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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
V.K. Jain, Presiding Member
New India Assurance Co. Ltd. —Petitioner
versus
Surinder Singh —Respondent
Revision Petition No.1246 of 2014
(Against the Order dated 16/01/2014 in Appeal No. 504/2013 of the State Commission Chandigarh)
Decided on 10.7.2020
Counsel for the Parties:
For the Petitioner:Dr. Sushil Kumar Gupta, Advocate
For the Respondent:Mr. Parminder Singh, Advocate
IMPORTANT POINT
Insurer cannot be allowed to travel beyond ground taken in repudiation letter issued by it while rejecting claim.
Headnote:
Consumer Protection Act, 1986 – Sections 15, 17, 19 and 21 – Insurance – Mediclaim Policy – Angioplasty – Repudiation of claim by invoking exclusion clause – Vide impugned order State Commission set aside order passed by District Forum and allowed consumer complaint directing petitioner to pay a sum of Rs. 3,37,228/- along with compensation quantified at Rs. 25,000/- and cost of litigation quantified at Rs. 15,000/- – Contention that terms and conditions attached to Policy was not supplied to complainant, cannot be accepted – There is no evidence to prove that complainant was suffering from any coronary ailment at the time insurance policy was taken by him – No evidence was produced by Insurer to prove that complainant was suffering from coronary ailment at the time policy was initially taken by him in year 2011 – Possibility of coronary ailment having been discovered by complainant after taking policy but before his admission in hospital cannot be ruled out – It is not proved to be a pre-existing disease at the time insurance policy was taken – No evidence was led by insurer to prove that that blood pressure of complainant was uncontrolled and had led to coronary ailment for removal of which angioplasty had to be done by at PGI Chandigarh – It is true that hypertension has been concealed by complainant while obtaining insurance policy, but such concealment was not a ground for repudiation of claim – Insurer cannot be allowed to travel beyond ground taken in repudiation letter issued by it while rejecting claim – Such concealment cannot be a ground for dismissing complaint, same not being one of grounds for repudiating claim – No justification to interfere with order passed by State Commission – Revision petition dismissed. (Paras 3, 4, 6 and 7)
Result: Revision Petition dismissed.
ORDER (ORAL)
V.K. Jain, Presiding Member—The complainant/respondent obtained a mediclaim policy from the petitioner company for the period from 31.01.2011 to 30.01.2012 which was later on renewed for the period from 31.01.2012 to 30.01.2013. The complainant suffered from some heart ailment and was taken to Government Hospital Chandigarh. From there he was shifted to PGI Chandigarh in September 2012. He underwent angioplasty incurring expenses of Rs. 3,44,703/- on his treatment. The claim lodged by him which was repudiated by the letter dated 03.11.2012 written by the TPA to the insurer and filed by the complainant along with the consumer complaint. The said letter, to the extent it is relevant, reads as under:-
“1. PATIENT SUFFERED FROM CORONARY ARTERY DISEASE, HYPER TENSION. AS PER THE MEDICAL RECORDS AVAILABLE, PATIENT IS KNOWN CASE OF HYPERTENSION FROM 5-6 YEARS AND PATIENT ALSO HAS HISTORY OF OLD INFERIOR WALL MYOCARDIAL INFARCTION. POLICY IS IN 2nd YEAR OF INCEPTION. HYPERTENSION IS CAUSE OF CAD. THEREFORE THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.1 (PRE-EXISTING DISEASE).
2. PATIENT HAS SUFFERED FROM HYPERTENSION, CORONERY ARTERY DISEASE, CHOLELITHIASIS, ‘RENAL CONCRETIONS. BOTH HYPERTENSION AND STONE DISEASE ARE EXCLUDED FROM THE 1st 2 YEARS OF THE POLICY. THEREFORE CLAIM IS NON PAYABLE AS PER CLAUSE 4.3 OF THE POLICY. CORONERY ARTERY DISEASE, HYPERTENSION CLAIM NON PAYABLE.”
2. Aggrieved from the repudiation, the complainant approached the District Forum by way of consumer complaint. The complaint was resisted by the petitioner primarily on the ground with which the claim had been repudiated by the TPA.
3. The District Forum having dismissed the consumer complaint the petitioner approached the concerned State Commission by way of an appeal. Vide impugned order dated 16.01.2014 the State Commission set aside the order passed by the District Forum and allowed the consumer complaint directing the petitioner to pay a sum of Rs. 3,37,228/- along with compensation quantified at Rs. 25,000/- and the cost of litigation quantified at Rs. 15,000/-. The said amount was to carry interest at the rate of 9% p a. in case the payment was not made within 45 days of the receipt of the copy of the order. Being aggrieved from the order passed by the State Commission the insurer is before this Commission.
4. It would be seen that the entire case of the insurer is based upon class 4.1 and 4.3 of the terms and conditions attached to the mediclaim policy. Though the case of the complainant is that the said terms and conditions were never supplied to him I am unable to accept this part of the stand taken by him. It is clearly stated in the policy document itself that it is subject to “Mediclaim Policies (2000) Clause as attached.” Had the clauses as applicable to the policy not been attahced the complainant in the ordinary course of human conduct would have written to the insurer asking for those clauses the same having been specifically referred in the policy document. There is no evidence or even an allegation in the complaint having sought those clauses/terms from the insurer. The submission of the Ld. counsel for the complainant is that the complainant had sought the terms and conditions from the agent but since the agent was not impleaded as a party to the consumer complaint the plea taken by the complainant in this regard cannot be verified. Therefore I am unable to accept the contention that the terms and conditions attached to the Policy was not supplied to the complainant.
5. Clauses 4.1 and 4.3 of the policy have been reproduced in the written version to the consumer complaint and read as under:-
“Clause No 4.1
4.1 Pre-existing diseases/condition: All diseases/ injuries/conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre existing disease/ ailment/injury will be considered as a part of preexisting condition. This exclusion will be deleted af
