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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
S.N. Aggarwal, President and Jasbir Kapoor, Member
UNITED INDIA INSURANCE CO. LTD. - Appellant
Versus
KRISHAN NARAIN SHARMA - Respondent
First Appeal No. 619 of 2003
Decided on : 27-08-2008
Mr. D.C. Kumar for Mr. D.P. Gupta, Advocates, for the Appellant; Mr. Rajesh Gupta, Advocate, for the Respondent
The insurer has the burden of proving fraudulent suppression of material facts by the insured, and mere concealment of some facts will not amount to concealment of material facts.
Headnote:
Insurance - Mediclaim Policy - Exclusionary Clause, Pre-existing Condition - 29.12.1999 to 28.12.2000 - 29.12.2000 to 28.12.2001 - 29.12.2001 to 28.12.2002 - 4.1 of the insurance policy - National Insurance Co. Ltd. v. Swaraj Jain (Smt.) - M/s. Modern Insulators Ltd. v. Oriental Insurance Company - LIC v. Smt G.M., Channabasemma - National Insurance Co. Ltd. v. Bipul Kunda - New India Assurance Co. Ltd. and Ors. v. Sant Kumar Puri - Oriental Insurance Company Limited v. Rajinder Singh
Fact of the Case:
Krishan Narain Sharma had taken mediclaim policy from the appellants for the year 1999. He was admitted to the hospital with chest pain and underwent bye-pass surgery. The appellants repudiated the claim, alleging pre-existing heart ailment and suppression of material facts.
Finding of the Court:
The appellants failed to prove that the respondent had suppressed material facts regarding his pre-existing heart ailment. The court dismissed the appeal and directed the appellants to make the payment of the insurance amount with interest.
Issues: Pre-existing heart ailment, suppression of material facts, validity of repudiation of claim
Ratio Decidendi: The onus probandi of fraudulent suppression of material facts rests on the insurer. Mere concealment of some facts will not amount to concealment of material facts. The insurer must prove that a statement on a material fact was fraudulently made by the insured with the knowledge of its falsity.
Final Decision: The appeal was dismissed, and the appellants were directed to make the payment of the insurance amount with interest.
ORDER
S.N. Aggarwal, President- Krishan Narain Sharma had taken mediclaim policy from the appellants for the year 1999. It was got renewed in the year 2000-01. On 2.1.2002 the respondent was admitted in the Hero DMC Heart Institute, Tagore Nagar, Ludhiana with a complaint of chest pain radiating to left arm. Thereafter a bye-pass surgery was performed on his body and ultimately on 17.1.2002 he was discharged from the Hero DMC Heart Institute, Tagore Nagar, Ludhiana. The respondent incurred an expenditure to the tune of Rs. 1,51,278 as medical expenses in the said hospital.
2. It was also pleaded that the respondent lodged the claim with the appellants vide CR No. 10003 but the appellants repudiated the claim vide letter dated 14.5.2002. Hence the respondent filed the complaint in the learned District Consumer Disputes Redressal Forum, Ludhiana (in short "District Forum").
3. The appellants filed written reply. Preliminary objections were pleaded and the case was also contested on merits. It was pleaded that the respondent has not come to the Forum with clean hands and had suppressed material facts. It was pleaded that the respondent was having heart ailment since the year 1995 and the disease was pre-existing. This fact was suppressed by the respondent while filling the proposal form. It was admitted that the respondent had taken mediclaim policy for the period from 29.12.1999 to 28.12.2000 which was got renewed from 29.12.2000 to 28.12.2001 and 29.12.2001 to 28.12.2002. It was denied if the respondent had spent an amount of Rs. l,51,278 on his treatment. Since the heart disease of the respondent was pre-existing, therefore, the exclusionary clause of the insurance policy applied under which the respondent is not entitled to any medi-claim. Therefore, the repudiation was legal and valid. Dismissal of the complaint was prayed.
4. The respondent tendered in evidence documents Ex. Cl to Ex.C7. On the other hand, the appellants produced documents Ex. R1 to Ex. R12.
5. On the basis of these pleadings and the documents placed on the file by the parties, the learned District Forum accepted the complaint and directed the appellants to make the payment of the insurance amount with interest at the rate of 9% per annum from the date of repudiation till the date of payment.
6. Hence the appeal.
7. Record has been perused. Submissions have been considered.
8. It is not disputed that the respondent had got the mediclaim policy for the period from 29.12.1999 to 28.12.2000. It was got renewed from 29.12.2000 to 28.12.2001 and 29.12.2001 to 28.12.2002. It was also not disputed that on 2.1.2002 the respondent was admitted in the Hero DMC Heart Institute, Tagore Nagar, Ludhiana with a complaint of chest pain and thereafter bye-pass surgery was performed on his body and ultimately he was discharged on 17.1.2002. The insurance policy has been proved as Ex. C4 according to which the mediclaim policy was for Rs. 2,00,000. It is also not seriously disputed that the respondent had incurred an expenditure of Rs. 1,51,278 in the said hospital as medical expenses. The certificate of expenditure of the Hero DMC Heart Institute, Tagore Nagar, Ludhiana showing this expenditure is Ex. C3.
9. The submission of the learned Counsel for the appellants was that the heart ailment of the assured was pre-existing and in support of this submission reference was made to the discharge summary Ex. Rl which reads as under:
"PRESENTING HISTORY: 67 years old male known case of NIDDM, hypertension, ischemic heart disease, was admitted on 2.1.2002 with the complaint of chest pain radiating to left arm. No associated symptoms of vomiting/sweating/dyspnoea. History of MI in 1995."
10. Learned Counsel for the appellants also made reference to the exclusionary clause of para 4.1 of the insurance policy Ex. R5 which reads as under:
"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
