BRANCH MANAGER, THE ORIENTAL INSURANCE v. SUBHASH CHAND KHURANA
2014-09-22
B.C.KANDPAL, D.K.TYAGI
body2014
DigiLaw.ai
ORDER (Per: Justice B.C. Kandpal, President): This is insurer’s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 31.05.2008 passed by the District Forum, Dehradun in consumer complaint No. 72 of 2002. By the order impugned, the District Forum has allowed the consumer complaint and directed the appellants – opposite parties to pay the insured amount of Rs. 1,00,000/- to the respondent – complainant together with interest @9% p.a. from the date of filing of the consumer complaint till payment and Rs. 20,000/- towards mental agony. 2. Briefly stated, the facts of the case as mentioned in the consumer complaint, are that the complainant had purchased an Industrial Mediclaim Insurance Policy from The Oriental Insurance Company Limited for insured sum of Rs. 1,00,000/-. The said policy was valid for the period from 27.10.2000 to 26.10.2001. It was alleged that during the validity of the insurance policy, on 16.06.2001, the complainant met with an accident and during treatment of which, the complainant suffered heart ailment. On 20.01.2000, the complainant had got himself medically examined at Escorts Heart Institute & Research Centre, New Delhi and he was found hale and hearty and no abnormality was found in his health. On 06.09.2001, the complainant was admitted in Escorts Heart Institute & Research Centre, New Delhi, wherein his coronary artery bypass surgery was performed, in which the complainant spent a sum of Rs. 3,00,000/-. The complainant submitted the claim with the insurance company, which was repudiated by the insurance company through their letter dated 28.12.2001 on the ground that the complainant was suffering from angina disease for the last 2½ years, i.e., before taking the mediclaim policy in question and, as such, the claim was not payable as per exclusion clause No. 4.0 of the policy. Alleging deficiency in service on the part of the insurance company, the complainant filed a consumer complaint before the District Forum, Dehradun. 3.
Alleging deficiency in service on the part of the insurance company, the complainant filed a consumer complaint before the District Forum, Dehradun. 3. The insurance company filed written statement before the District Forum and pleaded that the complainant has concealed the material facts with regard to his health at the time of taking the policy; that the complainant was suffering from angina disease from before taking the policy, which he did not disclose in the proposal form; that as the complainant was suffering from pre-existing disease and hence the claim was not payable by the insurance company and was rightly repudiated and that there is no deficiency in service on their part. 4. The District Forum, on an appreciation of the material on record, allowed the consumer complaint vide impugned order dated 31.05.2008 in the above manner. Aggrieved by the said order, the insurance company has filed the present appeal. 5. We have heard the learned counsel for the parties and have also perused the record. 6. The mediclaim policy in question was purchased by the complainant on 24.10.2000 and the same was valid for the period from 27.10.2000 to 26.10.2001. The insurance company has repudiated the claim of the complainant on the ground that the complainant was suffering from angina disease for the last 2½ years, i.e., before taking the mediclaim policy in question and which had increased to 3rd stage and, as such, the claim was not payable by the insurance company. 7. There is no dispute with regard to the fact that the complainant had got himself medically examined at Escorts Heart Institute & Research Centre, New Delhi on 20.01.2000 and the Echo report issued by the said hospital (Paper Nos. 5kha/22 to 23 of the original record) shows that no abnormality was found in the health of the complainant and at that time, the complainant was not found suffering from angina disease. The test reports attached with the said report also show that no abnormality was found in the health of the complainant and everything was found within the manageable limit. 8.
The test reports attached with the said report also show that no abnormality was found in the health of the complainant and everything was found within the manageable limit. 8. The insurance company in support of its defence has placed reliance on the discharge summary of the complainant issued by Escorts Heart Institute & Research Centre, New Delhi (Paper No. 22kha/3 of the original record), wherein it has been mentioned that the complainant was having angina on exertion class II for the last 2½ years which had increased to class III for the last 2 months. In the said discharge summary, it has further been mentioned that the complainant was not having any history of myocardial infarction in the past. The said report has been made basis by the insurance company for repudiating the claim of the complainant. The complainant has specifically averred in para 7 of his affidavit dated 23.12.2002 (Paper Nos. 21ka/1 to 21ka/5) that when he consulted the doctor in regard to the discharge summary and stated that the doctor has stated that he was suffering from angina for the last 2½ years, the doctor told him that inadvertently, he may have mentioned 2½ years instead of 2½ months. However, as the case may be, as is stated above, the complainant was medically examined at Escorts Heart Institute & Research Centre, New Delhi on 20.01.2000 and at that time, no abnormality was found in the health of the complainant and he was not found suffering from any disease. The policy in question was purchased by the complainant on 24.10.2000 and the same was effective for the period from 27.10.2000 to 26.10.2001 and there is nothing on record to suggest that at the time of taking the policy, the complainant was suffering from angina disease or some other disease and he suppressed this fact in the proposal form and made deliberate misstatement at the time of taking the policy. 9. This apart, the record does not show that the complainant was in the knowledge of the fact that he was suffering from any angina disease at the time of taking the policy and since the complainant was not in the knowledge of the said disease at the time of taking the policy, he can not be held liable for concealing the said disease.
The insurance company has certainly made deficiency in service by repudiating the legitimate claim of the complainant and the view to that effect taken by the District Forum is perfectly justified and can not be faulted with. 10. Learned counsel for the insurance company cited a decision of the Hon’ble Apex Court in the case of Satwant Kaur Sandhu Vs. New India Assurance Company Limited; IV (2009) CPJ 8 (SC), wherein it has been held that the insured is under obligation to make true and full disclosure of information within his knowledge. There can not be any doubt with regard to the above principle, but in the present case, as is stated above, it is not proved that the complainant was having the knowledge of the said disease at the time of taking the policy and he can not be held liable for concealing the same. Learned counsel for the insurance company also cited a decision of the Hon’ble Allahabad High Court rendered in the case of Brahm Dutt Sharma Vs. Life Insurance Corporation of India; AIR 1966 Allahabad 474, wherein it has been held that the declarations made in the application for a policy on life amount to warranty and form basis of the policy and if it is found that the averments contained in the application are false, the contract would be vitiated and become unenforceable in law. In the instant case, it is not proved that the complainant has made any false statement at the time of taking the policy. 11. So far as the quantum is concerned, there is no dispute with regard to the complainant that the complainant has spent more amount than the insured amount in his treatment, but since the insured amount is Rs. 1,00,000/- and hence the District Forum has rightly awarded the said amount. The District Forum has also awarded interest @9% p.a., which in our considered opinion, is on the higher side and need to be reduced to 7% p.a. Since the complainant has been awarded interest, there is no question of any separate compensation for mental agony and hence the award of Rs. 20,000/- passed by the District Forum towards compensation for mental agony need to be set aside. This way, the appeal succeeds partly and is to be allowed accordingly and the order impugned passed by the District Forum is to be modified as such. 12.
20,000/- passed by the District Forum towards compensation for mental agony need to be set aside. This way, the appeal succeeds partly and is to be allowed accordingly and the order impugned passed by the District Forum is to be modified as such. 12. For the reasons aforesaid, appeal is partly allowed. Order impugned dated 31.05.2008 passed by the District Forum is modified and the appellants are directed to pay the insured amount of Rs. 1,00,000/- to the respondent together with interest @7% p.a. from the date of filing of the consumer complaint till payment. No order as to costs.