State Consumer Disputes Redressal Commission
M/S Royal Sundaram Alliance Insurance ... vs Mr. Virender Kumar Jain & Anr. on 3 July, 2023
FA NO.950/2014
ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of Institution:26.09.2014
Date of hearing:08.05.2023
Date of Decision: 03.07.2023
FIRSTAPPEAL NO.950/2014
IN THE MATTER OF
ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD.
1505-506, 15TH Floor, Ambadeep Building,
14, Kasturba Gandhi Marg, New Delhi
ALSO AT:
Sundaram Towers,
45 & 46, Whites Road, Chennai - 600014.
...Appellant
(Through: Mr. S.M. Tripathi, Advocate)
VERSUS
VIRENDER KUMAR JAIN (Since deceased)
S/o Late Shri A.K. Jain,
C-9/1, Vasant Vihar, New Delhi,
Sector- 13, Rohini, Delhi
Now Represented by LRs
1. Indu Jain (wife)
C-9/1, Vasant Vihar, New Delhi,
Sector- 13, Rohini, Delhi
2. Sheeba Bansal (Daughter)
1301, Sector- 15 Part-II,
Gurgaon, Haryana.
...Respondent
(Through: None)
DISMISSED PAGE 1 OF 6
FA NO.950/2014
ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
HON'BLE MS PINKI, MEMBER (JUDICIAL)
MR. J.P. AGRAWAL, MEMBER
Present: None for the parties.
PER: HON'BLE JUSTICE SANGITA DHINGRA
SEHGAL,PRESIDENT
JUDGMENT
1. The facts relevant that disbursal of the case as per the District Forum regard as under:
"1. The case of the complainant, in brief, is that the complainant had a medi-claim policy coverage to the tune of Rs.1,50,000/- to be reimbursement under policy No.HE0001058000100 effective from 24.03.2006 to 23.03.2007. Complainant had earlier gone for surgery during 1996 i.e. CBAG surgery. Thereafter, he was advised by doctor for treatment of oozing pus. He took treatment in USA and was advised removal of keloid to prevent it from mixing with blood through pus, which was a life threatening. He approached Indraprastha Apollo, with plastic surgeon for cashless treatment to remove keloids with sinuses and incurred Rs.1,72,520.27 whereas coverage did not provide cashless facility consequently claim was filed on 20.12.2006 but OP repudiated the claim on 10.01.2007 on the ground 'pre-existing'
2. The said complaint filed by the complainant under Section 12 of the Consumer Protection Act, 1986 was allowed by the District Commission, vide orderdated 06.08.2014, whereby it held as under:
DISMISSED PAGE 2 OF 6 FA NO.950/2014 ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN " While going through WS and evidence, OP has admitted that there is no dispute over coverage of Rs.1,50,000/- in Para No.2 of evidence but objected about surgery of 1996 which was concealed by complainant while taking the medi-claim which was done 10 years before. It is not related to claim of Rs.1,72,000/- incurred after ten years. Disease can be attracted to any human being at any time which has no relevance with presented claim after a lapse of 10 years which OP has co-related to pre-existing disease without any judicial justification of the facts except to deny the claim. Thus, it is clear case of breach of contract without applying judicial application of mind rather OP arbitrarily denied the claim.
Thus, OP is deficient and directed to pay Rs.1,50,000/- @9% from the date of claim till realization within 30 days failing which 12% interest will be payable. We also award Rs.50,000/- as harassment and litigation expenses as complainant had been suffering for 08 years for justice."
3. Aggrieved by the aforesaid order of the District Commission, the Appellant/OP has preferred the present appeal, contending that the District Commission failed to appreciate that while obtaining the insurance policy the Respondent had concealed the fact of his having undergone CBAG in 1996 and development of Keloids thereby; that Keloid is an abnormal condition of the skin which at any time may erupt where some injury/operation had taken place in the past; that the insurance policy was only 04 months old at the time of CT Scan (Chest) and the disease did not incept for the first time during the period of insurance, that the illness was not contracted during the policy period but had been contracted prior to the inception of the policy.
4. The main Controversy existing between the parties pertains to the rejection of the claim filed by the complainant. The written DISMISSED PAGE 3 OF 6 FA NO.950/2014 ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN statement filed on behalf of the O.P. would show that the repudiation of the claim proceeded on the premise that the disease suffered by the insured was pre-existing disease which stood excluded by exclusion clause of the policy. It has been further stated that any ailment/ disease which are pre-existing when the cover incepts for the first time, are excluded upto 5 years of the policy being in force continuously as per exclusion clause, since the disease suffered in the first year so the claim was rejected on the basis of exclusion clause. It is the case of the insurance that the insured had undergone CABG surgery in the year 1996 and definitely the disease was pre-existing one, hence no claim.
5. Now it is to be seen whether the insurance company was justified in pressing into the service, the exclusion clause of the policy terms and conditions to avail the claim. The answer is in negative. First of all it needs to be clarified as to what does pre-existing disease actually mean. Every disease can't be termed as pre-existing disease. The pre-existing disease can be termed as one which was very much in knowledge of the insured at the time of obtaining the policy or for which the insured was hospitalised or had undergone surgery soon before taking the policy. As per own admission of O.P. the complainant had undergone CABG surgery in the year 1996 i.e. nearly after 10 years of the policy, therefore, the plea taken by the insurance company as to pre-existing disease does not hold any water. The Hon'ble State commission in case titled National Insurance Co. V. Smt. Krishna Avtar Aggarwal II (2005) CPJ 747 held as under:
DISMISSED PAGE 4 OF 6 FA NO.950/2014 ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN "Insurance-Mediclaim Policy- Repudiation of claim- Concealment of pre-existing disease alleged- Complaint allowed by Forum- Hence Appeal- Non-Disclosure of disease for which insured was treated 15/20 years before,not amounts to concelament- Word "existing" means disease which exists at the time of taking the policy - O.P. should have insured that person in whose favour policy was being given was entitled to same or not- Contributory Negligence on part of O.P. cannot be ruled out- O.P. liable under policy- Order of Forum upheld."
6. Besides aforesaid, it is the case of the Appellant that Keloid is an abnormal condition of the skin, which at any time may erupt at any time where some injury/operation had taken place in past.
7. As part of Guidelines on Standardization IRDAI has already defined Pre-Existing Disease. A Pre-existing disease is defined as under (reproduced verbatim).
"Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and I or were diagnosed, and I or for which medical advice I treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter. (Life Insurers may define norms for applicability of PED at reinstatement)."
8. Furthermore, the CABG surgery, cannot be in any manner connected to the development of Keloid as even per the Appellant Keloid is an abnormal condition of the skin, which at any time may erupt at any time where some injury/operation had taken place in past. It is admitted case that after 1996 till 2006, the deceased Complainant had live a healthy life without any such problem. Further, it is well known that Keloid growth can trigger by any sort of skin injury -- an insect bite, acne, an injection, body piercing, burns, hair removal, and even minor scratches and bumps.
DISMISSED PAGE 5 OF 6 FA NO.950/2014 ROYAL SUNDARAM ALLIANCE INSURANCE CO. LTD. V. VIRENDER KUMAR JAIN Sometimes keloids form for no obvious reason. Keloids aren't contagious or cancerous. A keloid is different from a hypertrophic scar. Therefore, co-relation of Keloid with CABG surgery carried out in the year 1996 is mere a presumption and cannot hold water.
9. Keeping in view of the aforesaid discussion stated above of the case, we are of the considered view that the repudiation of claim of the insured by the O.P. was wholly unwarranted and devoid of any merit and therefore, it constituted deficiency of service. We, therefore, dismiss the appeal with no order as to costs.
10. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
11. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
12. File be consigned to record room along with a copy of this Judgment. Record of the District Commission be returned forthwith.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) (J.P. AGRAWAL) MEMBER Pronounced On:03.07.2023 DISMISSED PAGE 6 OF 6