NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ram Surat Ram Maurya, Presiding Member
Star Health & Allied Insurance Co. Ltd.
and Anr. – Appellants
versus
Vineet Khanna and Ors. – Respondents
First Appeal No.383 of 2021
(Against the Order dated 03/02/2021 in Complaint No.1094/2019 of the State Commission Delhi)
Decided on 17.9.2021

IMPORTANT POINTS
(1) No dispute regarding proposition of law that contract of Insurance is a contract of uberrima fides and non-disclosure of any material fact vitiates the policy.
(2) Appellant Insurer cannot be permitted to raise grounds other than ground taken for repudiation of the claim in the Complaint.
(3) Sec. 45 of Insurance Act, 1938 provides 2-yr. limitation for questioning the policy on grounds of suppression/non-disclosure/misrepresentation of the fact at the time of obtaining policy

Headnote:

Consumer Protection Act, 1986 – Section 19 (Consumer Protection Act, 2019 – Section 24) – First Appeal – Appeal against order dt. 03.02.2021 of State Commission – State Commission directed the Appellant to reimburse medical claim of the respondent of Rs.16,09,336/- with interest @ 6% p.a. from date of repudiation till date of payment - Delay of 75 days in filing Appeal condoned - Deceased insured not suffering from any disease prior to death of his mother - After his mother’s death, the insured came in depression and died due to Schizophrenia per Discharge Summary of Columbia Asia Hospital – Insured obtained initial Mediclaim Insurance Policy from Apollo Munich Health Insurance in February, 2013 and ported Mediclaim Insurance Policy from the appellant on 27.02.2017 - Both policies obtained prior to the death of the mother - Columns relating to information of the diseases were replied in negative – Appellant Insurer cannot be permitted to raise grounds other than ground taken for repudiation of the claim in the Complaint – Deceased’s brother is legal heir of deceased insured per Hindu Succession Act, 1956 - No dispute regarding proposition of law that contract of Insurance is a contract of uberrima fides and non-disclosure of any material fact vitiates the policy - Indian Medical Council Regulation, 2002, provides mandatory provision for the hospitals/doctors to record/maintain Case Summary and Discharge Summary - In absence of personal affidavit of Dr. Manjeet, no reliance can be placed on the ltr. dt. 17.09.2019 - Not proved that deceased Insured concealed about his disease in proposal form – Sec. 45 of Insurance Act, 1938 provides 2-yr. limitation for questioning the policy on grounds of suppression/non-disclosure/misrepresentation of the fact at the time of obtaining policy - Appellant issued Ported Mediclaim Insurance Policy on 27.02.2017, in continuation of the policy issued by Apollo Munich Health Insurance, in 2013 - Even from 27.02.2017, the period of 2 years has expired - Policy was questioned for the first time in repudiation letter dated 04.11.2019.

Held: State Commission, after hearing the parties, by judgment dated 03.02.2021 found that in Discharge Summary of Columbia Asia Hospital it was noted that “ Known case of Schizophrenia”. It was not noted that “the patient was on mild medication for last 20 years”. In the alleged letter of Dr. Manjeet Nath Das, the name of the relative, who had informed that the patient was suffering from Schizophrenia and was on mild medication for last 20 years, was not disclosed. It was vague letter and no reliance can be place upon it. The disease Schizophrenia was developed after, obtaining Insurance Policy. In any case, this was a ported policy, in continuation of earlier policy which was obtained in 2013. As the claim was made of the treatment in September, 2019 as such exclusion clause of the policy was not applicable as 4 years had expired. On these findings, State Commission allowed the complaint and passed order as stated above. Hence this appeal has been filed.

There is no dispute regarding the proposition of law that the contract of Insurance is a contract of uberrima fides and non-disclosure of any material fact vitiates the policy. According to the complainant, Vivek Khanna, the deceased Insured, was not suffering from any disease prior to death of his mother on 02.11.2017. After death of the mother, he came in depression, i.e. during continuance of the policy. Vivek Khanna obtained initial Mediclaim Insurance Policy from Appollo Munich Health Insurance in February, 2013 and ported Mediclaim Insurance Policy from the appellant on 27.02.2017. Both these policies were obtained prior to the death of the mother. At that time of obtaining these policies, Vivek Khanna was not suffering from any disease, as such, in the proposal form, the columns relating to information of the diseases were replied in negative. Apart from handwritten letter of Dr. Manjeet Nath Das dated 17.09.2019, there is no evidence of the record to prove that Vivek Khanna was suffering from any disease at the time of obtaining policy.

Indian Medical Council (Professional Conduct Etiquette and Ethics) Regulation, 2002, (published in Gazette of India dated 06.04.2002) provides mandatory provision for the hospitals/ doctors to record/maintain Case Summary and Discharge Summary. Neither in Case Summary nor in Discharge Summary of Columbia Asia Hospital or of Sir Ganga Ram Hospital, this fact was noted that the patient was on mild medication, for last 20 years. This handwritten letter dated 17.09.2019 was contrary to the hospital record. Dr. Manjeet Nath Das was arrayed as opposite party-5 in the complaint. He did not dare to file his Affidavit of Evidence, admitting execution of this letter and explaining the circumstance, under which he had written this letter, contrary to the hospital record, maintained in discharge of mandatory provision of law. In the absence of personal affidavit of Dr. Manjeet Nath Das, no reliance can be placed on the letter dated 17.09.2019, in preference of the hospital records, which are maintained in discharge mandatory provisions of law. As such, it is not proved that the deceased Insured had concealed about his disease, in the proposal form.

13. Section 45 of Insurance Act, 1938 provides two year limitation for questioning the policy on the ground of suppression/non-disclosure/misrepresentation of the fact at the time of obtaining policy. The appellant issued Ported Mediclaim Insurance Policy on 27.02.2017, in continuation of Mediclaim Insurance Policy issued by Apollo Munich Health Insurance, in the year 2013. Even from 27.02.2017, the period of two years has expired. The policy was questioned for the first time in repudiation letter dated 04.11.2019. (Paras 7, 10, 12 & 13)

Result: Appeal has no merit and is dismissed.