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2010(2) CPR 398 (NC)
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ashok Bhan, President and S.K. Naik, Member
National Insurance Company Ltd. —Petitioner
versus
Sardar Kulbir Singh —Respondent
Revision Petition No. 1516 of 2006
Decided on 14.5.2010
Counsel for the Parties:
For the Petitioner:Mr. Kishore Rawat, Advocate.
For the Respondent:Mr. Ajay Uppal, Advocate.
IMPORTANT POINT
Only on basis of discharge summary insurance company could be said to have proved that insured complainant was suffering from psre-existing diseases mentioned in discharge summary in absence of any evidence to prove that insured in fact was suffering from such disease before taking policy.
Headnote:Consumer Protection Act, 1986—Sections 12 and 17—Mediclaim policy claim—Policy was taken on 6.9.1994 and continued to be renewed lastly from 24.9.1997 to 23.9.1998—Complainant-Insured underwent Artey By-pass Grafting on 15.7.1998—Claim repudiated on ground that respondent suppressed fact that he was suffering from heart problem while taking policy—Fora below allowed complaint—Revision—Petitioner relied on report of its panel doctor who after examining discharge summary came to conclusion that disease for which respondent was suffering was a pre-existing—No evidence was produced to show that respondent was suffering from Chronic Stable Angina for 10 years—Affidavit of doctor who prepared discharge summary was not filed—Discharge Summary did not disclose on whose information Doctor had recorded fact that respondent was suffering from Chronic Stable Augina for last 10 years—Except discharge summary no other evidence or material to show that respondent was suffering from such disease—No reason or ground to interfere. (Paras 11 to 16)
Ashok Bhan, President—Complainant/respondent obtained a Mediclaim (Hospitalisation and Domicillary Hospitalisation Benefit) Policy from the petitioner-Insurance Company for the first time on 06.09.1994 for Rs.1,00,000/- which was effective till 05.09.1995. Thereafter., respondent kept on subscribing to the said Mediclaim Policy and the last spell of the Policy was for the period 24.09.1997 to 23.09.1998 and the insured amount was enhanced to Rs. 2,00,000/-.The respondent suffered from some Cardiac problem and was admitted to Escorts Heart Institute and Research Centre, Okhla on 15.07.1998 and, after necessary tests, had undergone three Artery By-pass Grafting on 15.07.1998 where he incurred an expense ofRs.1,73,850/- regarding which respondent filed a claim with the petitioner-Insurance Company. Petitioner repudiated the claim on twin grounds, firstly, that the last Policy was obtained after a gap of 17 days as the earlier Policy had expired on 07.09.1997 and the same was renewed on 24.09.1997 and, secondly, that the respondent had suppressed the fact that he was suffering from Heart problem while obtaining the Mediclaim Policy and, as such, the case of the respondent falls squarely within the ambit of Exclusion Clause 4 of the Terms and Conditions of the Policy. Being aggrieved, complainant/respondent filed the Complaint before the District Consumer Disputes Redressal Forum (Central), Maharana Pratap Bus Terminal, Mezzanine Floor, Kashmere Gate, Delhi (for short ‘the District Forum’).
2. On being served, petitioner filed its Written Statement stating that the rejection of the claim of the respondent was made after thorough investigation of the case after due application of mind. That while obtaining the Mediclaim Policy, the respondent deliberately concealed the facts about his illness and fully knowing about his Heart problem, respondent increased the insured amount from Rs.l,00,000/- to Rs.2,00,000/- surreptitiously. That it was on the detailed Report of their Panel Doctor, Dr. Vinod Gandotra that the claim of the respondent was repudiated. Thus, denying the allegation made in the Complaint, petitioner prayed for dismissal of the Complaint.
3. District Forum, after taking into consideration, the pleadings and the.. evidence led by the parties, allowed the Complaint, holding petitioner-Insurance Company guilty of deficiency in service. The petitioner was directed to pay the sum of Rs. 1,73,000/- to the respondent along with interest @ 9% p.a. within 3 months of the filing of the claim till the date of payment. Rs. 1,000/- were awarded as litigation expenses.
4. Aggrieved by the Order passed by the District Forum, petitioner-Insurance Company flied the Appeal before the State Consumer Disputes Redressal Commission, Delhi (for short ‘the State Commission, which has been partly a1lowed directing the petitioner-Insurance Company to pay Rs.15,000/-besides the actual claim of Rs. 1,73,850/- which shall include the cost of litigation also. It was held that in such cases, in terms of Section 14 of the Consumer Protection Act, 1986 (for short ‘the Act1, instead of granting interest on the awarded amount, lump sum compensation should be awarded. The view taken by Hon’ble the Supreme Court of India in Sovingtore (India) Limited v . State Bank of India, New Delhi1 was relied upon in which it was held that unless and until there are such terms of contract as to the liability to pay interest, the interest cannot be awarded under the provisions of the Act. Interest can be awarded, if there are strong equitable grounds.
5. Aggrieved by the Order passed by the State Commission, petitioner- Insurance Company has preferred this Revision Petition. Counsels for the parties have been heard at length.
6. Before the State Commission, two fold arguments were raised, one, that the Policy obtained by the respondent was not continuous because the last Policy was obtained on 24.09.1997, after a gap of 17 days as the earlier Policy had expired on 07
