National Consumer Disputes Redressal
New India Assurance Co. Ltd. & Anr. vs Rajinder Singh on 31 October, 2022
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2495 OF 2018 (Against the Order dated 23/05/2018 in Appeal No. 588/2017 of the State Commission Haryana) 1. NEW INDIA ASSURANCE CO. LTD. & ANR. REGISTERED AND HEAD OFFICE 87, MAHTMA GANDHI ROAD, MUMBAI-400001 MAHARASHTRA 2. NEW INDIA ASSURANCE CO. LTD. THROUGH ITS BRANCH MANAGER, DISTRICT-KAITHAL HARYANA ...........Petitioner(s) Versus 1. RAJINDER SINGH S/O. SH. TARLOCHAN SINGH, R/O. HOUSE NO. 1201, SECTOR 19-II, HUDA, DISTRICT-KAITHAL HARYANA ...........Respondent(s)
BEFORE: HON'BLE MR. SUBHASH CHANDRA,PRESIDING MEMBER
For the Petitioner : MR. J.P. SHEOKAND For the Respondent : Mr R K Ruhil and Mr Rahul Kasana,
Advocates
Dated : 31 Oct 2022 ORDER
PER MR SUBHASH CHANDRA
1. This revision petition filed under section 21 of the Consumer Protection Act, 1986 (in short, the 'Act') assails the order dated 23.05.2018 of the Haryana State Consumer Dispute Redressal Commission, Panchkula (in short, 'State Commission') dismissing First Appeal No. 588 of 2017 filed against order dated 15.12.2016 in complaint no. 83/16 of the District Consumer Disputes Redressal Commission, Kaithal (in short, 'District Forum').
2. The facts, in brief, are that the petitioner had issued a 'Family Mediclaim' policy to the respondent valid from 18.06.2014 to 17.06.2015. He was migrated to a 'New India Family Floater' subsequently. On 27.04.2015 the respondent was admitted in Shah Hospital, Kaithal and thereafter in Fortis Hospital, Mohali for a cardiac ailment. An expenditure of Rs.28,732/- was incurred on treatment in Kaithal and another bill dated 05.05.2015 for Rs.7,13,209/- was also submitted from Fortis Heart Institute Multi Speciality Hospital, Mohali where he was referred for treatment of blocked arteries. The petitioner approved payment of Rs.2,70,000/- and refused to honour the balance amount on the grounds that the Third Party Administrator (TPA) indicated that respondent was an existing patient of hypertension and diabetes and therefore the treatment undergone was for a pre-existing illness which the respondent had not disclosed at the time of obtaining the policy as per condition 5.1 and that enhancement of sum insured cannot be considered for insured persons suffering from diabetes and hypertension as per condition 5.11. The respondent filed a consumer complaint before the District Forum against this repudiation which was contested by the petitioner. The District Forum vide its order dated 15.12.2016 dismissed the appeal on the ground that the bill was inflated and should have been settled as per 'package charges' for implantation of a stent. Aggrieved with this order, the respondent appealed before the State Commission which on consideration of records and submissions by both parties allowed the appeal on 23.05.2018 directing the petitioner to pay the balance amount of Rs.4,41,940/- spent on treatment with interest of 9% per annum from the date of filing of the complaint along with costs of Rs.25,000/- towards mental agony and litigation expenses. It is this order that has been impugned by the petitioner by way of this revision petition before this Commission.
3. The submissions of both parties have been heard and the records perused carefully by me.
4. The learned counsel for the petitioner has contended that the State Commission has erred in incorrectly appreciating the facts. It is argued that the State Commission failed to appreciate that the repudiation of the claim was done since the TPA reported that the respondent was suffering from pre-existing diseases such as hypertension and diabetes and therefore the policy was void. Reliance is placed on an internal circular dated 24.03.2014 stating that the "increased sum insured shall be treated fresh and all terms and conditions of policy shall be attracted". It was submitted that the repudiation was based on the expert opinion of the TPA as per IRDAI regulations. It was argued that the State Commission overlooked the fact that since there was misrepresentation and non-disclosure of facts in the proposal, there was no deficiency in service and therefore the District Forum had correctly dismissed the complaint. According to the petitioner, Rs.2,70,000/ was paid as per policy conditions and TPA recommendations. It is also claimed that the patient availed the package rate of Rs.1,04,150/- but paid Rs.7,13,209/-.
5. Learned counsel for the respondent per contra argued that the impugned order was correct and that the disallowing of the full amount of treatment was unjust since the migration of the respondent to the policy of higher insurance cover was at the request of the petitioner. It is argued that diabetes and hypertension are common lifestyle diseases in today's world and that such diseases often go undetected unless there is a medical episode, as was the case in the present matter. It is also submitted that there was no direct causative link between these diseases and blockage of arteries in the heart for which a stent is required. He has relied upon this Commission's orders in National Insurance Company Ltd. Vs Raj Narain dated 15.01.2008, 1 (2008) CPJ 501 NC and Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. in RP No. 3619 of 2013 dated 11.01.2016 which held that diabetes and hypertension alone cannot be the basis for concluding that there was a pre-existing heart disease to exclude settlement of a claim of insurance.
6. Admittedly, the claim of Rs.2,70,000/- for the medical treatment of blockage in the heart and implant of a stent in the insured respondent has been settled by the petitioner. While it is contended by the petitioner that the claim of the respondent cannot be considered in terms of the policy, it is not understood on what basis that settlement has been done since repudiation of the balance amount is on the grounds of the policy being void in terms of conditions 5.1 and 5.11 of the policy and the circular dated 24.03.2014. If the policy has to be considered void as contended by the petitioner, then even this settlement of claim is unjustified per its own norms. The reliance on the 'package rate' for a stent cannot be a case for disallowing the claim of the respondent since by its own action, the petitioner has settled the claim for an amount of Rs.2,70,000/-. The petitioner has also failed to bring on record any evidence or expert opinion to substantiate his argument that the pre-existence of diabetes and hypertension was the causative factor for the blockage in the heart necessitating implantation of a stent. On the contrary, the respondent has relied upon two cases (supra) in support of his argument that even the pre-existence of diabetes and hypertension which were not detected at the time of declaration for the purpose of the policy, can be held to be a factor that would render the policy void ab initio. We are inclined to accept this submission.
7. In the light of the foregoing, I do not find merit in the contentions of the petitioner. The revision petition is accordingly dismissed and the order of the State Commission affirmed.
...................... SUBHASH CHANDRA PRESIDING MEMBER