Mahendra Prasad, Mahendra Pd. Bhadani v. General Manager, New India Assurance Company
2007-11-06
NAVANITI PRASAD SINGH
body2007
DigiLaw.ai
Judgment 1. Heard. 2. The petitioner had taken a Mediclaim Insurance Policy from the respondent-New India Assurance Company Limited, in the year 2001. This policy was thereafter renewed for the next year. It was thereafter renewed for 2003-2004 as well. In 2004 she was taken seriously ill and had to be admitted in All India Institute of Medical Sciences, New Delhi where she underwent an open heart surgery. Claims were accordingly made on basis of Mediclaim Insurance Policy, which ultimately came to be rejected. The rejection was primarily based on the report of a surveyor, as contained in Annexure A being the report of Dr. Arun Agrawal. The tenor of the report is that the petitioner had been suffering from Rheumatic heart disease from before and had been hospitalized way back in 1991 also. This report also indicates that the said medical surveyor could not take copy of medical report from All India Institute of Medical Sciences, New Delhi and could meet "some persons at a separate place and settled the issue". This clearly discloses that he could not receive officially any document to support his report. Insurance Company then consulted a local doctor, who opined that the disease might have started in early age with gradual progression. In his opinion the disease starts at the age of 5-15 years. On basis of the aforesaid in view of clause 4.1 of the prospectus to the policy the claim was rejected as a case of suppression and non-disclosure of pre-existing disease, which was material to the policy. The stand of the Insurance Company apart from above disclosure is that the report of the surveyor is binding on them and once the surveyor reported pre-existing disease they had no option but to repudiate the insurance claim. 3. Having considered the matter, I would like to point out a general misapprehension on behalf of the Insurance authority that they are not bound by the report of surveyor as they professed in the counter affidavit. It is a plea of convenient taken by them. Every day before the Consumer Forum there are large number of cases wherein if one surveyor reports in favour of the insurance, the insurance company appoint another surveyor till they get a negative report and report in favour of the insurance company.
It is a plea of convenient taken by them. Every day before the Consumer Forum there are large number of cases wherein if one surveyor reports in favour of the insurance, the insurance company appoint another surveyor till they get a negative report and report in favour of the insurance company. Their stand is that they have to be satisfied and the surveyor is not the last word but apparently when they wanted to reject a claim they conven-iently take the stand as is in the present counter affidavit that they are bound by the report of the surveyor which, in fact, and in law they are not. The surveyors only supply them with basic facts investigated but the decision has to be taken by the insurance company itself. In the present case the petitioner has denied the knowledge of Rheumatic heart disease from before and has denied concealing the said information even though she had knowledge of it. Here I may point out that clause 4.1 of the Prospectus to the policy can be invoked only in those cases where a person is aware of a disease and knowingly and deliberately suppresses its disclosure. It cannot be invoked to repudiate a claim even in a case where a person was suffering from a disease earlier but was not aware of it. By way of illustration I may point out that large number of people suffer from Rheumatic heart disease for long period either without being diagnosed of Rheumatic heart disease or without the disease reaching serious proposition to be tackled and diagnosed seriously. Unaware of the disease people continue to suffer and when it is aggravated, such diagnosis is made to the disease and past symptoms co- related to them. From this it cannot be said that the person was aware of the disease and deliberately concealed the same. Clause 4.1 would not come into play in such a case. Therefore, as a matter of law when the insurance company revoked the claim of the petitioner, it had to come a finding based on material on records that the petitioner was suffering from a disease from before taking the policy and that she was aware of it and had failed to disclose the same or in other words, deliberately concealed the same. 4.
4. In the present case, though there is a finding of disease being from before, there is no material to support it. No report of All India Institute of Medical Sciences, New Delhi has been filed or brought on record and admittedly none is available to the insurance company. Further there is no finding nor any material to justify the finding that the petitioner was aware of Rheumatic heart disease from before and had concealed the same knowingly. In that view of the matter the decision to revoke the policy or repudiate the claim cannot be sustained. The decision impugned not to honour the Mediclaim Policy is thus set aside. 5. However, in the present facts and circumstances the insurance company would disclose the material available to it to disclose apart from two reports aforesaid for the purpose of repudiating the claim having there being an explanation on the material so disclosed and given, the company would then take a decision and communicate the same to the petitioner. All this would be done within a period of two months from the date when the petitioner files a copy of this order before the Chief Regional Manager, New. India Assurance Company, Patna. 6. The writ petition is thus disposed of.