State Consumer Disputes Redressal Commission
National Insurance Company Limited, vs Balwinder Singh S/O S. Shangara Singh, on 31 May, 2011
2nd Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB,
SCO NOS.3009-12, SECTOR 22-D, CHANDIGARH.
First Appeal No. 1360 of 2006
Date of institution : 31.10.2006
Date of Decision : 31.5.2011
1. National Insurance Company Limited, Regional Office SCO No. 332-
334, Sector 34-A, Chandigarh.
2. National Insurance Company Limited, Divisional Office No. 1,
Lawarance Road, Amritsar through its Divisional Manager
(Both 1 and 2 through its authorized signatory Chief Regional
Manager, National Insurance Company Limited, SCO 332-334, Sector
34-A, Chandigarh)
....Appellants.
Versus
Balwinder Singh S/o S. Shangara Singh, Resident of Village Ranike, Post Office
Rangarh, Tehsil & District Amritsar.
...Respondent.
First Appeal against the order dated 29.8.2006 of
the District Consumer Disputes Redressal Forum,
Amritsar.
Before:-
Shri Inderjit Kaushik, Presiding Member.
Shri Piare Lal Garg, Member.
Present:-
For the appellants : Sh. Rahul Sharma, Advocate for Sh. Ashwani Talwar, Advocate For the respondent : Sh. Vivek Salathia, Advocate PIARE LAL GARG, MEMBER:
This is an appeal filed by National Insurance Co. Ltd. (hereinafter called 'the appellants') against the order dated 29.8.2006 of the District Consumer Disputes Redressal Forum, Amritsar(hereinafter called the 'District Forum') by which the complaint of the respondent was allowed by the District Forum.
2. Brief facts of the case are that the respondent had obtained mediclaim policy of Rs. 2 lacs by paying premium of Rs. 2445/-. Appellants issued cover note No. 1069803, which was valid for 28.2.2002 to First Appeal No. 1360 of 2006 2 27.2.2003. Respondent pleaded that on 18.3.2002, he had consulted Doctors of Tagore Heart Care and Research Centre. After examining him, Doctors admitted him in the hospital and operated and discharged from the hospital on 27.3.2002. Rs. 2,50,000/- were spent on the treatment by the respondent for which the claim of Rs. 2 lacs was lodged with the appellants as per mediclaim policy. Investigation was conducted by the Investigator and all the medical bills and treatment record was provided. All other formalities were completed. Respondent received letter dated 23.7.2003 by which his claim was repudiated on the recommendation of Dr. Suresh Aggarwal. Respondent requested the appellants to release the claim amount but of no use. Thereafter legal notice dated 27.9.2003 was served upon the appellants. Complaint was filed alleging that the appellants were deficient in service and prayed that appellants may be directed to pay the claim amount with 24% per annum interest from the date of lodging the claim till the actual payment and prayed for compensation of Rs. 50,000/- on account of harassment and litigation expenses.
3. Appellants replied by taking preliminary objections that the complaint was an abuse of process of the law and filed with a view to get wrongful gain and to cause wrongful loss to the appellants. It was admitted that the insurance was obtained for the period from 28.2.2002 to 27.2.2003. It was not denied that the respondent was admitted to Tagore Heart Care and Research Centre Pvt. Ltd., Jalandhar on 18.3.2002 with the diagnoses of Acyanotic Heart Disease in the form of Large Atrial Septal Defect and was operated on 20.3.2002 and discharged on 27.3.2002. The disease was a congenital heart disease, which always exists since birth as such, it existed before the purchase of the policy. All the diseases existed before the purchase of the insurance policy were excluded from coverage First Appeal No. 1360 of 2006 3 under the policy. The claim was rightly repudiated which was not payable as per the report of Dr. Suresh Aggarwal. All other allegations were denied and prayed that complaint may be dismissed.
4. Learned District Forum after hearing the learned counsel for the parties and going through the record, partly allowed the complaint and the appellants were directed to pay an amount of Rs. 1,20,000/- within one month from the receipt of the copy of the order, failing which appellants were liable to pay interest @ 6% per annum from the date of filing the complaint till its realization and also awarded Rs. 1,000/- as litigation expenses.
5. Hence, the appeal.
6. 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.
7. There is no dispute between the parties that the respondent purchased the medi-claim policy from the appellants, which was valid for the period of 28.2.2002 to 27.2.2003. It is also not denied by the appellants that the respondent was operated by the Doctors of Tagore Heart Care and Research Centre Pvt. Ltd., Ludhiana on 20.3.2002 and was discharged on 27.3.2002 from the hospital. There is also no dispute regarding the expenses of treatment which were incurred by the respondent.
8. The only dispute between the parties is that whether the respondent was suffering from the disease before the purchase of the policy for the period of 28.2.2002 to 27.2.2003 and whether he concealed this fact at the time of purchase of the policy from the appellants?
9. On the submission of the bills of the treatment by the respondent to the appellants, the claim of the respondent was got First Appeal No. 1360 of 2006 4 verified/investigated by the appellants from Dr. Suresh Aggarwal, MBBS, M.D. (Medicine), who was on the panel of the appellants.
10. Dr. Suresh Aggarwal vide its report Ex. R-3 gave his conclusion, which are as under:-
"The full record, as made available to the undersigned by your office has been studied in detail. Conclusions are:
The insured/ patient was admitted to "Tagore Heart Carre & Research Centre Pvt. Ltd., Jalandhar" on 18/03/2002 with the diagnosis "Acyanotic Heart Disease in the form of Large Atrial Septal Defect (Osteum Secundum Type)". He was operated upon in the hospital on 20/03/2002 for the same & was finally discharged on 27/03/2002. Please note that the disease under consideration is a congenital heart disease, which means it always exists since birth & hence obviously in this case naturally existed before the beginning of the policy period. Since all the diseases existing since before the beginning of the policy period are excluded from coverage under the policy, the claim is to be considered "non-payable".
However, the medical bills submitted by the insured are all as per expectations in the management of the disease under consideration."
11. The conclusion of Dr. Suresh Aggarwal is that the respondent was suffering from congenital heart disease, which always exists since birth. But to come to this conclusion, Dr. Suresh Aggarwal has not given any reasons or any basis on which he had given the opinion that the respondent was suffering from the disease for which he was operated since his birth. Even Dr. Suresh Aggarwal has not examined the patient and not consulted the Doctor, who had operated the respondent. It is admitted case of the appellants that Dr. Suresh Aggarwal is on the panel of the appellants and as such, he had given the opinion for the repudiation of the claim without any iota of evidence only to favour the appellants. First Appeal No. 1360 of 2006 5
12. The appellants have not produced any evidence to prove that before the purchase of the policy, the respondent had taken any treatment from any doctor or any hospital and the insured/respondent had the knowledge that he was suffering from the heart disease and he concealed this fact from the appellants at the time of issuance of the medi-claim policy.
13. The Hon'ble Supreme Court in the case of "LIC vs. G.M. Channabasamna", 1991 (1) SCC 357, has held that the burden of proving that the insured had made false statement and suppressed material facts is on the insurance company. In the present case the insurance company has produced no evidence on record to prove alleged pre-existing disease. In the present case there is no evidence on record to show that the respondent had ever taken any treatment for alleged pre-existing disease prior to taking Medi-claim policy from the insurance company.
14. Further the Hon'ble National Commission in the case of "LIC Vs. Joginder Kaur and other", 2005(2) CLT 229 has clearly held that in the absence of any reasonable inquiry and in the absence of any reasonable evidence the insurance company was not correct in repudiating the claim under the policy.
15. The order passed by the learned District Forum is legal and valid and there is no ground to interfere with the same. The appeal being without any merit is dismissed and the impugned order of the District Forum is affirmed and upheld. No order as to costs.
16. The arguments in this appeal were heard on 23.5.2011 and the order was reserved. Now the order be communicated to the parties.
17. The appellants had deposited an amount of Rs. 25,000/- with this Commission at the time of filing of the appeal. This amount of Rs. 25,000/- with interest accrued thereon, if any, be remitted by the registry to First Appeal No. 1360 of 2006 6 the respondent by way of a crossed cheque/demand draft after the expiry of 45 days under intimation to the learned District Forum and to the appellants.
18. Remaining amount shall be paid by the appellants to the respondent 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
May 31, 2011. (Piare Lal Garg)
as Member