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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
K.S. Chaudhari, Presiding Member and Prem Narain, Member
Ravinder Singh Bindra —Petitioner
versus
National Insurance Company Limited
and Ors. —Respondents
Revision Petition No.91 of 2013
(Against Order dated 13.9 2012 in Appeal No. 460/2012 of Haryana Stale Consumer Disputes Redressal Commission, Panchkula)
Decided on 27.10.2016
For the Petitioner:Mr. Sagar Bhatia, Advocate
For the Respondent Nos.1 and 2:Mr. Yogesh Malhotra and Mr. Udit Grover, Advocates
For the Respondent No.3: Ex parte
IMPORTANT POINT
It is not necessary that every person having hypertension shall suffer with heart disease.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Health-cum-Accident Policy—Treatment for Septicemia—Repudiation of claim based on Exclusion Clause—Claim is not within 30 days of issuance of policy and therefore, this exclusion relating to claim being inadmissible for treatment or admission within 30 days from issuance of policy is not applicable in present case—It is not necessary that every person having hypertension shall suffer with heart disease—Insurance Company has not produced any evidence or filed any document to show that deceased was suffering from any heart ailments or was treated for same before date of proposal—Even proposal form has not been filed by Insurance Company—Insurance Company has erroneously repudiated claim by relying upon so-called certificates of Doctors to whom they have paid fees—None of certificates by Doctors would establish that insured was aware of heart ailment—Claim allowed for Rs. 2,50,000/- alongwith 6% interest. (Paras 15 to 17)
Result: Revision Petition allowed.
Prem Narain, Member—This revision petition has been filed by the petitioner / complainant-Mr. Ravinder Singh Bindra against the order dated 13.9.2012 of the learned State Consumer Disputes Redressal Commission, Haryana, Panchkula (in short, ‘the State Commission’), passed in Appeal No. 460 of 2012.
2. Brief facts of the case are that the petitioner/complainant (insured) was the customer of Respondent No. 3 (State Bank of Bikaner and Jaipur, Faridabad). The Respondent No. 1 (National Insurance Company Ltd.) in tie-up with Respondent No. 3 floated Health-cum-Accident Policy namely ‘SBBJ-National Medikavach Bima’ for the account holders of Respondent No. 3. Respondent No. 1 insured the Petitioner under the aforesaid policy and issued a Policy Schedule bearing Policy No. 361102/48/06/8500004595 for sum assured of Rs. 2,50,000 covering the period from 2.1.2007 to midnight of 1.1.2008.
3. During the currency of the aforementioned ‘Medi Kavach Bima Policy’, the Complainant was admitted in Maharaja Agrasen Heart Institute and Research Centre, West Punjabi Bagh, New Delhi with complaint of loose motion and breathlessness. The complainant was admitted from 1.2.2007 to 12.2.2007 and incurred the expenses to the tune of Rs. 55,500. The case history of the complainant mentioned in the discharge summary mentions that the complainant was admitted with the ailment of difficulty in breathing with loose motion and upon investigation was found to be a case of Septicemia. Later, the complainant was aga in admitted in the Escorts Heart Institute and Research Centre, New Delhi (admitted from 23.2.2007 to 13.3.2007).
4. After discharge from the Escorts Heart Institute, the complainant submitted the claim form along with Discharge Summary, Final Bill and other medical Bills (Maharaja Agrasen Heart Institute and Research Centre and Escorts Heart Institute and Research Centre) to Opposite Party No. 3/Respondent No. 3 and claimed reimbursement of Rs. 2,50,000 i.e. total sum assured under the Policy, against the total expenses to the tune of Rs. 5,58,466. The latter forwarded the claim papers to Respondent No. 2/Opposite Party No. 2 for processing of the claim. While processing tire daim, the Opposite Party No. 2/Respondent No. 2 demanded more information, documents and raised query regarding the treatments, payments and previous history of the disease. After sending replies to the Respondent No. 2, the Petitioner requested tire same to process the claim at the earliest. Later on, the complainant received letter from tire Branch Manager of Respondent No. 1 informing that his claim has been repudiated in accordance with Policy Clause Nos. 4.1 and 4.2 as the patient was diagnosed to be suffering from Hypertension for 24 years and DM for six months, with severe MVR+AVR with Septicemia).
5. Aggrieved by the repudiation letter, the Complainant approached the District Consumer Disputes Redressal Forum, Faridabad alleging, deficiency of service against the Respondents/ Opposite Parties. The complaint was resisted by the opposite parties on the ground that the repudiation of the claim was based on the Exclusion Clause 4.1 and 4.2 of the terms and conditions which related to the pre-existing disease and bar of claim raised within 30 days of the issuance of policy. The District Forum vide its order dated 13.1.2012 passed the following order:—
“Respondent No. 1 Insurance Company is directed to pay an amount of Rs. 2,50,000 to the complainant with interest @ 9% p.a. from the date of complaint till the date of payment and also to pay Rs. 2,200 as litigation expenses.”
6. Aggrieved with the above order of the District Forum, opposite party No. 1/ respondent No. 1 preferred appeal before the State Commission, which was partly allowed on 13.9.2012 and the following order was passed:—
“This appeal is partly accepted and the impugned order is modified with the direction to the appellant-opposite party to pay the expenses incurred by the complainant for the first
