State Consumer Disputes Redressal Commission
Oriental Insurance Company Limited, vs Smt. Surinder Kaur Widow Of Sh. Pritpal ... on 30 September, 2011
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH
First Appeal No. 541 of 2009
Date of institution : 17.4.2009
Date of Decision : 30.9.2011
Oriental Insurance Company Limited, Divisional Office Queens Road, Amritsar
through its authorized signatory Chief Regional Manager, Oriental Insurance
Company Limited, Regional Office SCO No. 109 to 111, Sector 17-D,
Chandigarh.
....Appellant.
Versus
1. Smt. Surinder Kaur widow of Sh. Pritpal Singh Supervisor SGPC
resident of H. No. 3480/9, Mohalla Hargobindpura Gate Hakiman,
Amritsar.
2. Shiromani Gudwara Parbandhak Committee, Golden Temple, Amritsar
through its President.
...Respondents.
First Appeal against the order dated 16.2.2009 of
the District Consumer Disputes Redressal Forum,
Amritsar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Piare Lal Garg, Member.
Present:-
For the appellant : Sh. Mrigank Sharma, Advocate for Ms. Ashwani Talwar, Advocate For respondent No.1 : Sh. Anil Chawla, Advocate For respondent No.2 : None.
PIARE LAL GARG, MEMBER:
This is an appeal filed by appellant-Oriental Ins. Co. Ltd. (hereinafter called 'the appellant') against the order dated 16.2.2009 of the District Consumer Disputes Redressal Forum, Amritsar (hereinafter called the 'District Forum') by which the complaint of the respondent No.1/complainant (hereinafter called 'the respondent No.1') was allowed by the District Forum.
2. Brief facts of the case are that the husband of the respondent No. 1 was working as Supervisor with the Shiromani Gurdwara First Appeal No. 541 of 2009 2 Prabandhak Committee(in short 'the respondent No.2'). It was pleaded that the appellant - insurance company contacted the office of the respondent No. 2 and offered medical insurance policy for the employees of the respondent No.2. The respondent No.2 after consulting with its employees opted for taking Group Mediclaim Insurance Policy for the health of its 72 employees and prepared a list dated 12.1.2007 of 72 officials. The respondent No. 2 deposited Rs. 2,12,760/- as premium of the policy @ Rs. 2955/- per head with the appellant. The respondent No. 2 thereafter deducted medical allowance of 72 employees vide order dated 12.1.2007. The agent of the appellant at the time of filling the proposal form assured all the applicants that they are authorized to get an amount of upto Rs. 3,00,000/- as medical claim, which they may incur on the medical treatment of the insured persons as well as on their family members. The appellant also issued identity cards to the insured employees as well as of their dependent family members. The card was also issued to the husband of the respondent No. 1 and to his family members.
3. It was pleaded that the respondent No. 1's husband Pritpal Singh fell ill on 27.1.2007 and was admitted in Escorts Hospital, Amritsar for medical treatment. The respondent No.1's husband was suffering from jaundice and his kidneys failed and he died on 7.2.2007. The respondent No. 1 had spent Rs. 2,00,000/- on the treatment of Sh. Pritpal Singh. The respondent No. 1 filed medical claim with the appellant and also submitted the medical bills regarding the treatment of her husband. The appellant used the dilatory tactics and did not settle his claim, as such, the respondent had filed Complaint No.673 of 2007, which was decided on 2.5.2008 and the District Forum had directed the respondent No.1 to submit the claim with the appellant within 15 days and thereafter the appellant decided the same within 45 days, which the respondent No. 1 First Appeal No. 541 of 2009 3 had filed with the appellant. The appellant had repudiated the claim on 4.7.2008 on the ground that insured was suffering from pre-existing disease and he had not disclosed this fact at the time of obtaining the insurance policy. Complaint was filed on the ground that the appellant was deficient in service and prayed for a direction to the appellant to pay Rs. 2,00,000/- of the claim as well as compensation of Rs. 1,00,000/-.
4. Upon notice, the appellant replied and admitted about the filing of the previous complaint No. 673 of 2007. It was pleaded that the appellant considered the insurance claim alongwith the requisite documents of the treatment taken by the deceased. Dr. Neel Kanth was appointed by the appellant to verify the record of Escorts Hospital regarding the treatment taken by the deceased. The Doctors of the Escorts Hospital had verbally informed to Dr. Neel Kanth that Mr. Pritpal Singh remained admitted to Mahajan Hospital prior to the admission in the Escorts Hospital. Thereafter Dr. Neel Kanth visited Mahajan Hospital and it was revealed by him that Sh. Pritpal Singh remained an indoor patient in the hospital from 10.1.2007 to 27.1.2007 for Hepatitis and ARF. Dr. Neel Kanth also collected the record from Mahajan Hospital and as per record it was revealed that Sh. Pritpal Singh has left the hospital against medical advise on 27.1.2007 at 11.00 a.m. The appellant had insured the deceased for 16.1.2007, who had already taken the treatment from 10.1.2007 i.e. prior to the issuance of the policy. The appellant had repudiated the claim after due application of mind. All other allegations were denied and dismissal of the complaint was prayed.
5. Upon notice, the respondent No. 2 replied by taking preliminary objection that the respondent No. 1 was not his consumer as the mediclaim policy was issued by the appellant in respect of 72 employees of the respondent No. 2. It was pleaded that the appellant First Appeal No. 541 of 2009 4 offered the group medical insurance policy, which was purchased by it after consulting its employees. Appellant was negotiated and then the appellant offered Rs. 985/- to cover the mediclaim of Rs. 1,00,000/- and Rs. 2955/- for covering the amount of Rs. 3,00,000/- i.e. for 72 employees and total amount of Rs. 2,12,760/- was paid through cheque to the appellant. It was admitted that the husband of the respondent No. 1 was covered under the said mediclaim insurance policy as one of the 72 employees and the appellant should only be liable to make the payment of the claim amount. All other allegations were denied and dismissal of the complaint was prayed.
6. Learned District Forum after hearing the learned counsel for the parties and going through the record, allowed the complaint with Rs. 1,000/- as costs and the appellant was directed to pay an amount of Rs. 2,00,000/- to the respondent No. 1 with interest @ 9% per annum from the date of repudiation till the payment of the amount.
7. Hence, the appeal.
8. We have gone through the pleadings of the parties, perused the record of the learned District Forum and heard the arguments of the learned counsel for the parties.
9. The present appeal is filed by the appellant insurance co. on the grounds that the claim of the respondent No. 1 was rightly repudiated as the insured had concealed the pre-existence of the disease for which he remained admitted in Mahajan Hospital from 10.1.2007 to 27.1.2007 when the policy was valid for 16.1.2007 to 15.1.2008 and the order of the District Forum is against the conditions of the policy and is liable to the set-aside.
10. There is no dispute that the deceased was insured with the appellant under mediclaim policy, which was issued by the appellant in First Appeal No. 541 of 2009 5 respect of 72 employees of the S.G.P.C.. There is also no dispute that the insured died on 7.2.2007 during the validity of the insurance policy.
11. There is also no dispute that the premium of Rs. 2,12,760/- was paid by the respondent No. 2 to the appellant after deducting Rs. 2955/- from the pay of its employees. As such, the contract of insurance of the 72 employees of the respondent No. 2 was executed between the appellant and the respondent No. 2. The policy and terms and conditions of the same, if any, were also supplied by the appellant to the respondent No. 2. Neither copy of the policy nor the copy of the terms and conditions of the policy was ever supplied to the deceased, nor to other 71 employees of the respondent No. 2, who were insured under medi-claim policy by the appellant.
12. There is also no dispute that Sh. Pritpal Singh was admitted in Escorts Hospital on 27.1.2007 for the treatment of jaundice where he died on 7.2.2007. There is also no dispute that Rs. 2,00,000/- were spent by the respondent No. 1 on the treatment of deceased-insured Pritpal Singh.
13. On the submission of the claim, the same was repudiated by the appellant vide letter Ex. R-3 dated 4.7.2008 on the ground that:-
"Mr. Pritpal Singh was already admitted in the Mahajan Hospital on 10.1.2007 whereas the risk under cover note No. 246176 started w.e.f. 16.1.2007 to 15.1.2008. It is cardial principle of Group Medical Insurance Policy that if the person is already getting any ailment or any disease or is suffering from any disease, the insurance company is not liable to pay any compensation for the death caused on account of the said disease pre-existing one.
As per the certificate issued by Escorts Hospital it has been mentioned that patient Pritpal Singh was admitted on 27.1.2007 with history of jaundice. As the said disease is the same for which he First Appeal No. 541 of 2009 6 earlier remained admitted in the Mahajan Hospital nor this fact was disclosed to us at the time of obtaining of Group Insurance Policy by the S.G.P.C., hence, we are not liable to pay any claim as far as present claim is concerned.
Due to the reasons mentioned above, the company is not liable to pay the claim as preferred by you."
14. So as per the above reason that the insured had remained admitted in the Mahajan Hospital before the issuance of the medi-claim policy and this fact was not disclosed by the insured, the claim was repudiated. But the appellants have failed to produce any evidence as to whether any query was made by the Company from the respondent No. 2 i.e. Shiromani Gurdwara Parbandhak Committee regarding the ailment of the employees, who were insured by the appellants under the medi-claim policy and the premium was received from the respondent No. 2. It is also not the case of the appellants that any proposal form of any insured member was filled by the insurance company and the deceased had concealed the fact regarding his ailment prior to the validity/issuance of the policy. When no question was put by the appellant from the insured members regarding their health at the time of issuance of the policy, then concealment of pre-existence of any disease does not arise. It was the duty of the appellant to inquire the pre-existence ailment from the employees of the respondent No. 2 before the issuance of the policy regarding their state of health but it was negligence on the part of the appellant. The appellant for its own negligence could not repudiate the claim of the respondent No. 1 when there was no fault or concealment on the part of the insured - Pritpal Singh.
15. The order of the District Forum is speaking one and detailed and there is no infirmity in the same. The appeal being without any merit is First Appeal No. 541 of 2009 7 dismissed with costs of Rs. 10,000/- and the impugned order of the District Forum is affirmed. The appellant was liable to pay the same to the respondent No. 1 within one month from the receipt of the copy of the order. This amount be recovered fro the official, who was responsible for repudiating the claim on flimsy grounds and dragged the respondent No. 1 into unnecessary litigation.
16. The arguments in this appeal were heard on 29.9.2011 and the order was reserved. Now the order be communicated to the parties.
17. The appellant had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to the respondent No. 1 by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellant.
18. Remaining amount shall be paid by the appellant to the respondent No. 1 within 30 days from the receipt of the copy of the order.
19. The appeal could not be decided within the statutory period due to heavy pendency of Court cases.
(Inderjit Kaushik)
Presiding Member
September 30, 2011. (Piare Lal Garg)
as Member