National Consumer Disputes Redressal
National Insurance Co. Ltd. vs Shri Satya Pal (Sic)Uli on 25 July, 2003
Equivalent citations: IV(2003)CPJ98(NC)
ORDER
K.S. Gupta, Member
1. This revision is directed against the order dated 22.5.2001 of Consumer Disputes Redressal Commission Punjab, Chandigarh allowing appeal against the order dated 4.2.1999 of a District Forum and directing the petitioner/opposite party to pay Rs. 1,16,985/- being the total expenditure incurred on the treatment with interest @ 9% per annum to the respondent/complainant.
2. Facts giving rise to this revision lie in a narrow compass. Respondent took mediclaim policy valid from 16.6.1997 to 1.6.1998 from the petitioner and the limit of sum assured was Rs. 1,50,000/-. On 7.7.1997, the respondent suffered breathlessness and discomfort in chest and he got himself examined by Dr. Kukreja, heart specialist at Pathankot who advised him to get examined at Escorts Heat Institute and Research Centre, New Delhi. (SIC) angiography being done there on 9.7.1997, it was revealed that respondent (SIC) blockage in arteries. Expenditure incurred on angiography was Rs. 14,000/-. (SIC)alleged that on being advised ballooning of the heart by Dr. Praveen Chandra the respondent got himself admitted in the said hospital on 31.7.1997 and was discharged on 3.8.1997. On again suffering dis-comfort in chest, the respondent was admitted in the said hospital on 6.8.1997 where he underwent cardiac catherisation and coronary arteriography and was discharged on 7.8.1997. This time total expenditure incurred was Rs. 1,32,985/-. Respondent filed claim for reimbursement of the said amounts in September, 1997 which the petitioner repudiated by the letter dated 6.5.1998. Complaint filed by the respondent before District Forum was contested by the petitioner by filing written version. In short, the defence raised was that the respondent had failed to disclose the material facts regarding his pre-existing disease in the proposal form at the time of taking policy the respondent was detected as suffering from heart ailment within 30 days of the issuance of policy and he was, thus, not entitled to any amount under the policy. Upholding this defense, the District Forum dismissed the complaint and appeal taken out against the order of District Forum was, however, allowed by the State Commission in the manner noticed above.
3. We have heard Shri Pradeep Gaur for petitioner and Shri Sanjay S. Chaudhary for respondent.
4. Order dated 4.2.1999 of the District Forum (copy at pp 7-11 on the paper book) would show that to investigate the claim lodged by respondent, the petitioner had appointed Secret Branch of Investigations as Investigator and the Investigator obtained in writing the statement from respondent dated 22.12.1997 (copy at p-74) wherein he alleged that he felt heaviness in chest during nights in the months of June-July, 1997 for which trouble he consulted Dr. Kukreja and Dr. Subhash Gupta. On the basis of this admission, the District Forum was of the view that respondent was having heart problem even before takeing the policy but he intentionally suppressed it at he time of taking policy on 16.6.1997, District Forum was further of the view that the prescription slip issued on 7.7.1997 by Dr. Kukreja had been withheld by the respondent so that the truth may not comes out that he was suffering from heart ailment. After referring to Exclusion Clause 2.1.1 of the policy in question, the District Forum reached the conclusion that the repudiation of claim by the petitioner vide letter dated 6.5.1998 was made after applying his mind. Exclusion Clause 2 of the policy which is material, reads thus-
"EXCLUSION 2.1. 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.
2.1.1. Any disease other than those stated in Clause 2.1.13 contracted by the insured person during the first 30 days from the commencement of the policy. This exclusion shall not, however, apply if in the opinion of the panel of Medical Practitioners constituted by the company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company.
This condition 2.1.1 shall not, however, apply in a case of the insured persons having been covered under this scheme or group insurance scheme with any of the Indian insurance companies, for a continuous period of preceding 12 months without any break..."
5. In Clause 2.1.13, the disease excluded is given as AIDS.
Indisputably, date of commencement of policy in question was 16.6.1997. The averments made in a complaint as also the statement dated 22.12.1997, admittedly, handed over by the respondent to said investigator would show that on 7.7.1997, the respondent contacted Dr. Kukreja for treatment of breathlessness and dis-comfort in chest and on angiography being done at Escorts Hospital on 9.7.1997, he was detected of having significant blockages in arteries. This was within 30 days of the commencement of policy. Statement dated 22.12.1997 would further indicate that the respondent felt trouble in June, 1997 itself, presumably, before taking the policy but this material fact was suppressed by him in the proposal form. The State Commission did not examine aforementioned finding recorded by the District Forum as also above stated circumstances. The impugned order, thus, being bad in law deserves to be set aside in revisional jurisdiction under Section 21(b) of the Consumer Protection Act, 1986.
6. Accordingly, while allowing revision, the order dated 22.5.2001 is set aside and complaint dismissed. No order as to costs.