DR. S. M. KANTIKAR, PRESIDING MEMBER1. Heard the learned counsel for the revisionist –insurance co. and perused the material on record. 2. The dispute relates to repudiation of an insurance claim. 3. The District Forum heard both sides, appraised the evidence and through its Order dated 24.08.2017 partly allowed the complaint: 7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely. 8. After considering the respective arguments of both the counsel for the parties , we find that the purchase of the insurance policy from the opposite party after making a payment of premium for the period 11.04.2016 to 10.04.2017 is admitted fact and even the hospitalization of the complainant in hospital Mannat Super Speciality Hospital , Jalandhar from 07.11.2016 to 09.11.2016 and then in DMC and Hospital , Ludhiana from 11.11.2016 to 26.11.2016 as indoor patient is also not denied and even it is also not denied that the complainant submitted a claim with the opposite party and it is also admitted that the claim of the complainant has been repudiated by the opposite party vide letter dated 21.12.2016 on the ground that the complainant has concealed the previous ailment i.e. Alcoholic Liver Cirrhosis on the basis of exclusion clauses III.12 & III.2. The copy of the repudiation letter is placed on the file by the opposite parties as well as by the complainant which is Ex. C3 and now , the question remains to be decided whether there is any pre- existing disease of Chronic Liver Cirrhosis and Hypertension to the complainant or not ? For that purpose , counsel for the complainant submitted that there is no pre-existing disease nor any disease has been concealed by the complainant, rather the complainant himself not aware whether there is any disease of Alcoholic Liver Cirrhosis or hypertension to the complainant nor he ever felt , rather these diseases were firstly located by the Mannat Hospital as well as DMC & Hospital while he remained admitted in the Mannat Super Speciality Hospital , Jalandhar from 07.11.2016 to 09.11.2016 and DMC & Hospital, Ludhiana from 11.11.2016 to 26.11.2016, whereas the policy was obtained by the complainant in the month of April, 2016. 9. To the contrary, learned counsel for the opposite parties referred Discharge Card of the Mannat Hospital , Jalandhar which is Ex. OPs – 5. No – doubt , there is on page No. 3, it is mentioned that chronic liver disease , but we find that simply writing chronic liver disease is not sufficient, until any previous report of the doctor is not placed on the file i.e., prior to purchase of the policy. But, the opposite parties are not able to bring on the file any medical report/treatment got by the complainant from any hospital , before the date of purchase of the policy i.e. 11.04.2016 , wherein the said hospital has reported that the complainant is having any chronic alcoholic liver disease. No doubt the opposite parties have referred in para No. 3 of the written reply that the complainant also remained admitted in Dayanand Medical College & Hospital, Ludhiana from 07.08.2007 to 12.09.2007 and also remained admitted in the hospital from 23.01.2008 to 24.01.2008 , but regarding these admissions no record has been brought on the file by the opposite parties and in the absence of any record showing that the complainant has any liver problem or liver disease prior to the date of purchase of the policy i.e., 11.04.2016 , so under these circumstances , we find that the case of the complainant is not covered under the Exclusion Clauses III.12 & III.2 , as alleged by the opposite parties in para no. 3 of the written reply. In support of above observation , we like to refer a pronouncement of Hon’ble National Commission cited in 2015(3) C.P.R. 697, New India Assurance Co. Ltd. Versus B.Y. Srikantha , wherein His Lordship held that “the insurance company failed to show any iota of evidence to show that the complainant is having a pre-existing disease” and on the similar point, we further like to refer another pronouncement of Hon’ble National Commission cited in 2014(3) C.P.C 585 , Abhishek Jain versus HDFC Standard Life Insurance Co. Ltd. , and another . If we see the case of the complainant in the light of above judgments, then it is clearly established on the file that the opposite parties have miserably failed to establish that there is any Alcoholic Liver Cirrhosis ailment to the complainant prior to purchase of the policy i.e. 11.04.2016. If the said disease first time located by the doctor in the month of November, 2016 i.e. after the purchase of the policy, then that will have no affect on the right of the complainant to get the claim of the insurance from the opposite parties. So, with these observations, we reach to the conclusion that the opposite parties have illegally arbitrarily repudiated the claim of the complainant and accordingly, we find that the complainant is entitled for the relief claimed. 10. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and opposite parties are directed to pay the amount spent on the treatment and medicines which is fully proved on the file by way of bills mark C6 to mark C60 i.e. Rs. 2,00,000 /- and further the opposite parties are directed to pay compensation to the complainant to the tune of Rs. 7,000/- and litigation expenses of Rs. 3,000/-. The entire compliance be made within 30 days from the date of receipt of copy of the order. This complaint could not be decided within stipulated time frame due to rush of work. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room. (paras 7, 8, 9 and 10 of the District Forum’s Order) 4. The OP - insurance co. appealed in the State Commission. The State Commission heard both sides, appraised the evidence and through its Order dated 19.04.2018 dismissed the appeal: 10. - - - - From the above it was admitted that the date of the inception of the Health Insurance Policy is 11.04.2014 whereas the complainant remained admitted/hospitalized in the Mannat Super Specialty Hospital Jalandhar from 07.11.2016 to 09.11.2016 and further in DMC Hospital Ludhiana from 11.11.2016 to 26.11.2016 i.e. very well after the inception of the insurance Policy. Neither the insurance Company/ OP placed any document to evident any pre- existing disease of the complainant before inception of the Policy in the District Forum nor the OP has presented any application for placing additional evidence on record before this Commission to prove any pre-existing disease before inception of the policy. As such , simple documents on the record cannot be read in evidence. We are further fortified by a judgement of the Hon’ble national Commission cited in 2015 (3) CPR 697 titled as “New India Assurance Co. Ltd. V. B.Y. Srikantha” , wherein the insurance company failed to show any iota of evidence to show that the complainant is having a pre-existing disease”. It was not agreed by the counsel for the appellant that the cost falls under any other exclusion clause. 12. Sequel to the above, we are of the opinion that there is no merit in the appeal and the order of the District Forum is upheld. (paras 10 and 12 of the State Commission’s Order) 5. The OP – insurance co. has filed the instant revision petition under section 21 (b) of the Act 1986 against the said Order dated 19.04.2018 of the State Commission. 6. We find the Order of the State Commission to be well-appraised and well-reasoned. The State Commission concurred with the findings of the District Forum. Within the meaning and scope of section 21(b), we find no grave error in appreciating the evidence by the two fora below, as may cause to require re-appreciation of the evidence in revision. We note in particular the extracts of the respective appraisals / observations made by the two fora, quoted, verbatim, in paras 3 and 4 above. (The OP – insurance co. had issued an insurance policy in the month of April 2016, whereas the insured was subsequently diagnosed with Chronic Liver Disease in November 2016. It cannot be said that the insured concealed his disease while filling the proposal form. The OP - insurance co. failed to prove that the disease was a pre- existing disease and was willfully concealed.) We find the award made by the District Forum (quoted in para 3 above), and as affirmed by the State Commission, to be just and appropriate. And, on the face of it, we find no jurisdictional error, or a legal principle ignored, or miscarriage of justice. 7. The revision petition, being misconceived and devoid of merit, is dismissed. 8. Needless to add that the District Forum shall undertake execution of its Order as per the law. 9. A copy each of this Order be sent to the District Forum and to the complainant by the Registry within ten days. |
