National Consumer Disputes Redressal
National Insurance Company Limited vs Shiv Charan Gupta & Anr. on 18 May, 2017
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 399 OF 2017 (Against the Order dated 08/11/2016 in Appeal No. 342/2015 of the State Commission Haryana) 1. NATIONAL INSURANCE COMPANY LIMITED THROUGH ASSTT. MANAGER, NATIONAL INSURANCE COMPANY LTD. NATIONAL LEGAL VERTICAL, 2E/9, JHANDEWALAN EXT. NEW DELHI-110055 ...........Petitioner(s) Versus 1. SHIV CHARAN GUPTA & ANR. R/O. H.NO. 222, WARD NO. 9, KUKMHARWARA OLD FARIDABAD HARYANA 2. M/S. VIPUT MEDCORP PVT. LTD. 515, UDYOG VIHAR PHASE V, GURGAON HARYANA ...........Respondent(s)
BEFORE: HON'BLE MR. DR. S.M. KANTIKAR,PRESIDING MEMBER
For the Petitioner : Ms. Sonia Sharma, Advocate For the Respondent :
Dated : 18 May 2017 ORDER
1. The whole controversy swirls around the issue 'whether the circumstantial ground will absolve the insurance company from the liability of insurance claim in absence of production of proposal form ?"
2. Mr. Shiv Charan Gupta, the complainant took insurance policy from National Insurance Co. Ltd. During the subsistence of the policy, on 23.1.2006, he underwent hip replacement in G. M. Modi Hospital, Delhi. He was hospitalised from 22.1.2006 to 29.1.2006 and spent Rs.1,72,648/-. The policy was renewed and again, he was operated for hip joint at the same hospital and spent Rs.1,63,641/-. He was admitted there from 04.04.2007 to 10.04.2007. The complainant submitted the claim with bills to the OPs but the claim was repudiated stating that his case was covered by exclusion clause 4.1. of Medi-claim policy. Hence, the complainant filed a complaint before the District Forum, Faridabad.
3. The District Forum allowed the complaint and directed the OPs to pay Rs.1,63,641/- with interest @ 9% p.a. from the date of filing the complaint, also awarded compensation of Rs.5500/- and Rs.2200/- as litigation charges.
4. The OP preferred first appeal before the State Commission, Haryana. It was dismissed.
5. Learned counsel, Smt. Sonia Sharma for the petitioner argued that it was a pre-existing disease. She brought my attention to the G. M. Modi Hospital Discharge Summary, which reveals as "Known case of Avascular necrosis femoral head with secondary osteoarthritis"
6. It is the onus upon the insurance company to prove that the complainant was suffering from the pre-existing disease. Today, counsel expressed that the proposal form is not available. Therefore, the insurance company should consider the other evidences like discharge summary of the hospital. In my view, to ascertain whether the complainant was suffering from pre-existing disease and the material concealment about the status of his health, the proposal form is one of the important documents. In absence of proposal form, it is difficult to conclude whether the complainant concealed the relevant information. Therefore, in my view, the OP failed to prove their contention about pre-existing disease.
7. On the basis of aforesaid discussion, I do not find any merit in the instant revision petition, accordingly, it is dismissed.
...................... DR. S.M. KANTIKAR PRESIDING MEMBER