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PUNJAB STATE CONSUMER DISPUTES REDRESSAL COMMISSION
R.S. Mongia, President and C.P. Budhiraja and Jasbir Kapoor, Members
ORIENTAL INSURANCE COMPANY LIMITED - Appellant
Versus
RAJINDER SINGH - Respondent
Appeal No. 565 of 2001
Decided on : 25-05-2007
Mrs. Veena A. Talwar and Ms. Shagun Kathuria, Advocates, for the Appellant; Mr. Puneet Jindal, Advocate, for the Respondent
The insured must have knowledge of the pre-existing disease for the insurance company to disown liability under the medi-claim policy.
Headnote:
Insurance - Medi-claim policy - Clause 4.1 of the policy - [Oriental Insurance Company Ltd. v. Rajinder Singh] - [Praveen Damani v. Oriental Insurance Co. Ltd., 2007 (1) CPC 141] - The court discussed the interpretation of Clause 4.1 of the policy, emphasizing that the insured must have knowledge of the pre-existing disease for the insurance company to disown liability. The judgment in Praveen Damani v. Oriental Insurance Co. Ltd. was cited to support the interpretation.
Fact of the Case:
The complainant had a medi-claim policy and incurred medical expenses, but the claim was repudiated by the insurance company on the grounds of pre-existing hypertension and renal problems.
Finding of the Court:
The court found that the insured was not a known hypertension or renal failure patient at the time of taking the policy, and the knowledge of the disease is essential for disowning liability under the policy.
Issues: (i) Whether the complainant was suffering from hypertension/renal problems at the time of taking the policy, and (ii) whether he had any knowledge about the alleged disease.
Ratio Decidendi: The court upheld the interpretation of Clause 4.1 of the policy, emphasizing the requirement for the insured to have knowledge of the pre-existing disease for the insurance company to disown liability.
Final Decision: The court upheld the order of the District Forum, dismissing the appeal and directing the insurance company to pay the claimed amount along with interest.
ORDER
R.S. Mongia, President - This is an appeal by the Oriental Insurance Company Ltd. against the judgment and order of the District Forum dated 20.4.2001 by which the complaint of complainant Rajinder Singh was allowed in the following terms:
"Next question for determination is as to how much amount the complainant is entitled to recover. The complainant has placed on file a number of bills. Some of the bills are of Gurmail Medical Hall. Even the investigator in the report has mentioned that the said bills are forged. Any how the record shows that the complainant got the treatment from C.M.C. Final bill of the C.M.C. Ex. A64 is on the file showing that the complainant incurred total expenditure of Rs. 64,438 in C.M.C. Hospital. That amount is payable to the complainant. Bills, Ex. 99,111 and A.120 are for Rs. 5,238 each. Said bills relate to the medicine which was purchased from Chandigarh during admission of the complainant in the hospital. Genuineness of the said bills cannot be disputed. As such said amounts are also payable. In addition to the same bill Ex. A.191 of Avon Medicose shows that the medicine worth Rs. 10,788 were purchased by the complainant after his dicharge from the hospital on prescription given by Dr. D.R. Rajan, as such the said amount is also payable. Bill A.189 for Rs. 8,688 of Avon Medicose is also on the file through which the medicines were purchased after discharge on the prescription of Dr. Rajan. As such the amount of the said two bills have also to be allowed. Total amount of the above said bills comes to Rs. 1,01,628. Therefore, the complainant is entitled to recover the said amount. The claim of the complainant was repudiated on 28.10.1999. As such, the opposite party is directed to pay an amount of Rs. 1,01,628 along with interest @ 9% per annum w.e.f. 28.10.1999 till the date of actual payment. Compliance of the order be done within one month of the receipt of this order. Copy of the order be sent to the parties."
2. Brief facts are that the complainant had taken a medi-claim policy from the appellant Insurance Company for the period 12.3.1998 to 11.3.1999 in the sum of Rs. 2.50 lacs. According to the complainant, he fell ill and he was admitted in the CMC, Ludhiana on 13.7.1998 (wrongly mentioned in the impugned order as 18.3.1998) and was discharged from the said hospital on 8.9.1998. According to him, he had spent Rs. 2,88,125 on medical treatment and medicines in the hospital. The claim was lodged but the same was repudiated primarily on the ground that prior to the taking of the policy the complainant was suffering from hypertension and renal problems. After appreciating the evidence, etc. on the record the complaint was allowed as aforesaid. Hence, the present appeal.
3. The points for determination, in this case, are, (i) whether there is anything on the record to show that the complainant respondent was suffering from hypertension/renal problems at the time he took the policy and (ii) whether he had any knowledge about the alleged disease
4. In the discharge summary issued by CMC, Ludhiana in the column of history it is mentioned that "this is 38 years old man and not a known hypertension or renal failure patient". In the final diagnosis, though it is mentioned that there is chronic renal failure and hypertension, but the fact remains that it was not a known case of hypertension or renal failure as has been mentioned in the history . It is the case of the appellant Insurance Company that under Clause 4.1 of the policy it would not cover all diseases/injuries which are pre-existing when the cover incepts for the first time. According to the appellant, whether a patient has the knowledge of the disease or not is immaterial; mere pre-existence of a disease prior to the taking of the policy would disentitle the insured from claiming under the medi-claim policy.
5. While interpreting Clause 4.1 of the policy, National Commission in a recent judgment Praveen Damani v. Oriental Insurance Co. L
