State Consumer Disputes Redressal Commission
Reena Kansal vs Uiic on 26 April, 2012
PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No.1194 of 2008
Date of institution: 17.10.2008
Date of decision : 26.04.2012
Reena Kansal resident of 83, The Mall, Civil Lines, Ludhiana.
.....Appellant
Versus
1. United India Insurance Company, 92, the Mall, Ludhiana through
authorized signatory.
2. Paramount Health Services Pvt. Ltd., New Delhi through its Branch
SCO 138, 3rd Floor, Feroze Gandhi Market, Ludhiana.
.....Respondents
First Appeal against the order dated 04.09.2008
passed by the District Consumer Disputes
Redressal Forum, Ludhiana.
Before:-
Mr.Jagroop Singh Mahal, Presiding Judicial Member
Mr.Jasbir Singh Gill, Member Mr.Vinod Kumar Gupta, Member Argued by:-
For the appellant : Sh.J.S.Ahluwalia, Advocate For the respondents : Sh.Munish Goel, Advocate JAGROOP SINGH MAHAL, PRESIDING JUDICIAL MEMBER This is complainant's appeal under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as the Act) against the order dated 4.9.2008 passed by the learned District Consumer Disputes Redressal Forum, Ludhiana (in short the District Forum) vide which the complaint was dismissed.
2. The complainant-appellant obtained a mediclaim policy from the OP-respondents for the period from 19.9.2006 to 18.9.2007. She developed very serious and acute problem in her knees and, therefore, got First Appeal No.1194 of 2008 2 admitted in Breach Candy Hospital Trust, Mumbai where knee replacement was done. She was discharged on 20.1.2007. The complainant-respondent submitted the claim of Rs.6,26,062/- for payment but her claim was repudiated on the ground that it was a pre-existing disease which stands excluded in view of Clause 4.1 of the insurance policy. Her contention is that she has no knowledge of filing the personal statement on her health at the time of obtaining the insurance and the said statement may have been filed by the agent. According to her, the agent did not ask her any question about her past health; that she was medically examined by the OPs before selling the insurance policy and that the knee replacement was earlier got done by her 13 years back which could not be made a basis of repudiating her claim. It was alleged that Clause 4.1 was not made a part of the policy nor was it ever communicated to her. She, therefore, prayed for issuing directions to the OP-respondents to pay the claim amount of Rs.6,26,062/- along with Rs.5 lacs as compensation for harassment and Rs.11000/- as costs of litigation.
3. The OP-respondents admitted the issuance of the policy but contended that the complainant-appellant did not disclose her previous disease in the proposal form submitted by her and consequently, it being a pre-existing disease, no compensation could be claimed for its treatment in view of Clause 4.1 of the policy. It was admitted that before issuing the policy, she was medically examined which showed that the knee replacement had already been got done by her 13 years back and, therefore, she was not entitled to any compensation.
4. Both the parties were given opportunity to adduce evidence in support of their respective contentions.
First Appeal No.1194 of 2008 3
5. After hearing the arguments of the learned counsel for the parties and perusing the evidence on record, the learned District Forum dismissed the complaint vide impugned order dated 4.9.2008. She has, therefore, filed the present appeal against the said order.
6. We have heard the arguments of the learned counsel for the parties and have perused the record.
7. It is admitted by the appellant that about 13 years back, she got the knee replacement done which fact is proved from her medical examination, also the report of which is Ex.C14. The complainant-appellant submitted the proposal form Ex.R4 but did not mention if she had got the knee replacement done. Her answer to Clause (e) of Condition No.13 as to whether she had any disease of the bones or joints including rheumatic disease, was in the negative. She, therefore, concealed her previous illness from the OP-respondents. The previous illness related to the knee replacement and concealment thereof dis-entitles the complainant of any relief under the policy with respect to the said disease.
8. Apart from the concealment of fact, the contention of the OP- respondents is that she is not entitled to any claim in view of Clause 4.1 of the policy of insurance Ex.C9. Clause 4 relates to Exclusions which is as follows : -
"4. EXCLUSIONS The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of :
4.1 All diseases/injuries which are pre-existing when the cover incepts for the first time. For the purpose First Appeal No.1194 of 2008 4 of applying this condition, the date of inception of the initial mediclaim policy taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break."
In view of Clause 4.1, the insured is not entitled to claim any compensation with respect to the disease/injuries which are pre-existing when the cover incepts for the first time. There is no dispute about it that when the complainant-appellant purchased the policy, she had already got the knee replacement done. It is of common knowledge that once the knee replacement has been done, it has to be revived may be after 12 years, 15 years or 18 years thereafter. The learned counsel for the appellant has argued that she was got medically examined by the OP-respondents and in view of the medical report Ex.C14, the OP-respondents had been informed about the knee replacement having got done by the complainant-appellant about 13 years back. If even inspite of their knowledge, the OP-respondents went ahead to issue the insurance policy, they cannot, subsequently, refuse to pay the compensation for the said disease. We do not find any merit in this argument. Had this been the intention of the parties, then Clause 4.1 would have been deleted from the insurance policy. If, even inspite of knowing that the complainant-appellant had earlier got the knee replacement done, the parties retained Clause 4.1 in the contract of insurance, it means that for the knee replacement, no compensation would be granted whereas for other diseases which are not pre-existing, the complainant-appellant would be entitled to the insurance cover leading to compensation. The mere fact that the medical examination was conducted cannot be a sufficient ground to by- pass Clause 4.1 of the insurance policy.
First Appeal No.1194 of 2008 5
9. In view of the above discussion, we are of the opinion that the complainant-appellant is not entitled to any compensation and the learned District Forum has rightly dismissed the complaint. The present appeal is, therefore, devoid of merit and the same is, accordingly, dismissed. Parties are left to bear their own costs.
Copies of the orders be supplied to the parties free of costs.
(JAGROOP SINGH MAHAL) PRESIDING JUDICIAL MEMBER (JASBIR SINGH GILL) MEMBER (VINOD KUMAR GUPTA) MEMBER April 26, 2012.
Paritosh