Bipul Chanda v. Royal Sundaram Alliance Insurance Company Ltd.
2010-02-01
ASHOK BHAN, B.K.TAIMNI
body2010
DigiLaw.ai
JUDGMENT 1. BRIAN, President The present Revision Petition has been filed by Bipul Chanda petitioner herein who was the complainant before the Calcutta District Consumer Disputes Redressal Forum, Unit-I (hereinafter referred to as 'the District Forum' for short) against Order dated 10.08.2006 passed by the West Bengal State Consumer Disputes Redressal Commission, Kolkata (hereinafter referred to as 'the State Commission' for short) whereby and whereunder the State Commission dismissed the appeal of the petitioner/complainant. 2. BRIEFLY stated, the facts leading to filing of this Revision Petition are as under: It is alleged in the complaint that the petitioner is a credit card holder of American Express Bank Limited and he received a proposal through the card division of the bank for purchasing Mediclaim Insurance Policy of the respondent-Insurance Company for himself and other members of his family by paying Rs. 16,955/- towards the premium. That on receipt of the premium, the respondent-Insurance Company issued a health shield certificate bearing No. HA0000617000101 for the period from 16.10.2002 to 15.10.2003. Policy was renewed for the period from 16.10.2003 to 15.10.2004 by paying a premium of Rs. 17,936/-. That the mother of the complainant, Smt. Rekha Chanda, was admitted to Wockhard Hospital and Kidney Institute, 111 -A, Rash Behari Avenue, Kolkata-700 029 for treatment of gall bladder stone which was detected by Dr. B. Ramana after thorough investigation and check up. Dr. Raman advised complainant's mother for operation and operated complainant's mother for gall bladder stone on 08.01.2003 on which an expenditure of Rs. 34,094/- was incurred. As per the Policy Norms, complainant submitted the claim form for reimbursement of medical expenditure with the respondent-Insurance Company on 25.11.2003 at their Kolkata Office along with all related documents. Respondent-Insurance Company, vide its letter dated 10.02.2004, repudiated the claim on the ground of pre-existing disease. Being aggrieved by the same, petitioner/ complainant filed the Complaint before the District Forum. On being served, the respondent-Insurance Company filed its Written Statement denying all the allegations. It was stated that the petitioner did not produce the USG report in respect of the treatment of Pencreatitis in the year 2001 at time of taking the Insurance Policy. 3. THE District Forum, after taking into consideration, the pleadings and the evidence lead by both the parties, dismissed the Complaint. 4. AGGRIEVED by the Order passed by the District Forum, petitioner filed an Appeal before the State Commission.
3. THE District Forum, after taking into consideration, the pleadings and the evidence lead by both the parties, dismissed the Complaint. 4. AGGRIEVED by the Order passed by the District Forum, petitioner filed an Appeal before the State Commission. The State Commission dismissed the Appeal holding that no evidence was adduced by the petitioner/complainant before the District Forum to substantiate the allegation that the claim was repudiated on unjustified reasons. That the petitioner mainly depended on his argument and pleading. That the discharge certificate of the treating hospital also confirms that the disease 2 years old which proves a nexus between the ailment of pancreas in 2001 and gall bladder stone in 2003. That since no documentary evidence was adduced by the petitioner to prove the allegation made in the Complaint, the State Commission dismissed the same holding that the disease was pre-existing. Aggrieved by the Order passed by the State Commission, petitioner/complainant has preferred this Revision Petition. 5. COUNSEL for the parties have been heard at length. 6. STATE Commission, in paragraph 4 of its Order, has recorded the following findings:- "We have perused the memo of appeals, the impugned judgment passed by the learned Forum and the written objection filed by the Respondent. We have also examined the documents placed before us by both sides. We find that no evidence was adduced by the Appellant before the learned Forum to substantiate his allegation that the claim was repudiated without justified grounds. The appellant mainly depended on his argument and pleading. The discharge certificate of the treating hospital also confirms that the disease is 2 years old, which proves a nexus between the ailment of Pancreas in 2001 and Gall Bladder stone in 2003. Since no documentary evidence could be adduced by the Appellant to prove his allegation before us we are of the considered that the disease must have pre-existed at the time of taking out the policy. The appeal, therefore, fails and be dismissed on contest without cost. The orders of the learned Forum dated 9.6.05 are affirmed." We have perused the certificate issued by Dr. J. S. Rajkumar, relying upon which the District Forum as well as the State Commission have recorded the finding that the insured had suppressed the fact of preexisting disease at the time of taking of the Policy. The certificate dated 02.02.2004 issued by Dr.
J. S. Rajkumar, relying upon which the District Forum as well as the State Commission have recorded the finding that the insured had suppressed the fact of preexisting disease at the time of taking of the Policy. The certificate dated 02.02.2004 issued by Dr. J. S. Rajkumar reads as under: "Dear Ms. Sangeetha, Most probably, the gall stones caused the pancreatitis way back in Oct 2001. Funny that there was no U/S scan report! All pancreatitis patients, treated anywhere, have at least an U/S scan if not a CT Scan. So it is pre-existing disease. Yours truly... S/d." 7. PERUSAL of the same would show that Dr. J. S. Rajkumar issued the certificate on the basis of probability. According to him, the gall bladder stones caused the pancreatitis way Back in October 2001. But this does not prove that Smt. Rekha Chanda had stones in gall bladder at the time of taking the Insurance Policy. Even the discharge summary issued by Repose Clinic and Research Centre Private Limited, Kolkata states that Smt. Rekha Chanda was suffering from acute pancreatitis. There is nothing to indicate in the discharge certificate that Smt. Rekha Chanda was having stones in ' the gall bladder in the year 2001. The reliance placed by the Foras below on the certificate issued by Dr. J. S. Rajkumar and the discharge summary referred to above, does not show that the insured was either having stones in the gall bladder or that she had knowledge about the same prior to the taking of the Policy. 8. COUNSEL for the respondent-Insurance Company then contended that the petitioner had suppressed material fact of not disclosing in the proposal form that his mother (patient) was suffering from pancreatitis in the year 2001. The proposal form shows that the patient has stated NIL and Not Applicable respectively in the columns "illness/disease/disablement" and "existing since" against his mother's name. The aforesaid ground was taken by the respondent in the Written Statement. We do not find any substance in this submission either. The claim of the petitioner/complainant was not rejected by the Third Party Administrator on the ground that the petitioner had failed to disclose in the proposal form the fact that his mother was suffering from pancreatitis.
The aforesaid ground was taken by the respondent in the Written Statement. We do not find any substance in this submission either. The claim of the petitioner/complainant was not rejected by the Third Party Administrator on the ground that the petitioner had failed to disclose in the proposal form the fact that his mother was suffering from pancreatitis. The claim was repudiated on the ground that the mother of the petitioner was suffering from the disease prior to the taking of the Insurance Police in 2001. The ground of repudiation was not that the petitioner had suppressed the material facts by not disclosing in the proposal form that his mother was suffering from pancreatitis. In the Written Submission filed before the State Commission, the respondent- Insurance Company did not take the ground that the Complaint is liable to be rejected on the ground that the petitioner had suppressed the material facts by not disclosing in the proposal form the fact of his mother suffering from pancreatitis. It seems that the said ground was never stressed either before the District Forum or before the State Commission. Our belief is strengthened by the fact that the State Commission has not discussed this point in their Order. Since, this point was not taken before the State Commission, the respondent cannot be permitted to take this point for the first time before us. For the reasons stated above, the Order passed by the District Forum as well as that of State Commission is set aside and the Complaint filed by the petitioner is allowed. Respondent-Insurance Company is directed to pay to the petitioner/complainant Rs. 34,094/-, i.e., the amount claimed in the Complaint along with interest @ 9% p.a. from the date of filing of the Complaint till its realisation. A sum of Rs. 15,000/- is awarded by way of compensation for mental agony and undue harassment caused to the petitioner and Rs. 10,000/- are awarded are costs. The above-said amount is to be paid by the respondent-Insurance Company to the petitioner within one month from the date of this Order failing which the amount shall carry a further interest @ 9% p.a. from the date of default till realization.