State Consumer Disputes Redressal Commission
Life Insurance Corporation Of India vs Simarjit Kaur on 5 May, 2016
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No.1247 of 2015
Date of institution: 07.12.2015
Date of decision: 05.05.2016
1. Branch Manager, Railway Road, Life Insurance Company of
India, Sri Muktsar Sahib.
2. Regional Manager, Life Insurance Company, Model Town Road,
Jallandhar Division, Jallandhar.
.....Appellants/Opposite Parties
Versus
Smt. Simarjit Kaur wife of Gurjant Singh, resident of House
No.136, Village Chak Saido Ke, Tehsil Jalalabad (W) District
Ferozepur, M No.9855070287.
......Complainant/Respondent
First Appeal against the order dated
19.10.2015 passed by the District
Consumer Disputes Redressal
Forum, Sri Muktsar Sahib.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Sh. Jasbir Singh Gill, Member
Smt. Surinder Pal Kaur, Member
Present:-
For the appellant : Sh. Sandeep Bhardwaj, Advocate
For the respondent : Sh. A.S. Saini, Advocate
MRS. SURINDER PAL KAUR, MEMBER
ORDER
Appellants/OPs (hereinafter referred as the ('OPs' ) have filed the present appeal against the order dated 19.10.2015 passed by District Consumer Disputes Redressal Forum, Sri Muktsar Sahib (hereinafter referred as "District Forum") in Consumer Complaint No.23 dated 19.10.2015 vide which complaint filed by the F.A. No. 1247 of 2015 2 Respondent/complainant (hereinafter referred as complainant) was allowed. OPs were directed to pay Rs.2,21,516/- as claim amount and Rs. 10,000/- for attendant's diet etc with interest @ 7.5% per annum from the date of admission i.e. 18.08.2014 till realization alongwith Rs.5,000/- as litigation cost. It was further directed to comply with the order within 30 days from the receipt of the copy of the order.
2. Complaint was filed by the complainant under Section 12 of the Consumer Protection Act 1986(in short `the Act') against OPs on the averments that complainant had purchased a "LIC Health Protection Plus" Policy No.133196844 for the period from 11.12.2010 to 11.6.2048 after paying a premium of Rs 5,000/-. The mode of premium was half yearly. OPs assured that if complainant would suffer any illness, then OPs would pay Rs.1000/- per day as "initial daily hospital cash benefit" with total amount of treatment including operation, surgery etc. On 18.08.2014, she suddenly fell ill. She was got admitted in Amandeep Hospital, Amritsar and doctor advised for operation. Accordingly, complainant was got operated by the doctors of Amandeep Hospitals, Amritsar. She remained in emergency for one day and was discharged after nine days i.e. 27.8 2014. She spent Rs.4,00,000/- on her treatment and submitted her claim for reimbursement but the same was repudiated on the ground of pre- existing disease. Again she made request to OPs regarding reimbursement of her claim but all in vain. This act of OPs amounted to deficiency in their service. Hence, she filed the complaint before the District Forum seeking following directions against OPs:-
a) to pay Rs. 400,000 as treatment amount along with @18% per annum F.A. No. 1247 of 2015 3
b) to pay Rs./- 400,000 as compensation for mental tension and harassment.
c) to pay Rs./-22,000 as litigation cost.
3. Complaint was contested by OPs. Who filed written reply by taking preliminary objections that complainant obtained LIC's Health Protection plus Policy No. 133196844 for the period as mentioned in the complaint. However, in the proposal forum she made a wrong declaration and suppressed the material facts about her health and habits whereas the contract of insurance was based upon utmost good faith. Complicated question of law and facts were involved in the matter which required elaborate evidence which was not possible in the summary procedure under the Act, therefore, the matter should be relegated to civil court. On 18.08.2014, she was admitted in Amandeep Hospital and was diagnosed a patient of "ACM with Syringohydromyelia". She had pain over right side body i.e./neck/arm/lower back/ leg, from the last 9-10 years and symptoms of the above said disease were prior to policy inception in 2010. ACM is a congenital disease and the same was not covered under the policy and that after receiving the claim of the complainant, Medi Assist India TPA Private Limited scrutinized her claim and concluded that she was not eligible for the claim as this surgery was not listed in "Surgical Benefits". Accordingly, her claim was repudiated due to pre-existing disease irrespective of prior medical treatment and was informed vide registered letter dated 20.11.2014, On merits, it was denied that she spent Rs. 4,00,000/- on her treatment. She submitted IPD bill of Amandeep Hospital for Rs.1,01,919/- only. At the time of admission in Amandeep Hospital, her chief complaint was pain over right side of body i.e. neck, arm, lower back, right leg from the last 9/10 years and diagnosed "ACM F.A. No. 1247 of 2015 4 with Syringohydromyelia". She had undergone Cervical Decompression surgery i.e. Sub-ocupital craniectomy, C1-C2 laminectomy and foramen magnum decompression Durapasty. It was repudiated due to pre- existing illness irrespective or prior medical treatment or advice. There was no deficiency in their service and prayed for dismissal of the complaint with costs.
4. The parties were allowed by the learned District Forum to lead their evidence.
5. In support of the averments, the complainant tendered into evidence his affidavit Ex.C-1 along with other documents Ex.C-2 to Ex.C-59 and closed his evidence. On other hand OPs had tendered into evidence affidavit of Sh. Mohal Lal, Administrative Officer, Health Insurance LIC as Ex.OP-1 along with other documents Ex. OP-2 to Ex. OP-9 and closed their evidence.
6. After going through the allegations alleged in the complaint, written reply filed by OPs, evidences and documents brought on the record, the learned District Forum allowed the complaint on the ground that OPs should have examined the complainant before filling up the proposal form and at the time of repudiation of the claim they should have relied upon their own medical expert opinion. OPs should not have repudiated the claim on the ground of brief history recorded in the discharge summary that complainant had pain on right side of body.
7. Aggrieved against the order passed by the Ld. District Forum, OPs have preferred the present appeal.
8. We have heard learned counsel for the parties and carefully gone through the record of the District Forum.
09. It was submitted by the counsel for the appellants/OPs that complainant had suppressed the material facts regarding her health. In F.A. No. 1247 of 2015 5 the proposal form dated 11.12.2012 (Ex.OP-2) complainant made the false statement regarding her health that "she was not suffering from any congenital disorder". She was admitted in Amandeep Hospital, 18.8.2014, where she was diagnosed as patient of ACM (Arnold chiari malformation with Syringohydromyelia). It was specifically mentioned in the discharge summary that she had pain in right side neck/arm/low back/leg for last 9-10 years. ACM was a congenital internal malformation which was not covered under the policy. The claim of the complainant was rightly repudiated by the OPs as per terms and conditions of the policy. It was further submitted that District Forum committed an illegality while allowing the claim to the tune of Rs.2,21,516/- with Rs.10,000/- as diet money whereas, complainant had claimed an amount of Rs.1,01,919/- vide bill no.1469 dated 26.08.2014.He prayed for acceptance of the appeal and set-aside the impugned order.
10. On the other hand the counsel for the complainant submitted that District Forum had returned the correct findings that OPs were liable to pay the total amount spent by the complainant on her treatment. Complainant proved on bills issued by the Medicos Amandeep Hospital Ex.C-30 to Ex.C-35 and Ex.C-39. OPs were liable to pay that amount, spent by the complainant on diet. He prayed for dismissal of the appeal.
11. We have considered contention of both the parties. It was contended by the complainant that on 18.08.2014, she suddenly fell ill. She was admitted in Amandeep Hospital, Amritsar and doctor advised for operation. Accordingly, complainant was operated by the doctors of Amandeep Hospital, Amritsar. She also remained in F.A. No. 1247 of 2015 6 emergency for one day and was discharged after nine days i.e. 27.8 2014. She spent Rs.4,00,000/- on her treatment and submitted her claim form Ex.C-40 for reimbursement but the same was repudiated on the ground of pre-existing disease vide letter dated 26.11.2014 (ExC5). Whereas, OPs alleged that on18.08.2014, she was diagnosed a patient of ACM with Syringohydromyelia. She had complaint of on right side body pain/neck/arm/low back/leg for the last 9-10 years and symptoms of the above said disease were prior to policy inception in 2010. ACM was a congenital internal malformation and the same was not covered under the policy. As per discharge summary Ex.C-38 complainant was admitted in Amandeep hospital dated 18.08.2014 and discharged on 26.08.2014. During admission she was diagnosed as ACM with Syringohydromyelia. OPs proved on record the policy terms and conditions Ex.OP-4 under clause 6 (ii) (xi) which reads as under:-
"Surgery for correction of birth defects or congenital anomalies".
Syringohydromyelia: is a genetic term referring to a disorder which a cyst or cavity forms within the spinal cord.
But according to literature, which was produced before this Commission during arguments, as per that there are two types Syringohydromyelia of Congenital and Acquired. Congenital: the first major relates to an abnormality of the brain called an Arnold-Chiari malformation. This is the most common cause of syringomyelia.
Acquired: the second major form of syringomyelia occurs as a complication of trauma, meningitis, hemorrhage, a tumor, or arachnoiditis. Here, the syrinx or cyst develops in a segment of the F.A. No. 1247 of 2015 7 spinal cord damaged by one of these conditions. The syrinx then starts to expand. This is sometimes referred to as noncommunicating syringomyelia. Symptoms may appear months or even years after the initial injury, starting with pain, weakness, and sensory impairment originating at the site of trauma.
12. "A congenital disorder is a medical condition that is present at or before birth. These conditions also referred to as birth defects, can be acquired during the fetal stage of development or from the genetic make up of the parents". It was specifically mentioned in the discharge summary that complainant had pain in right side neck/arm/lower back/leg from last 9-10 years that means complainant not suffered by congenital disease by birth. Moreover, OPs admitted in the written reply that she was suffering from pain from the last 9 to 10 years. Therefore, claim of the complainant did not fall under the exclusion clause of 6(ii)(xi) of the policy (Ex C3) ""Surgery for correction of birth defects or congenital anomalies"., .
13 Further OPs alleged that complainant had concealed the pre-existing disease at the time of taking the policy. At the time of admission in the hospital her chief complaint was on right side body pain/neck/arm/low back/leg for the last 9-10 years and symptoms of the above said disease were prior to policy inception in 2010. OPs Proved on record proposal from Ex.OP-2 in which it was specifically mentioned under the health detail, column no (J) that Are you suffering from any disease related to " Mukculoskeletal diseases e.g.: prolapsed disc, back or neck complaint, any physical disability or other disorder of the bones, joints, arthritis, gout etc" and complainant made a reply in negative form.
F.A. No. 1247 of 2015 8Further, complainant made a declaration in the proposal form that "I have read the proposal form fully and the same was interpreted to me by the agent and also declare that I have understood the nature of the questions and the importance of disclosing all material information while answering such questions. I hereby declare that the foregoing statements and answers to all questions, including those in the annexure signed by me, have been given by me after fully understanding the questions and the same are true and complete in every particular and that I have not withheld any information and I do hereby agree and declare that these statements and this declaration shall be the basis of the contract of assurance between me and the Life Insurance Corporation and that if any untrue averment be contained therein, the said contract shall be absolutely null and void".
14. Hon'ble Supreme Court reported in IV (2009) CPJ 8 (SC) (SATWANT KAUR SANDHU v. NEW INDIA ASSURANCE COMPANY LIMITED) held that there is normal practice in the hospitals that the information about the medical history of the patient is being supplied by his family members at the time of his or her admission in the hospital. This Discharge Summary itself makes it clear that the complainant had complaint of right side body pain/neck/arm/low back/leg for the last 9-10 years. This was the abnormality, which was in the knowledge of the complainant at the time of submitting the proposal form and the contract of insurance being based upon utmost good faith; she was bound to disclose the same in the proposal form.
F.A. No. 1247 of 2015 9
15. It is now well settled that the claim of the insured can be repudiated in case there was suppression of material facts, which was in the exclusive knowledge of the insured before taking the policy.
16. While allowing the complaint, District Forum failed to consider the factum then complainant concealed the material information about the disease to which he was suffering by violating the principle of uberrima fides. In these circumstances order of District Forum is not legally sustainable.
17. In view of the above discussion, the appeal of the appellant/OPs is allowed. The order of the District Forum is set- aside. Consequently, the complaint of the complainant is dismissed.
18. The appellants/OPs had deposited a sum of Rs. 25,000/- at the time of filing of the appeal. They further deposited a sum of Rs1,56,500/- in compliance of order dated 12.01.2016.The Registry is directed to remit the above said amount to OP/appellant No.1 by way of a crossed cheque/ demand draft after the expiry of 45 days of the sending of certified copy of the order to the parties subject to stay if any by any higher Fora/ Court.
19. The arguments in this appeal were heard on 11.04.2016 and the order was reserved. Now, the order be communicated to the parties as per rules.
20. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(GURCHARAN SINGH SARAN) PRESIDING JUDICIAL MEMBER (JASBIR SINGH GILL) MEMBER (SURINDER PAL KAUR) May 5, 2016 MEMBER SK F.A. No. 1247 of 2015 10