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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Prem Narain,Presiding Member
Shiv Kumar Gaur —Petitioner
Versus
Religare Health Insurance Co. Ltd. —Respondent
Revision Petition No. 2830 of 2017
(Against the Order dated 18/05/2017 in Appeal No. 673/2016 of the State Commission Rajasthan)
Decided on 26.8.2020
Counsel for the Parties:
For the Petitioner:Mr. Vinay K. Sharma , Advocate
For the Respondent: Ex-parte
IMPORTANT POINT
Health insurance claim allowed but without interest.
Headnote:
Consumer Protection Act, 1986 – Section 21(b) – Consumer Protection Act, 2019 – Section 58 – Health insurance – Chest pain – Insurance claim – Scope – Complainant suffered left side chest pain – CABG operation performed and he was discharged from Hospital – His claim of Rs. 3,03,003/- under policy was repudiated on ground that complainant did not disclose the material information – District Form directed Insurance company to pay Rs. 3,03,003/- to complaint – State Commission set aside the order of District Forum – Challenge against – Insurance company has not filed any independent proof in support of their assertion that complainant developed chest pain in January, 2014 except the notes of nurses of Hospital which have recorded the same thing as recorded in the discharge summary of Hospital – Insurance claim of complainant is payable under the policy – However, since complainant did not take any action to get the discharge summary of Hospital corrected, complainant does not deserve any interest upon insurance amount – Therefore, complainant held entitled to Rs. 3,03,000/- but without any interest – Directions issued. (Paras 8 to 11)
Result: Petition disposed of.
ORDER
Prem Narain,Presiding Member—This revision petition has been filed by the petitioner Shiv Kumar Gaur challenging the order dated 18th May 2017 passed by the Rajasthan State Consumer Disputes Redressal Commission Jaipur, (in short ‘the State Commission’) in First Apple No. 673 of 2016.
2. Brief facts of the case are that the petitioner complainant was insured with respondent opposite party and the policy was issued on 20th February 2014. The proposal was prepared on sixth February 2014. This was a health insurance plan. On 5th June 2014, the complainant suffered left side chest pain and was admitted In the Chennai Apollo Hospital for treatment where his coronary angiogram was conducted and he was advised CABG/ PTCA. The complainant was admitted in this hospital on 9th June 2014 and was relieved on 11th June 2014. For CABG operation, the complainant was admitted in MIOT International Hospital on 26th June 2014 and was discharged on 5th.July 2014. The complainant submitted his claim under the policy for Rs.3,03,003. Insurance company got the matter investigated and repudiated the claim vide their letter dated 2nd December 2015 on the ground that the complainant did not disclose the material information at the time of filing of the proposal.
3. Aggrieved by the rejection of the claim, the complainant filed a consumer complaint before the District Forum. The complaint was resisted by the insurance company on the same grounds as mentioned in the repudiation letter. The Insurance Company claimed that in the discharge summary of MIOT hospital, it is clearly written that the complainant had a history of chest pain from one week of January 2014. Thus, the discharge summary of MIOT hospital confirmed that the complainant was suffering from the heart disease since January 2014 and the proposal form was filled on 6th February 2014 wherein no information about the heart disease was given and therefore this is a clear case of suppression of material information. It was requested to dismiss the complaint.
4. The District Forum, however, vide it’s order dated 13th May 2016 allowed the complaint and directed the opposite party insurance company to pay Rs.3,03,003/- to the complainant along with interest at the rate 9% per annum from the date of filing of the complaint i.e. from 30th December 2015 till actual payment along with a compensation of Rs.20,000 and litigation cost of Rs.5,000/-.
5. Being aggrieved by the order of the District Forum, the opposite party insurance company preferred an appeal before the State Commission and the State Commission vide impugned order accepted the appeal and set aside the order of the District Forum.
6. Hence the present revision petition by the complainant.
7. Heard the learned counsel for the petitioner as nobody turned up for the respondent and the respondent was proceeded ex-parte vide order dated 9th April 2019 of this commission. The learned counsel for the petitioner stated that in the discharge summary of MIOT International Hospital it is wrongly recorded that the complainant was suffering from left side chest pain since one week of January 2014. Actually, the complainant was first admitted in the Chennai Apollo Hospital when chest pain occurred and that was on 5th June 2014.The complainant was admitted in the Apollo hospital Chennai for the treatment of this chest pain on 9th June 2014 and coronary angiogram was conducted on 10th June 2014 in that hospital and the complainant was discharged on 11th June 2014.Even in the history recorded in the MIOT hospital where the complainant got admitted himself for the CABG operation which was advised by the Apollo hospital, the exact language of the discharge summary of the Apollo hospital is recorded except for the month of June January has been wrongly typed. The insurance company has not filed any medical paper or any other document to support that the complainant suffered chest pain in the month of January 2014. The discharge summary of the Apollo hospital i
