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2012(1) CPR 300
UTTARAKHAND STATE CONSUMER DISPUTES REDRESSAL COMMISSION, DEHRADUN
B.C. Kandpal, President C.C. Pant and Mrs. Kusum Lata Sharma, Members
National Insurance Company Ltd. —Appellant
versus
Ranjeet Kumar Gupta —Respondent
First Appeal No. 35 of 2008
Decided on 15.11.2011
Counsel for the Parties
For the Appellant:Mr. Savita Sethi, Advocate.
For the Respondent:Vijay Chandna, Advocate.
IMPORTANT POINT
Suppression of any material information by insuree would amount to breach of contract which would justify repudiation of claim by insurance company.
Headnote:Consumer Protection Act, 1986—Sections 15 and 17—Insurance—Bypass surgery—Claim for reimbursement repudiated by appellant on ground of pre-existing disease—District Forum directed Insurance Company to pay sum of Rs. 2,00,000 together with 9% interest—Complainant was hypertensive, diabetic, reformed smoker and had positive family history of ischemic heart disease—In history of patient, Escorts Heart Institute & Research Centre, New Delhi clearly mentioned that he presented himself with history of angina on exertion three months back—He was already suffering from the disease from before taking policy and suppressed this fact in proposal form and got policy issued—Insurance Company was fully justified in repudiating claim—View taken by District Forum being against evidence and material on record, order impugned suffers from legal infirmity and is liable to be set aside. (Paras 9 to 14)
B.C. Kandpal, President— This is insurer’s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 11.1.2008 passed by the District Forum, Dehradun in consumer complaint No.32 of 2005. By the order impugned, the District Forum has allowed the consumer complaint and directed the opposite parties Insurance Company to pay a sum of Rs.2,00,000 to the complainant together with interest @ 9% p.a. from the date of filing of the consumer complaint till payment.
2. In brief the facts of the case are that the complainant Sh. Ranjeet Kumar Gupta purchased a Hospitalisation and Domiciliary Hospitalisation Benefit Policy for himself; his wife and two children from National Insurance Company Limited. The said policy was valid for the period from 10.3.2004 to 9.3.2005. Under the, said policy, the complainant was insured for sum of Rs.2,00,000. On 5.4.2004, the complainant felt some medical problem and he contacted Dr. Gilhotra, Heart Specialist who referred him to Delhi. The complainant went to Escorts Heart Institute & Research Centre, New Delhi, where his Angiography was done and on 8.4.2004, the complainant was advised for surgical revascularization. On 10.4.2004, the complainant got himself admitted in Escorts Heart Institute and Research Centre, New Delhi and his bypass surgery was done. The complainant has alleged that he had spent a sum of Rs.2,08,505 on his treatment and Rs. 12,283 towards medical expenses. In all sum of Rs.2,36,088 was spent on his treatment. The complainant lodged a claim with the Insurance Company for the reimbursement of the medi-claim expenses. The claim of the complainant was repudiated by the insurance’ company. Thereafter, 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 claim was not found payable under Clauses 4.1 and 4.2 of the policy because the disease with which the complainant insured had suffered, was pre-existing at the time of obtaining the policy and that the expenses on Hospitalisation/Domiciliary Hospitalisation were incurred during first 30 days from the date of commencement of insurance cover. It was also pleaded that the claim of the complainant 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 11.1.2008 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. Learned Counsel for the Insurance Company submitted that the claim of the complainant has rightly been repudiated by the Insurance Company under Clauses 4.1 and 4.2 of the policy for the reason that the disease with which the complainant had suffered during the validity of the insurance policy was pre-existing and also for the reason that the medical expenses were incurred during first 30 days from the date of commencement of insurance cover/risk. Learned Counsel drew our attention towards the above-mentioned clauses of the policy, which read as under:
“4.1 Such diseases which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms, which existed prior to the insured person had knowledge that the symptoms were relating to the sickness. Complications arising from pre-existing disease will be considered part of that pre-existing condition.
4.2 Any expenses on Hospitalisation/Domiciliary Hospitalisation incurred during first 30 days from the date of commencement of insurance cover except in case of injury arising out of accident.”
7. Learned Counsel further referre
