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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Dr. B.C. Gupta, Presiding Member, Prem Narain, Member
Arun Kumar —Petitioner
versus
New India Assurane Co. Ltd. & Ors. —Respondents
Revision Petition No.3816 of 2012
(Against the Order dated 19/07/2012 in Appeal No. 250/2003 of the State Commission Delhi)
Decided on 23.9.2016
Counsel for the Parties:
For the Petitioner:Ms. Vandana Sharma, Advocate
For the Respondents:Mr. P. K. Seth, Advocate
IMPORTANT POINT
It is bounden duty of Insurance Company to have verified information given in proposal form by obtaining suitable expert opinion.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Mediclaim Policy—Repudiation of death claim on ground of suppression of pre-existing disease— Opinion given by panel doctors is based on presumption only that complainant would have been suffering from degenerative joint disease for last 4 to 5 years—Said presumption has not been supported by any medical evidence or record which may indicate that complainant withheld any material fact about his health condition from knowledge of Insurance Company while making application for getting policy—Complainant has been taking insurance policy since year 1997—It was bounden duty of Insurance Company to have verified information given in proposal form by obtaining suitable expert opinion—Discharge summary of Hospital stated that complainant had difficulty in walking for a long time and history of borderline hyper tension but not on any medication—District Forum rightly observed that non-disclosure of such conditions in proposal form cannot be blown out of proportion so as to disentitle complainant from claim amount from Insurance Company—Claim has been wrongly repudiated by Insurance Company on ground of non-disclosure of information about health conditions in proposal form—Impugned order passed by State Commission set aside and order passed by District Forum restored and Insurance Company directed to make payment to complainant. (Paras 10 and 11)
Result: Revision Petition allowed.
Dr. B.C. Gupta, Presiding Member—This revision petition has been filed under section 21(b) of the Consumer Protection Act, 1986, against the impugned order dated 19.07.2012, passed by the Delhi State Consumer Disputes Redressal Commission, (hereinafter referred to as “the State Commission”) in Appeal No. A-250/2003, New India Assurance Co. Ltd. & Ors. vs. Arun Kumar, vide which, while allowing the appeal on the ground of suppression of pre-existing disease at the time of obtaining the insurance policy, the order passed by the District Consumer Disputes Redressal Forum on 18.02.2003, allowing the consumer complaint, filed by the present petitioner was set aside.
2. The facts of the case are that the petitioner/complainant has been obtaining the medi-claim policy from the respondent, New India Assurance Company since 1997 and he also subscribed to the Good Health Medi-claim Insurance Plan, offered to the holders of Citibank Credit Card. As stated by the complainant, he suffered from degenerative joint disease in both knees, which was first detected and diagnosed on 20.01.2001. The complainant was hospitalised at Sita Ram Bhartiya Institute of Science and Research, New Delhi on 29.04.2001 and discharged on 30.04.2001. He submitted a claim on 16.06.2001 alongwith relevant documents, giving details of the treatment taken at the hospital and submitted a medical bill of Rs. 38,240.50. However, the Insurance Company repudiated his claim vide letter dated 14.08.2001, saying that as per the medical report, he had been suffering from the said disease for the last 4 to 5 years atleast and hence, the claim was not payable. The complainant filed the consumer complaint in question, seeking directions to the Insurance Company to pay him the amount claimed i.e. Rs. 38,240.50 and litigation cost of Rs. 11,000/- alongwith interest @ 24% per annum till the date of payment of claim.
3. The complaint was contested by the respondent, Insurance Company by filing their written submissions before the District Forum, stating that the complaint was not maintainable at Delhi as the Regional Office of the Insurance Company did not have a branch at Delhi. It was also stated that a contract of insurance was one of uberrima fides, that is of utmost good faith and hence, the claimant should have disclosed true condition about his health at the time of filling the proposal form. There was, therefore, no deficiency in service on the part of the respondent.
4. The District Forum, after taking into account the averments of the parties, allowed the complaint vide their order dated 18.02.2003, in which they stated as follows:-
7. As per the discharge summary (Annexure-C) has been shown history of difficulty in walking for a long time and history of borderline hypertension but not on any medication. Non-disclosure of such problem in the Proposal Form by the complainant can not be blown out of proportion to throw out the case of complainant or to disentitle him to claim the amount from the respondent.
The District Forum directed payment of Rs. 38,240/- to the complainant for his treatment alongwith interest @ 9% per annum, payable from 01.10.2001 till realisation.
5. Being aggrieved against the said order, the Insurance Company challenged the same before the State Commission. The State Commission decided the appeal vide order dated 04.01.2007, which was challenged by the Insurance Company by way of revision petition before this Commission. The said revision petition was allowed vide orders of this Commission on 26.05.2011, and a direction was given to the State Commission to decide the case afresh, after discussing the merits of the case as per law. Vide impugned order dated 19.07.2012, passed in this case and other allied cases, the State Commission set aside the order of the District Forum, taking the plea that the complainant had not disclosed his pre-existing disease at the time of taking the insurance policy. Being aggrieved against the said order, the complainan
