State Consumer Disputes Redressal Commission
United India Insurance Company ... vs Kanta Gupta on 8 September, 2010
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
SCO NO.3009-12, SECTOR 22-D, CHANDIGARH.
First Appeal No.1370 of 2004.
Date of Institution: 08.11.2004.
Date of Decision: 08.09.2010.
United India Insurance Company Limited, Regional Office, 136, Feroze Gandhi
Market, Ludhiana, through Sh. Rakesh Sachdeva, Assistant Manager.
.....Appellant.
Versus
Kanta Gupta w/o Late Sh.Sohan Lal Gupta, 614, Lakkar Bazar, Ludhiana,
deceased through her Legal Representatives:-
(i) Rakesh Kumar Gupta Son
(ii) Mahesh Gupta Son
(iii) Sanjay Gupta Son
(iv) Smt. Meena Gupta Daughter.
.....Respondents.
First Appeal against the order dated
15.09.2004 of the District Consumer
Disputes Redressal Forum, Ludhiana.
Before:-
Sh. Inderjit Kaushik, Presiding Member.
Sh. Piare Lal Garg, Member.
Present:-
For the appellant : Sh. Jagtar Kureel, Advocate for
Sh. D.P. Gupta, Advocate.
For the respondents : Sh. Sanjiv Pandey, Advocate.
INDERJIT KAUSHIK, PRESIDING MEMBER:-
The United India Insurance Company Limited (In short "the appellants") have filed this appeal against the order dated 15.9.2004 passed by the learned District Consumer Disputes Redressal Forum, Ludhiana (in short "the District Forum").
2. Facts in brief are that Sh. Sohan Lal Gupta husband of the respondent/complainant purchased a mediclaim policy no.200801/48/037/ 002688/2000 valid from 22.12.2000 to 21.12.2001 and the premium of Rs.5823/- plus service tax of Rs.291/- were paid. Deceased was the nominee of the policy, who regularly purchased the mediclaim policies for the last 3 years.
3. The husband of the respondent suffered DM Triopathy CRF LVF (Kidney Block problem) and he was admitted in Deepak Hospital, Sarabha Nagar First Appeal No.1370 of 2004 2 on 21.5.2001 and was discharged on 23.5.2001. The treatment of dialysis was started w.e.f. 21.5.2001 itself. The appellants were informed about the admission of husband of the respondent in the hospital. After discharge from the hospital, the husband of the respondent visited the hospital time to time for dialysis.
4. The husband of the respondent was again admitted in the said hospital on 6.11.2001 and discharged on 11.11.2001. Thereafter, dialysis continued and ultimately, husband of the respondent died on 21.6.2002.
5. The claim for the treatment was submitted to the appellants for a Rs.1,21,124/- on 27.12.2001 but the appellants repudiated the same vide letter dated 28.5.2002 on the ground of non-disclosure of pre-existing disease.
6. The husband of the respondent never suffered from any kidney problem prior to his admission in Deepak Hospital on 21.5.2001 and the appellants caused mental torture and inconvenience. It was prayed that the above amount along with compensation, interest and costs be paid.
7. The appellants filed written statement taking objections that the claim of the respondent has been rightly repudiated after considering all the facts. Intimation of the claim was received on 25.5.2001 and Dr. Pankaj Bhalla after verifying the facts, gave his report dated 25.7.2001 to the effect that the insured was a chronic diabetic mellitus for the last 15 years and the complications thereof. The patient knew about his disease at the time of taking the policy, but he did not disclose the same. Respondent has no cause of action and the question involved is of complicated nature and triable by civil court.
8. On merits, it was admitted that the patient was admitted in Deepak Hospital on 21.5.2001 and discharged on 23.5.2001. The history mentioned in the discharge card of Deepak Hospital, clearly shows that the insured was 63 years old male, diagnosed to have DM (Diabetic Mellitus) for the last 15 years along with other diseases such as asthama, anorexia and breathlessness and the claim was not payable. It was admitted that the information was sent on 25.5.2001 and prayed that the complaint be dismissed. First Appeal No.1370 of 2004 3
9. Parties led evidence in support of their respective contentions by way of affidavits and documents.
10. After going through the documents and material placed on file and after hearing the learned counsel for the parties, the learned District Forum accepted the complaint and directed the appellants to decide the claim of the respondent as per rules and regulations as well as terms and condition of the policy.
11. Aggrieved by the impugned order dated 15.9.2004, the appellant insurance company has come up in appeal.
12. 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.
13. It was contended by the learned counsel for the appellants that husband of the respondent had purchased a mediclaim insurance policy and he remained admitted on 21st May, 2001 to 23rd May, 2001; 4.9.2001 to 11.9.2001 and 6.11.2001 to 11.11.2001. It was a clear cut case of pre-existing disease which was not disclosed by the insured at the time of signing the proposal form. Ex.C7 is the discharge card and in the discharge card, in the column of history, it is mentioned as follows:-
"63 years old male diagnosed to have DM for the last 15 years, presented with the complaint of asthama, anorexia and breathlessness".
Dr. Pankaj Bhalla has filed his affidavit after investigating the case.
14. On the other hand, learned counsel for the respondent has argued that Sh. Sohan Lal Gupta was having good health and before admission in Deepak Hospital, he had no kidney problem. The history sheet is not the document which can be taken into consideration. Reliance has been placed on "Reliance General Insurance Vs High Court Lawyers, Public Charitable Trust", 2010(1) CPC-373(State Commission, U.T. Chandigarh).
15. We have considered the submissions made by the learned counsel for the parties.
First Appeal No.1370 of 2004 4
16. The appellant insurance company has repudiated the claim of the respondent on the ground that husband of the respondent was suffering from pre-existing disease. The appellant insurance company has relied upon in the column of history recorded in Deepak Hospital Ex.C7 and Dr. Pankaj Bhalla in his affidavit Ex.R6, has deposed that he checked the medical record including the discharge card issued by Deepak Hospital. Dr. Pankaj Bhalla on the basis of this, has given his report on the basis of which the appellant insurance company has repudiated the claim of husband of the respondent, taking the plea of pre- existing disease. The insurance company has not led any evidence to prove that at the time of signing the proposal form, the deceased Sohan Lal Gupta was suffering from any pre-existing disease. The identity of the person, who gave the opinion to the doctor, has also not been disclosed and the doctor of the insurance company namely Dr. Pankaj Bhalla has also not examined the husband of the respondent himself and based his opinion on the discharge summary. In similar circumstances, the Hon'ble National Commission in its latest judgment, has not found any substance in pleas of the insurance company. Hon'ble Mr. Justice Ashok Bhan in case reported as "National Insurance Company Limited Vs Sardar Kulbir Singh", 2010 CTJ-1032 (CP)(NCDRC), observed in para no.17 as follows:-
"17. It is not the case of the petitioner that the respondent was guilty of suppression of facts. The case put forth is that there was pre-existing disease. That the case of the respondent falls under the Exclusion Clause-4 as the respondent was suffering from a pre-existing disease. As mentioned above, the petitioner has failed to produce any evidence, whatsoever, except what has been stated in the discharge summary, to show that the respondent was suffering from chronic stable angina".
17. In case "Life Insurance Corporation of India (LIC) Vs Smt. Chandra Kanta Lohande", 2009 CTJ-73 (CP) (NCDRC), the Hon'ble National Commission, in para no.10 observed as follows:-
"10. In today's world, people face problems like acidity, indigestion, back pain and headache, which are sometimes chronic in nature. These symptoms may occur from time to time with different levels of intensity.First Appeal No.1370 of 2004 5
They cannot be considered as diseases, which required to be enumerated while answering the questionnaire of the LIC in its proposal form.
18. In case "Reliance General Insurance Vs High Court Lawyers, Public Charitable Trust", 2010(1)CPC-373, the Hon'ble State Consumer Disputes Redressal Commission, Union Territory, Chandigarh, relied upon the certificate of the doctor that the patient had no pre-existing disease and allowed the claim.
19. The learned District Forum vide the impugned order, accepted the complaint and directed the appellant insurance company to decide the claim of the respondent as per rules and regulations as well as terms and conditions of the policy, but instead of passing any order, the appellant insurance company filed the present appeal.
20. We find no merit in the present appeal and the same is dismissed. However the order of the District Forum is required to be modified. Accordingly, the appellant insurance company is directed to pay Rs.2,00,000/- (Rupees Two Lacs) which is the sum insured to the respondent/complainant along with interest @ 7.5% from the date of repudiation of the claim till the date of realization. The appellant insurance company shall also pay cost of litigation to the tune of Rs.5,000/- for unnecessarily dragging the respondent in the present litigation. The order be complied within two months from the receipt of copy of the order.
21. The arguments in this appeal were heard on 31.08.2010 and the order was reserved. Now the order be communicated to the parties.
22. The appeal could be decided within the stipulated timeframe due to heavy pendency of Court cases.
(Inderjit Kaushik) Presiding Member (Piare Lal Garg) Member.
September 8, 2010.
(Gurmeet Singh)