Judicial Analysis Court Copy Headnote Facts Arguments Court observation

NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Dr. Inder Jit Singh, Presiding Member
R.P. Verma and Anr. – Petitioners
versus
National Insurance Company Limited and Ors. – Respondents
Revision Petition No.501 of 2016
(Against the Order dated 08/06/2015 in Appeal No. 915/2013 of the State Commission Punjab)
Decided on 17.10.2024

Advocates:
Counsel for the Parties:
For the Petitioners:Mr. Sanjeev Kumar Verma, Advocate
For the Respondents:Mr. Shubhranshu Padhi, Advocate with Mr. Pranav Giri, Advocate

IMPORTANT POINT
Insurance Policy must be read holistically so as to give effect to reasonable expectations of all parties including insured & beneficiaries.

Headnote:
Consumer Protection Act, 1986 – Section 21(b) – Insurance Policy – Medi-claim – Repudiation of claim – Not Justified – Suppression of material facts with respect to pre-existing disease & exclusion clause under condition 4.1 – Not proved & exclusion clause not applicable – No relevant documents placed on record with respect to suppression of pre-existing ailment, issue not pressed during hearing on 09.05.2024, when judgment was reserved – Case pertaining to passing of two earlier claims within four years, Insurance Company choosing not to file requisite documents, documents at page 46 of paper book remained undisputed, exclusion clause will not apply – Insurance Company was not justified in repudiating the claim on this ground – Order of SC is set aside – Order of Forum is restored. (Paras 11, 12 and 13)
Result: Complaint allowed.

ORDER

The present Revision Petition (RP) has been filed by the Petitioners against Respondents as detailed above, under section 21 (b) of Consumer Protection Act 1986, against the order dated 08.06.2015 of the State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 915 of 2013 in which order dated 30.05.2013 of District Consumer Disputes Redressal Forum, Patiala (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 404 of 2012 was challenged, inter alia praying for setting aside the order dated 08.06.2015 of the State Commission.

2. While the Revision Petitioner No.1 and 2 (hereinafter also referred to as Complainant No.1 and 2) were Respondent No.1 and 2 respectively before the State Commission and Complainant No.1 and 2 before the District Forum and the Respondent No.1 and 3 (hereinafter also referred to as Opposite Party No. 1 and 3) were Opposite Party No. 1 and 3 respectively before the District Forum and Respondent No. 2 (hereinafter also referred to as Opposite Party No. 2) was Appellant before the State Commission and Opposite Party No. 2 before the District Forum.

3. Notice was issued to the Respondent(s) on 4.8.2016. Parties filed Written Arguments on 28.10.2023 (Petitioner) and 10.11.2021 (Respondent) respectively.

4. Brief facts of the case, as presented by the Complainants and as emerged from the RP, Order of the State Commission, Order of the District Commission and other case records are that: -

(i) Petitioners/Complainants took the medi claim from the Respondents/Opposite Parties. Petitioners gave every detail/information about their health without concealing anything and got examined by OPs’ panel doctors. The insurance covers medical expenses up to Rs.5 lacs as cashless facility.

(ii) In June 2008, Complainant No. 2 felt behavioral problems and treated by local doctors and then admitted at Silver Oaks Hospital, Mohali on 26.08.2008 and discharged on 08.09.2008. In July 2011, Complainant No. 2 again felt pain in his brain. He was taken to Fortis Hospital, Mohali where he was admitted on 25.7.2011 and discharged on 28.07.2011. Doctors diagnosed a case of Brainstem Cavernoma in Midbrain. OP paid the medi claim of both the treatments.

(iii) Complainant No. 2 was taken to Medanta Institute of Neuro Sciences Gurgaon due to ill health despite previous treatments and was admitted on 14.03.2012 and surgery was conducted on 19.03.2012. The Complainant spent more than Rs.4 lacs for this treatment.

(iv) Complainant lodged claim with OP No. 1 and completed all formalities and provided all original claim papers including treatment and medical bills which are in OPs custody. Vide letter dated 11.9.2012, OPs refused to pay the genuine claim stating the disease as “per-existing”.

(v) However, OPs are insuring the complainant for the last 5 years and as per own rules of OPs, pre-exist disease if any is also covered under the insurance. Due to non-payment of genuine claim, OPs have committed deficiency in service and complainants have suffered harassment and mental agony.

5. Vide Order dated 30.05.2013, in the CC no. 404 of 2012 the District Commission has allowed the complaint and passed the following order:

“We accordingly accept the complaint and direct the OPs to make the payment of Rs.3,42,356.71 with interest @9% per annum from the date of the repudiation i.e. 11.9.2012 till final payment. In view of the facts and circumstances of the case, the complaint is accepted with costs accessed at Rs.3000/-. The order be complied within one month on receipt of the certified copy of the order.”

6. Aggrieved by the said Order dated 30.05.2013 of District Commission, Respondent No. 2 Insurance Company appealed in State Commission and the State Commission vide order dated 08.06.2015 in FA No. 915 of 2013 allowed the appeal and passed the following order:

“17. In view of the above discussion, the appeal filed by the appellant/O