National Consumer Disputes Redressal
Lalit Kumar Garg & Anr. vs United India Insurance Co. Ltd. & 2 Ors. on 25 January, 2018
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 621 OF 2017 (Against the Order dated 16/11/2016 in Appeal No. 532/2016 of the State Commission Haryana) 1. LALIT KUMAR GARG & ANR. S/O. LT. DHARAMVIR GARG, S/O. BHAJAN LAL, R/O. KALRA COLONY, NEAR GEETA BHAWAN, PALWAL, TEHSIL AND DISTRICT-PALWAL HARYANA 2. VIPIN KUMAR GARG, S/O. LT. DHARAMVIR GARG, S/O. BHAJAN LAL, R/O. KALRA COLONY, NEAR GEETA BHAWAN, PALWAL, TEHSIL AND DISTRICT-PALWAL HARYANA ...........Petitioner(s) Versus 1. UNITED INDIA INSURANCE CO. LTD. & 2 ORS. THROUGH ITS BRANCH MANAGER, 68/1, JANPATH, NEW DELHI 2. UNITED INDIA INSURANCE CO. LTD. REPRESENTED THROUGH THE DULY AUTHORIZED SIGNATORY OF REGIONAL OFFICE SCO NO. 123-124, SECTOR 17B, CHANDIGARH 3. MEDSAVE HEALTH CARE(TPA) LTD. THROUGH ITS MANAGER, F-7011, LADO SARAI MEHRAULI, NEW DELHI-110030 ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE V.K. JAIN,PRESIDING MEMBER
For the Petitioner : Mr. Sameer Singh, Advocate For the Respondent :
Dated : 25 Jan 2018 ORDER
JUSTICE V.K.JAIN (ORAL)
Late Sh. Dharamvir Garg, father of the petitioner/claimant obtained a Tailor Made Group Mediclaim and Personal Accident Insurance Policy from the respondent. Initially the policy was purchased on 9.9.2011 for one year. The policy was renewed on 9.9.2012 for another year. Sh. Dharamvir Garg fell ill on 23.7.2012 and remain admitted in Metro Heart Institute, Faridabad. A sum of Rs.2 lakh was spent on his treatment out of which Rs.1 lakh was paid by the Insurance Co. The claim submitted by him, however, was repudiated on the ground that he was suffering from Coronary Artery Disease and Unstable Angina at the time the policy was initially taken by him and, therefore, he had concealed a material fact with respect to the state of his health. Since Dharamvir Garg later expired, the complainants approached the concerned District Forum by way of a consumer complaint seeking benefit under the insurance policy which the deceased had taken.
2. The complaint was resisted by the insurer which pointed out in its written version that as per the Discharge Summary of the deceased, he was a known case of Coronary Artery Disease, Unstable Angina Post PTCA and Stenting of his RCA was done on 13.8.2009 with Drug Coated Stenting. Reliance was placed on Exclusion Clause 4.1 which took pre-existing disease out of the scope of coverage under the policy taken by the deceased.
3. The District Forum having ruled in favour of the complainant, the insurer approached the concerned State Commission by way of an appeal. Vide impugned order dated16.11.2016, the State Commission allowed the said appeal and consequently dismissed the consumer complaint.
4. The Discharge Summary issued by Metro Heart Institute, Faridabad on 25.7.2012, to the extent it is relevant reads as under:-
"Mr. Dharam Vir Garg, 65 years old male, K/c/o CAD unstable Angina Post PTCA with stenting to RCA (13.8.2009), HTN, COPD, was admitted with complaints of chest pain, sweating & ghabrahat since half an hour."
It would thus be seen that the deceased was a CAD patient way back on 13.8.2009 when stenting to his RCA was done. The aforesaid disease was not disclosed by him while taking the insurance policy on 9.9.2011 or while getting the same renewed on 9.9.2012. The insured, therefore, concealed a material fact with respect to the state of his health from the insurer and in any case the pre-existing ailment was excluded under the Exclusion Clause contained in the insurance policy. The insurer was wholly justified in repudiating the claim. The view taken by the State Commission does not call for any interference by this Commission in exercise of its revisional jurisdiction. The revision petition is, therefore, dismissed.
......................J V.K. JAIN PRESIDING MEMBER