Haryana

StateCommission

A/104/2016

ORIENTAL INSURANCE CO. - Complainant(s)

Versus

CHANDER SHEKHAR - Opp.Party(s)

D.C.KUMAR

12 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      104 of 2016

Date of Institution:      03.02.2016

Date of Decision :       12.07.2016

 

1.     The Oriental Insurance Company Limited, Branch Office LIC Building GT Road, Panipat.

2.     The Oriental Insurance Company Limited, Branch Office near York Hotel G.T. Road, Karnal.

BOTH THROUGH Shri S.P. Singh, Regional Manager, The Oriental Insurance Comp0any Limited, Regional Office, LIC Building, II Floor, Jagadhri Road, Ambala Cantt.

                                      Appellants/Opposite Parties

Versus

 

Chander Shekhar Bhardwaj s/o Sh. Sudesh Chander Bhardwaj, Resident of House No.357, Virat Nagar, Model Town, Panipat.

 

                                      Respondent/Complainant

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Present:               Shri D.C. Kumar, Advocate for appellants.

                             Shri Parveen Kumar, Advocate for respondent.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

The Oriental Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Parties, are in appeal against the order dated January 8^th, 2016 passed by District Consumer Disputes Redressal Forum, Panipat (for short ‘the District Forum’) in Complaint No.325 of 2014.

2.      Chander Shekhar-complainant/respondent, (hereinafter called as “the insured”) took a PNB-Oriental Royal Mediclaim Policy (Annexure C-1) for the period December 31^st, 2012 to December 30^th, 2013 from the Insurance Company for Rs.5.00 lacs.

3.      On December 7^th, 2013, the insured suffered chest pain. He was taken to K.G. Hospital and Child Care Centre, Panipat. After examining, the doctors diagnosed the insured as “not a known case of D.M. & H.T.” vide prescription slip Annexure C-4. The insured was admitted in Panipat Cath Lab & Heart Care Centre, Prem Hospital, Panipat on the same day, that is, 7^th December, 2013 and was discharged on 9^th December, 2013 vide Clinical Summary Annexure C-10, reproduced as under:-

                   “                            Clinical Summary

Sh. Chander Shekhar age 59/M Non-Diabetic Non-Hypertension, old Male Residents of Virat Nagar Panipat complaint of two episode of chest pain mainly Retrosternal with radiation to left arms since 4 pm. The Patient was refd to us on the same day and was admitted in the hospital of 7/12/2013 at 19:10 hours.

On examination his blood Pressure 175/100 mmHg, Pulse 86/min, respiratory rate 14/min. and O2 saturation 90%, Chest was clinically clear CVS System was Normal. ECG shows ST segment depression in Inf. Leads and ST segment flattening in lateral leads. His cardiac enzyme were raised and he was managed medically and discharged on request on 9/12/2013 at 11: 30 AM.”

4.      The insured was admitted in Fortis Hospital, Delhi on 9^th December, 2013 where he was operated upon on 12^th December and was discharged on 19^th December, 2013 as per the Discharge Summary Annexure C-11. The relevant extract of Annexure C-11 is as under:-

                   “Final Diagnosis:

 

Coronary artery double vessel disease

                   Hypertension

                   LVEF=60%

                   COPD”

         

“Brief History:  Mr. Chander Shekhar Bhardwaj, 59 yrs old male a known case of hypertension was admitted in Fortis Hospital, Shalimar Bagh on 09^th December, 2013 with chief complaints of left sided chest pain. His coronary angiography was performed on same day which revealed coronary artery double vessel disease and advised for coronary artery bypass grafting surgery. He was taken up for CABG on 12^th December, 2013 after detailed pre operative check up.

 

5.      The insured filed claim of Rs.2,95,815/- with the Insurance Company but the Insurance Company vide letter dated 11^th January, 2014 (Annexure C3) repudiated the claim. The insured also invoked the jurisdiction of Ombudsman, Chandigarh by filing claim but to no effect. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Forum.

6.      In the written version filed on behalf of the Insurance Company, it was pleaded that the insured was a known case of hypertension and therefore as per clause 4.1 of the terms and conditions of the policy, the insured was not entitled for any compensation. It was prayed that the complaint be dismissed.

7.      After evaluating the pleadings and evidence of the parties, the District Forum vide impugned order allowed complaint and directed the Insurance Company to pay Rs.2,95,815/- to the insured/complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization and Rs.2200/- as cost of litigation.

8.      Aggrieved by the impugned order, the Insurance Company filed the instant appeal.

9.      Annexure C-4 is the Prescription Slip issued from K.G. Hospital and Child Care Centre, Panipat. It has clearly been mentioned in it that the patient (Chander Shekhar) was “not a known case of DM & HT”.  

10.    In Fortis Hospital, Delhi, the insured was treated by a team of doctors namely Dr. Vinay Sanghi, Dr. Raju Vyas, Dr. Rajat Agarwal, Dr. Pradeep Poswal, Dr. Munindra Borah and Dr. Yatish Sharma. The insured was admitted in the said hospital on December 9^th, 2013; operated upon on 12^th December and discharged on 19^th December, 2013. It has been mentioned in the Discharge Summary (Annexure C-11) the patient was a known case of hypertension, non-diabetic and with active life style. No abnormality was found in the patient.

11.    There is nothing on the record to show that the insured was suffering from any disease prior to the date of obtaining the insurance policy. The Insurance Company has not led any evidence in this regard.

12.    The question which falls under consideration is that whether the Insurance Company is liable to pay the claim to the insured/complainant or not?

13.    Though as per Prescription Slip (Annexure C-4) issued from K.G. Hospital and Child Care Centre, Panipat, the patient (Chander Shekhar) was “not a known case of DM & HT”, yet even it considering that Fortis Hospital, Delhi treated it a case of hypertension, but that cannot be a ground to repudiate complainant’s claim in view of the judgment rendered by Hon’ble National Commission in First Appeal No.1674 of 2002 “L.I.C. of India and others v. Ramandeep Kaur and another” decided on 2.2.2009, wherein it was held as under:-

 “16. So far as the law on the subject is concerned it was held by the Hon’ble Supreme Court in the judgment dated 10.10.1995 recorded in “Biman Krishna Bose vs. United India Insurance Co.” Civil Appeal No.3438 of 1995 that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance Company. Moreover hypertension is not a material disease which is fatal in itself.”

14.    In a recent judgment cited as Satish Chander Madan versus M/s Bajaj Allianz General Insurance Company Limited, 2016(1) C.P.J. 613, Hon’ble National Commission by applying the same principle held the Insurance Company liable to pay the insurance claim to the claimant.

15.    The treatment record of the insured issued from K.G. Hospital and Child Care Centre, Panipat and Fortis Hospital, Delhi do not mention that the insured had disclosed any previous history of heart problem. Even no evidence has been produced by the Insurance Company that the insured was suffering from hypertension prior to the purchasing of the insurance policy and he concealed the said fact at the time of taking the policy. Even otherwise the disease of hypertension is so common in our country men that huge percentage of the population is suffering from hypertension and diabetes.  Malaise of hypertension in the body is normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease.  Thus, by applying the parameters of the judgment cited supra, it cannot be said that the insured concealed any material fact with respect to his health at the time of obtaining the policy. So, no case for interference in the impugned order is made out.

16.    Hence, the appeal is dismissed being devoid of merits.

17.    The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant/respondent against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced 12.07.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL