National Consumer Disputes Redressal
United India Insurance Co. Ltd. vs Kanta Gupta on 14 February, 2012
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 4697 OF 2010 (From the order dated 08.09.2010 of the Punjab State Consumer Disputes Redressal Commission, Chandigarh in First Appeal no. 1370 of 2004) United India Insurance Co. Ltd Regional Office 136, Feroze Gandhi Market, Ludhiana Through its Deputy Manager Petitioner Regional Office 1, Kanchanjanga Building 18, Barakhambha Road New Delhi 110 001 versus Smt Kanta Gupta Wife of Late Sohan Lal Gupta 614, Lakkar Bazar, Ludhiana Respondent Through the legal representatives (i) Rakesh Kumar Gupta, son (ii) Mahesh Gupta, son (iii) Sanjay Gupta, son (iv) Smt Meena Gupta, daughter BEFORE: HONBLE MR. ANUPAM DASGUPTA PRESIDING MEMBER HONBLE MR. SURESH CHANDRA MEMBER For the Petitioner Mr. A. K. De, Advocate For the Respondent Mr. Sanjeev Ailawadi, Advocate Pronounced on 14th February 2012 ORDER
ANUPAM DASGUPTA This revision petition is directed against the order dated 08.09.2010 of by the Punjab State Consumer Disputes Redressal Commission, Chandigarh (in short, the State Commission) in First Appeal no. 1370 of 2004.
2(i) The respondent in this petition was the complainant before the District Consumer Disputes Redressal Forum, Ludhiana (in short, the District Forum). In her complaint, she alleged deficiency in service on the part of the opposite party (OP petitioner herein) insofar as the OP repudiated the claim for reimbursement of the expenditure of Rs.1,21,124/- that was incurred on the medical treatment availed of by the insured Sohan Lal, husband of the complainant. The mediclaim insurance policy for Rs. 2 lakh obtained by Sohan Lal was valid for the period 22.12.2000 - 21.12.2001. During 21 - 23.05.2001 and 06 - 11.11.2001 the insured had to be admitted to a local hospital for treatment of his renal problem. Despite treatment (including haemodialysis) on these two occasions and thereafter, the insured unfortunately expired on 21.06.2002. The claim of Rs.1,21,124/- was in respect of the expenditure incurred by the deceased insured for the aforesaid treatment and was filed with the OP/petitioner on 27.12.2001. However, the OP repudiated the claim, leading to the complaint.
(ii) On consideration of the pleadings, evidence and documents produced on record, the District Forum partly allowed the complaint by its order dated 15.09.2004 and directed the OP to decide the claim of the complainant as per the rules and regulations as well as terms and conditions of the policy, within one month of receipt of the copy of the order.
(iii) Against this order, the OP/petitioner went up in appeal to the State Commission. After hearing the parties and considering the pleadings, etc., the State Commission, however, passed the following order dismissing the appeal:
20. We find no merit in the present appeal and the same is dismissed. However, the order of the District Forum is required to be modified. Accordingly, the appellant insurance company is directed to pay Rs.2 lakh which is the sum insured to the respondent/complainant along with interest @ 7.5% from the date of repudiation of the claim till the date of realisation. The appellant insurance company shall also pay cost of litigation to the tune of Rs.5000/- for unnecessarily dragging the respondent in the present litigation. The order be complied within two months from the receipt of copy of the order.
3. In other words, the State Commission not only held the insurance claim to be admissible in the teeth of evidence to the contrary (as discussed below) but also went to the extent of directing the OP to pay the entire sum insured (Rs. 2 lakh) with interest, though the insurance claim of the complainant/respondent was of Rs.1,21,124/-. This naturally led to the OP filing this revision petition.
4. We have heard Mr. A. K. De, learned counsel for the petitioner- insurance company and Mr. Sanjeev Ailawadi, learned counsel for the respondent/complainant.
5. Mr. De has stated that the petitioner would press its general point regarding non-admissibility of an insurance claim under a mediclaim insurance policy in the event of the insured failing to disclose the material facts relating to the status of his health at the time of submitting the proposal for insurance. However, without prejudice to its above-mentioned stand, the petitioner would not object to a direction to pay to the respondent the sum of Rs. 1,21,124/- without any interest thereon.
6. Mr. Ailawadi has, however, repeatedly pressed for award of a reasonable amount of interest, mainly on the ground that the expenditure had been incurred in 2001.
7 We have carefully considered the submissions of the learned counsel for the parties, in the light of the evidence on record.8
(i) Both the Fora below have somehow failed to notice the non-disclosure of material facts by the deceased insured regarding the status of his health.
(ii) The complainant has clearly stated in her complaint that her husband suffered from DM Triopathy CRF LVF (kidney problem) and he was admitted to Deepak Hospital, Sarabha Nagar on 21.05.2001 and was put on haemodialysis from that date. An attempt has been made in making this statement in the complaint as if this was a sudden attack of some disease, noticed on that specific date. However, it is a well-known fact that a person cannot suddenly develop diabetes mellitus (DM) or CRF (chronic renal failure) - in fact, not even in a short period of time. In other words, the only logical and medically acceptable explanation in respect of the facts recorded in the discharge certificate issued by the Deepak Hospital could be what was stated by the petitioner insurance company in repudiating the claim which, in turn, was based on the advice of a qualified and experienced medical practitioner, namely, Dr. Pankaj Bhalla. Dr. Bhalla gave an affidavit before the District Forum that the insured was a patient of diabetes mellitus and chronic renal failure for the last 15 years, as mentioned in the discharge certificate of Deepak Hospital. Dr. Bhalla further opined that the diabetic nephropathy that the insured deceased suffered from and was treated for at that hospital was a complication of long standing diabetes mellitus. Chronic renal failure was also the result of the same long-standing disease. This expert evidence, based on admitted record could not be brushed aside in the manner that the Fora below have.
(iii) This would clearly establish that the insured had deliberately suppressed some vital information about the status of his health while obtaining the mediclaim insurance policy in question and renewing it from time to time, including for the period mentioned-above.
(iv) Therefore, in accordance with the legal position settled in this respect by the Apex Court in a catena of judgments, the petitioner insurance company could not be held guilty of deficiency in service in repudiating the insurance claim for reimbursement of the medical expenditure on the treatment of the deceased insured.
9. In conclusion, therefore, we dispose of this revision petition by observing that without prejudice to its contentions in this case the petitioner insurance company shall pay to the respondent/complainant the sum of Rs.1,21,124/- within four weeks from the date of this order. This being so in the specific facts and circumstances of the case, this direction shall not be cited as a precedent prejudicial to the petitioner. We also direct that deposits, if any, made by the petitioner with any Forum in compliance of the directions of this Commission in the course of these proceedings be refunded to the petitioner on appropriate application being made.
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[Anupam Dasgupta] Presiding Member Sd/-
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[Suresh Chandra] Member satish