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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Dr. B.C. Gupta, Presiding Member and Dr. S.M. Kantikar, Member
Vipin Grover and Anr. —Petitioners
versus
New India Assurance Co. Ltd. —Respondent
Revision Petition No.2393 of 2011
(Against the Order dated 15/02/2011 in Appeal No. 1045/2009 of the State Commission Haryana)
Decided on 15.11.2017
For the Petitioners:Mr. Sameer Nandwani and Ms. Pooja Tandon, Advocates
For the Respondent:Dr. Anand Vardhan Sharma, Advocate
IMPORTANT POINT
In medical science, any major disease is a complex pathophysiological phenomenon having co-relation with other minor diseases also.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Mediclaim Policy—During subsistence of insurance policy petitioner No. 2 underwent procedure of PTCA and stent RCA—Claim rejected by OP on ground that petitioner No. 2 was suffering from pre-existing disease at the time of commencement of policy—Complaint dismissed by State Commission in appeal—Complainant underwent CABG in 1990 and it was brought to notice of OP at the time of filling of proposal form—For more than 16 years, Insured had no cardiac complaints—Disease was treated completely and patient was under medication—Patient remained active for more than 16 years—OP failed to prove that present treatment was due to pre-existing disease—Every human suffers trivial or minor health problems during his life span—In medical science, any major disease is a complex pathophysiological phenomenon having co-relation with other minor diseases also—If insurance companies co-relate each and every disease with pre-existing condition, helpless consumers will never succeed to get his genuine claim from insurance company—OP had repudiated claim on wrong premise which is unjustifiable—Order passed by State Commission set aside and revision petition allowed with costs of Rs.10,000/- to be paid by OP to complainant.
Held: The main controversy in this case is ‘whether the repudiation under clause 4.1 of the policy excludes all diseases/injuries which are from pre-existing disease when the cover incepts for the first time? It is an admitted fact that the complainant underwent CABG in 1990 and it was brought to the notice of the OP at the time of filling of proposal form. Thereafter, for more than 16 years, the insured had no cardiac complaints. In our view, the disease was treated completely and the patient was under medication. The patient remained active for more than 16 years. It appears that the OP had relied upon preponderance of probability that the persons who underwent CABG are prone for the recurrence. Even as per clause 15, already four years waiting period was over from commencement of policy. In 2007, he underwent angiography and angioplasty at Batra Hospital. Therefore, in our view, the present treatment of coronary PTCA was not a consequence of any pre-existing disease. It was neither late effect of previous cardiac ailment nor was there any pre-existing condition for which the patient needed angioplasty.
We are rather surprised that the insurance company tried all means to repudiate the claim on one or the other ground. The OP failed to prove that the present treatment was due to the pre-existing disease. It should be borne in mind that every human suffers trivial or minor health problems during his life span. In the medical science, any major disease is a complex pathophysiological phenomenon having co-relation with other minor diseases also. Therefore, if the insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, the insured i.e. helpless consumers will never succeed to get his genuine claim from the insurance company. For example, if one suffers Tuberculosis (TB) in childhood, gets cured completely by the radical Anti-koch’s treatment for 9 months; then, if he develops meningitis in his adulthood after span of 10 to 20 years, it shall not be construed as it was due to pre-existing disease. Therefore, in our view, the OP had repudiated the claim on wrong premise, which is unjustifiable.
On the basis of foregoing discussion, we set aside the order passed by the State Commission and allow this revision petition with costs of Rs.10,000/- to be paid by the OP to the complainant. The OP shall comply with the entire order within four weeks from the date of receipt of a copy of this order, failing which, the entire amount will carry interest @ 12% per annum till its realization. The parties are directed to bear their own costs. (Paras 9, 10 and 11)
Result: Revision Petition allowed.
Dr. S.M. Kantikar, Member—This revision petition has been filed under Section 21(b) of the Consumer Protection Act, 1986 against the order dated 15.02.2011 passed in First Appeal No. 1045 of 2009 by Haryana State Consumer Disputes Redressal Commission, Panchkula whereby the State Commission allowed the appeal of the opposite party and dismissed the complaint.
2. The brief facts that since 2001, Mr. Vipin Grover, petitioner No.1/complainant No. 1 took the medi-claim insurance policy from OP/New India Assurance Company Ltd.. The insurance cover was for his family members, including his father, R. K. Grover (Petitioner No. 2). The policy was continuously renewed every year. At the time of taking the policy, petitioner No. 2 had declared that he had heart attack in the year 1990 and took treatment. During the subsistence of the insurance policy, on 15.02.2007, petitioner No. 2 underwent procedure of PTCA and stent RCA at Batra Hospital and Research Centre. He was hospitalized there from 14.2.2007 to 17.2.2007. It was the cashless policy but the OP refused to allow cashless facility. Therefore, the petitioner/complainant No. 2 had to spend a sum of Rs.1,29,783/- on the treatment. Thereafter, he filed a claim before the OP for the hospitalization expenses, but it was rejected by the OP on the ground that the petitioner No. 2 was suffering from pre-existing disease at the time of commencement of policy. The claim could not be paid under exclusion clause 4.1 of the policy.
3. Aggrieved by the repudiation, the complainants filed the complaint before the District Consumer Disputes Redressal Forum, Sonepat ( in short, ‘the District Forum’).
4. The OP resisted the complaint by filing written statement and submitted that as per the exclusion clause 4.1 of the terms and conditions of the policy, the claim had been repudiated. It was submitted that Shri R. K. Grover was suffering from pre-existing disease at the commencement of the policy. Hence, the claim was not payable. Therefore, there was no deficiency in service on their part. The cashless facility is the discretion of the OP and for the patients having pre-existing disease, the said facility (cashless facility) could not be provided.
5. The District Forum allowed the complaint and directed the OP to pay Rs. 1,29,783/- with interest @ 9% per annum with costs of Rs.2,000/-. Being aggrieved by the order of the District Forum, the OP preferred first appeal before Haryana State Consumer Disputes Redressal Commission (in short, ‘the State Commission’). The State Commission allowed the appeal and dismissed the complaint. Being aggrieved by the impugned order of State Commission, the complainants have filed this revision petition.
6. We have heard the learned counsel for both the parties. The learned counsel for the complainants submitted that the policy was continuously in force since 2002 onwards and the complainants never claimed any hospitalization benefits till 2007. He further submitted that the complainant No. 2 took treatment at Batra Hospital wherein he underwent procedure of PTCA and stent was placed. He incurred Rs.1,29,523/- as medical expenses, which was claimed from the OP under the medi-claim policy. It was a genuine claim wrongly repudiated by the OP. Learned counsel for the OP/insurance company submitted that it was a clear case of pre-existing disease, as the patient had heart problems in 1990 and subsequently, in 2007, due to same cardiac problems, he took treatment of PTCA and stent was placed. Therefore, exclusion clause 4.1 of the policy is squarely applicable in the instant case. Accordingly, the repudiation was proper.
7. We have perused the insurance policy, the terms and conditions, and given our thoughtful consideration to the arguments of both the parties. It is an admitted fact that the patient suffered coronary artery disease and underwent CABG in 1990. The OP/insurance company is trying to take benefit under garb of exclusion clause 4.1 stating that the present d
