J&K STATE CONSUMER DISPUTES REDRESSAL COMMISSION, JAMMU

Quorum:

Hon’ble Mr. Justice (Retd.) Sunil Hali                              ...President

Sh. D.K. Kapoor (Retd.) District Judge                             ...Member

R. Petition No. 4086A/18

Date of Institution: 14.12.2018

Date of Decision: 28.03.2019

National Insurance Co. Ltd.,

through Divisional Manager, Divisional Office No.II,

Canal Road, Jammu.

                                                                    … (Appellant)

      Versus

    Dharam Singh S/O Sain Dass, R/O H.No.80, Sector No.14,

Nanak Nagar, Jammu.

                                                                 … (Respondent)

Appearing Counsel:

Mr. Baldev Singh for appellant.

Mr. Parvinder Singh for respondent.

O R D E R

Per President                              

This appeal has been preferred against the order of District Forum dated 30^th March, 2018 whereby appellant has been directed to pay Rs. 133840 alongwith interest at 7 per cent plus compensation and litigation charges of Rs.5000/- each.  Aggrieved of the order, this appeal has been filed. 

In order to appreciate the controversy, certain facts are required to be indicated.  Complainant had procured an medi-claim policy in the year 2016 w.e.f 05.04.2016 to 04.04.2017.  Prior to procuring the policy, he had submitted a proposal form in which certain information was required to be supplied by him.  In column 12 sub-clause (a), he had declared that he was in a good health and free from all mental and physical disease.   He was also subjected to medical check-up on the advice of the respondents/appellants.  He was examined by Dr. Adnan Rafiq who found that he is fit to be insured.  Medical check-up done, found no infirmity in his health.  As a consequence, the policy was issued. 

It so happened that the petitioner/complainant in August, 2016 suffered suffocation and decided to consult the Doctor at Chandigarh.  He was admitted in the hospital and after examination, it was found there was block in his arteries.  As a result of which, stent was embedded in the arteries.  He is stated to have incurred an expenditure of Rs.133814 on his treatment which included medicines and implants which were fixed during the treatment.  He raised the claim with the respondent.  Respondent on the receipt of the information and perusing the documents, found that the complainant had concealed the fact that he was suffering from the heart disease.  Reliance was placed on OPD issued by PGI Chandigarh while seeking history from the complainant, it was disclosed that he was suffering from AOE-9 months, Grade III.  After taking cue from this, his claim was rejected on the premise that prior to seeking policy, he did not disclose this disease at the time of filing proposal form.

I have heard learned counsel for the parties.  The short question for determination in this case is:-

1. Whether the complainant was aware of the disease at the time of filing of proposal form?
2. Whether this information after being aware of it, he had concealed.

It is right that while seeking mediclaim, the insurer is required to disclose all the facts relating to his health condition in the proposal form.  The risk is at the insurer as to whether to accept the proposal or not even if it is disclosed that he is suffering from certain disease.  Therefore, it is essential that any information with regard to his health status is required to be disclosed.  This principle has been specifically laid-down in Satwant Kaur Sandhu Vs New India Assurance Co. Ltd reported as 2010 ACJ 265.  While adverting to the legal position, it clearly emerges that complainant should be aware of the disease which he has been suffering.  Even if he may be suffering from some disease but may not be aware of it, cannot become a ground for rejecting his claim.  Awareness and knowledge is essential in this matter.  The only proof the respondent have produced of the fact that the complainant was suffering from this disease is the endorsement made in the OPD.  This AOE-9 months, Grade III has not been explained by either of the parties.  It is clear that the complainant had given history of his ailment without being aware that he was suffering from heart disease.  Admittedly, the hospital where he was treated would not become aware about the nature of the problem he was suffering from which could be detected only after conducting various tests.  The burden lay on the respondents to prove that the word “AOE-9 months, Grade III” by in itself in the medical terminology tantamount to the fact that he was suffering from some heart disease.  Even in their repudiation letter also, word “AOE-9 months, Grade III” has not been explained.  Since it was a medical term, the matter should have been referred to some expert Did this connote only symptoms of an ailment which the insured was not aware.  There is no proof produced by the respondent that the complainant was being treated for this ailment prior to 04.04.2016.  If the complainant was undergoing treatment for the disease, for which sufficient proof was to be provided by the appellant.  Which is not the case here.  Merely writing letters by the respondent to complainant after it become known that he was suffering from this disease in August, 2016 would not absolve the respondent from proving this fact.

Viewed thus, we do not find any force in this appeal.  Reference has been made to section 45 of the Insurance Act which is uncalled for. Section 45 can be invoked only in cases of Life Insurance claims not for medical claims.  We therefore dismiss this appeal.  The ¼ amount deposited in this Commission shall be released in favour of the respondent.  The remaining amount shall be deposited within 4 weeks from today.  

Announced

28.03.2019

MEMBER                     PRESIDENT