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2013 DIGILAW 622 (UTT)

NEW INDIA ASSURANCE COMPANY v. SHASHI RANI

2013-10-03

B.C.KANDPAL, C.C.PANT

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ORDER (Per: Mr. C.C. Pant, Member): This is insurer’s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 19.03.2010 passed by the District Forum, Dehradun in consumer complaint No. 26 of 2006. By the order impugned, the District Forum has allowed the consumer complaint and directed the appellant – opposite party to pay sum of Rs. 2,00,000/- to the respondents – complainants together with interest @7% p.a. from the date of filing of the consumer complaint till payment. 2. Briefly stated, the facts of the case as mentioned in the consumer complaint, are that late Sh. Vinod Kumar Singhal, the deceased husband of respondent No. 1 and father of respondent Nos. 2 to 4, had during his lifetime, purchased a Hospitalisation and Domiciliary Hospitalisation Benefit Policy from the appellant – The New India Assurance Company Limited for himself as well as his wife for insured sum of Rs. 2,00,000/- each. The said policy was valid for the period from 08.09.2004 to 07.09.2005. It is alleged that after taking the said policy, the insured late Sh. Vinod Kumar Singhal suffered heart attack and was admitted in Indraprastha Apollo Hospital, New Delhi, where he had to undergo surgery for Double Valve Replacement and CABG grafts. The claim for reimbursement of the medical expenses was lodged with the insurance company and the required documents were also submitted with the insurance company. However, the claim lodged was repudiated on the ground that the claim falls under exclusion clause No. 4.2 of the policy and that the discharge summary states that he was suffering from hypertension since 15 years, which falls under exclusion clause No. 4.1 of the policy. Thus, alleging deficiency in service on the part of the insurance company, a consumer complaint was filed before the District Forum, Dehradun by late Sh. Vinod Kumar Singhal, who unfortunately died during the pendency of the consumer complaint and, as such, his legal heirs were substituted in his place. 3. The insurance company filed written statement before the District Forum and pleaded that the policy was taken on 08.09.2004 and late Sh. Vinod Kumar Singhal was admitted in Indraprastha Apollo Hospital, New Delhi on 04.10.2004, within 26 days of taking the policy and hence the claim was not payable; that in the discharge summary of late Sh. 3. The insurance company filed written statement before the District Forum and pleaded that the policy was taken on 08.09.2004 and late Sh. Vinod Kumar Singhal was admitted in Indraprastha Apollo Hospital, New Delhi on 04.10.2004, within 26 days of taking the policy and hence the claim was not payable; that in the discharge summary of late Sh. Vinod Kumar Singhal issued by Indraprastha Apollo Hospital, New Delhi, it was clearly written that he was suffering from hypertension since last 15 years, which fact was not disclosed by him in the proposal form at the time of taking the policy and that the claim lodged was rightly repudiated and no deficiency in service was made by the insurance company. 4. The District Forum, on an appreciation of the material on record, allowed the consumer complaint vide impugned order dated 19.03.2010 in the above terms. Aggrieved by the said order, the insurance company has filed this appeal. 5. We have heard the learned counsel for the parties and have also perused the record. 6. At the time of taking the mediclaim policy in question, the insured late Sh. Vinod Kumar Singhal was medically examined by Dr. R.K. Jain, M.B.B.S., M.D., Combined Medical Institute, Dehradun and in the proposal form, it has been mentioned that E.C.G. and blood reports of the life assured were found normal. This shows that the policy was issued after medical examination of the life assured and that no abnormality was found in his health status and he was not suffering from any disease. 7. The case of the insurance company is that the life assured late Sh. Vinod Kumar Singhal was suffering from hypertension since last 15 years, as is mentioned in the discharge summary of the life assured issued by Indraprastha Apollo Hospital, New Delhi and this fact was suppressed by him at the time of taking the insurance policy and hence the claim was not payable and was rightly repudiated. 8. As stated above, at the time of taking the policy, the life assured was medically examined by a medical practitioner possessing the degree of M.B.B.S. and M.D. and the E.C.G. and blood reports of the life assured were found normal and no abnormality/shortcoming in his health status was found. 8. As stated above, at the time of taking the policy, the life assured was medically examined by a medical practitioner possessing the degree of M.B.B.S. and M.D. and the E.C.G. and blood reports of the life assured were found normal and no abnormality/shortcoming in his health status was found. The onus to prove that the life assured was suffering from hypertension since last 15 years from taking the policy of insurance and that he deliberately suppressed the said fact, was upon the insurance company. The insurance company has not filed any evidence to prove that the life assured was having knowledge that he was suffering from hypertension. The insurance company has also not filed any evidence to show that the life assured had taken treatment of the said illness from any medical practitioner or was admitted in any hospital in connection with the said disease prior to 04.10.2004, the date of admission of the life assured in Indraprastha Apollo Hospital, New Delhi. When the life assured was not in the know that he was suffering from hypertension, he was not supposed to disclose this fact in the proposal form. Even otherwise, as stated above, at the time of taking the policy, the life assured was medically examined and he was found hale and hearty and no abnormality in his health was found. 9. This apart, hypertension is usually a lifestyle disease and can easily be controlled with conservative medicine, as has been held by the Hon’ble National Commission in the case of Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose; IV (2012) CPJ 839 (NC), pressed into service by the learned counsel for respondents. “Disease” means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately fatal, for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim policy. As stated above, the insurance company has not filed any evidence to show that the life assured had ever taken treatment in connection with hypertension or was admitted in connection with the said disease prior to taking the mediclaim policy. As stated above, the insurance company has not filed any evidence to show that the life assured had ever taken treatment in connection with hypertension or was admitted in connection with the said disease prior to taking the mediclaim policy. If the insured had been hospitalized or operated upon for any disease in the near past, say, six months or a year, he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to “pre-existing disease”. Thus, the repudiation of the claim in the present case on the ground that the life assured was suffering from hypertension since last 15 years, can not be said justified. 10. So far as repudiation of the claim on the ground that the same falls under exclusion clause No. 4.1 of the policy is concerned, the insurance company has not filed any cogent or reliable evidence to show that at the time of taking the mediclaim policy, the life assured was having the knowledge that he was suffering from hypertension and he deliberately suppressed this fact in the proposal form. The insurance company has also not filed any evidence to show that the life assured was ever hospitalized prior to 04.10.2004. Thus, the repudiation of the claim on the ground that the life assured was suffering from pre-existing disease, also can not be said to be justified. 11. On account of the above discussion, we are of the definite view that the insurance company has definitely made deficiency in service by repudiating the claim by taking recourse to exclusion clause Nos. 4.1 and 4.2 of the policy and the District Forum was perfectly justified in allowing the consumer complaint. 12. So far as the quantum is concerned, from the perusal of the impugned order, it is evident that bills for sum of Rs. 3,40,642/- were filed on record, but since the insured amount was Rs. 2,00,000/- and hence the District Forum was justified in awarding the said amount and it can not be said that the District Forum has awarded any excess amount. The interest awarded @7% p.a. is also justified and is not on the higher side. Thus, the appeal lacks merit and is liable to be dismissed. 13. For the reasons aforesaid, appeal is dismissed. No order as to costs.