This revision petition has been filed by the petitioner Shiv Kumar Gaur challenging the order dated 18th May 2017 passed by the Rajasthan State Consumer Disputes Redressal Commission Jaipur, (in short ‘the State Commission’) in First Apple No. 673 of 2016.
2. Brief facts of the case are that the petitioner complainant was insured with respondent opposite party and the policy was issued on 20th February 2014. The proposal was prepared on sixth February 2014. This was a health insurance plan. On 5th June 2014, the complainant suffered left side chest pain and was admitted In the Chennai Apollo Hospital for treatment where his coronary angiogram was conducted and he was advised CABG/ PTCA. The complainant was admitted in this hospital on 9th June 2014 and was relieved on 11th June 2014. For CABG operation, the complainant was admitted in MIOT International Hospital on 26th June 2014 and was discharged on 5th.July 2014. The complainant submitted his claim under the policy for Rs.3,03,003. Insurance company got the matter investigated and repudiated the claim vide their letter dated 2nd December 2015 on the ground that the complainant did not disclose the material information at the time of filing of the proposal.
3. Aggrieved by the rejection of the claim, the complainant filed a consumer complaint before the District Forum. The complaint was resisted by the insurance company on the same grounds as mentioned in the repudiation letter. The Insurance Company claimed that in the discharge summary of MIOT hospital, it is clearly written that the complainant had a history of chest pain from one week of January 2014. Thus, the discharge summary of MIOT hospital confirmed that the complainant was suffering from the heart disease since January 2014 and the proposal form was filled on 6th February 2014 wherein no information about the heart disease was given and therefore this is a clear case of suppression of material information. It was requested to dismiss the complaint.
4. The District Forum, however, vide it's order dated 13th May 2016 allowed the complaint and directed the opposite party insurance company to pay Rs.3,03,003/- to the complainant along with interest at the rate 9% per annum from the date of filing of the complaint i.e. from 30th December 2015 till actual payment along with a compensation of Rs.20,000 and litigation cost of Rs.5,000/-.
5. Being aggrieved by the order of the District Forum, the opposite party insurance company preferred an appeal before the State Commission and the State Commission vide impugned order accepted the appeal and set aside the order of the District Forum.
6. Hence the present revision petition by the complainant.
7. Heard the learned counsel for the petitioner as nobody turned up for the respondent and the respondent was proceeded ex-parte vide order dated 9th April 2019 of this commission. The learned counsel for the petitioner stated that in the discharge summary of MIOT International Hospital it is wrongly recorded that the complainant was suffering from left side chest pain since one week of January 2014. Actually, the complainant was first admitted in the Chennai Apollo Hospital when chest pain occurred and that was on 5th June 2014.The complainant was admitted in the Apollo hospital Chennai for the treatment of this chest pain on 9th June 2014 and coronary angiogram was conducted on 10th June 2014 in that hospital and the complainant was discharged on 11th June 2014.Even in the history recorded in the MIOT hospital where the complainant got admitted himself for the CABG operation which was advised by the Apollo hospital, the exact language of the discharge summary of the Apollo hospital is recorded except for the month of June January has been wrongly typed. The insurance company has not filed any medical paper or any other document to support that the complainant suffered chest pain in the month of January 2014. The discharge summary of the Apollo hospital is a testimony to the fact that chest pain developed only in the month of June 2014. As the proposal form was filled on 6th February 2014 and the chest pain occurred only in the month of June 2014, it cannot be said that the complainant concealed any material information in the proposal form. The State Commission has not seen the papers relating to tests and the discharge summary of the Apollo hospital and has not correlated this with the discharge summary of MIOT hospital, otherwise, the things would have been clear. It was requested that the order of the State Commission be set aside and the order of the District Forum be maintained.
8. I have carefully considered the arguments advanced by the learned counsel for the petitioner and have examined the record. The discharge summary of the Apollo hospital mentions the following
“History of Present Illness
“Present Medical History & Examination Findings:
History of left side chest pain- 1 week of Jan 2014, upon positive TMT, Coronary angiogram done on 10.06.2014 at Apollo Hospital, revealed Double vessel disease, advised CABG surgery.”
10. If one compares the language of these two observations recorded in the discharge summary of the two hospitals, it becomes evident that MIOT hospital has recorded this history on the basis of the history recorded in the discharge summary of Apollo hospital because the language is exactly the same except that for the month of June, January has been recorded. This may be an inadvertent mistake, however, the complainant should have got it rectified for which he has failed. But due to this failure of the complainant, the claim cannot be totally denied to him which seems a genuine claim. The insurance company has not filed any independent proof or paper in support of their assertion that the complainant developed chest pain in the month of January 2014 except the notes of nurses of the MIOT hospital which have recorded the same thing as recorded in the discharge summary of MIOT hospital which is not surprising.
