediclaim Policy was effective from 01.09.2012. According to Dr. Rajesh M. Ballal, the respondent No.1 (complainant No.1) came to him on 17.12.2012 which is after obtaining the Mediclaim Policy. When the respondent No.1 (complainant No.1) contacted Dr. Rajesh M. Ballal, at that time the respondent No.1 (complainant No.1) was not having knowledge regarding his problem. Dr. Avijit Royzada, simply opined that the disease of respondent No.1 (complainant No.1) was // 10 // progressive in nature and most probably it can be pre-existing disease".
20. The burden to prove that the insured had taken medical treatment within period of preceding 12 months and he fraudulently suppressed the same, was on the insurer and mere production of opinion of the Doctor, is not sufficient to prove that the insured was having pre-existing disease and he had suppressed material facts. The burden of proof establishing pre-existing disease and the insured was having knowledge regarding the disease, is on insurer. The documents filed by the appellants (OPs), are not sufficient to prove the pre-existing disease of the respondent No.1 (complainant No.1). Therefore, merely filing the opinion of Dr. Rajesh M. Ballal and report of Dr. Avijit Royzada, are not sufficient to prove that the respondent No.1 (complainant No.1) was having knowledge regarding his pre- existing disease and he malafidely suppressed the above facts from the appellants (OPs) at the time of making proposal for the insurance policy, therefore, the repudiation of the claim of the respondent No.1 (complainant No.1) by the appellants (OPs) on the ground of not disclosing the material information, is erroneous and thus the appellants (OPs) have committed deficiency in service by repudiating the claim on the ground of suppression of material facts, which is not justified.
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21. Thus, in the light of aforesaid discussions, we are of the view that learned District Forum, has not committed irregularity or illegality and the impugned order passed by the District Forum, does not call for any interference by this Commission.
22. Hence, the appeal filed by the appellants (OPs), being devoid of any merits, deserves to be and is hereby dismissed. No order as to the cost of this appeal.
(Justice R.S. Sharma) (Ms. Heena Thakkar) (Narendra Gupta)
President Member Member
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