(Delivered on 27/11/2019)

PER SHRI A. Z. KHWAJA, HON’BLE PRESIDING MEMBER.

1.         Appellant – Oriental Insurance Company Ltd. has preferred  the present appeal  challenging  the judgment  and order passed by the  learned  District Consumer Forum, Nagpur  dated 17/01/2012 in consumer complaint  No. 357/2011 whereby  the learned District Consumer Forum, Nagpur  allowed the complaint  of  the complainant and  directed the appellant  to pay sum of Rs. 1,87,500/- with interest and  compensation  of Rs. 5,000/- and litigation cost of Rs. 2000/-. Short facts leading  to  filing  of  the present appeal  may be narrated briefly   as under. (Appellant  and respondent shall  hereinafter  be referred  by their  original  nomenclature)

 2.         Complainant – Mr. Amulya  Sinha , is a  resident   of  Trimurti Nagar, Nagpur  and had taken  medical  insurance policy  namely  Family Floater Policy  from   Oriental Insurance Company  and same  was for the period  from 20/06/2009 to 19/06/2010. The complainant  had also paid  premium of Rs. 20,681/-.  Earlier to the same, the complainant had also taken the medical policy from 2002 to 2009 but complainant had not submitted any claim.  On 27/08/2009 the complainant   felt pain  in the chest  and so he came to be  examined  Dr.  Nikhil Balankhed and he referred  him to  Wockhardt Hospital. The complainant   has contended that on 01/04/2010 the Angioplasty was performed and complainant incurred medical expenses to the tune of Rs. 3,95,908/-.  The complainant  therefore,  submitted  the claim with the O.P.- Oriental  Insurance Company Ltd.  for the sum of Rs. 3,00,000/- but  O.P.- Oriental  Insurance Company Ltd  accepted the claim only to the extent   of Rs. 1,25,000/-  and repudiated  rest of the  claim  for  remaining  sum of Rs. 1,75,000/- on the  ground that  the complainant  has suppressed  his  illness  and he was  already  suffering from  chronic hyper tension.  The complainant  has suffered  from great  mental agony and also  pecuniary  loss due to  repudiation of the claim and so  the  complainant  was  constrained  to  file complaint  under section 12 of the Consumer Protection Act, 1986.

  3.        The O.P. has appeared and resisted the complaint by filing written version. The O.P. has admitted  that   the complainant  had taken the Happy Floater   Policy  for a sum of Rs. 3,00,000/-. The O.P. has categorically  denied  that  the complainant  was not suffering  from any  illness or hyper tension  prior  to the  time when he  had taken  the Floater Policy. The O.P. has taken  a stand  that the complainant  was suffering  from hyper  tension  since one  year prior  to taking  the  Happy Floater Policy  and so  as per  exclusion  clause  Nos. 4.1 and 4.3 of the terms  and conditions,  the complainant  was not at all eligible  for a sum of Rs. 3,00,000/-, but  complainant  was  eligible  only to the extent  of Rs. 1,25,000/-, which  was already  paid. The O.P. therefore, has contended   that  the complaint filed by the  complainant  deserves to be  dismissed  with cost.

 4.         The complainant as well as O.P. thereafter laid their evidence affidavit on record  as well as written notes of argument .  The learned District Consumer Forum, Nagpur  then  heard the learned advocates for both the parties  and thereafter came to the conclusion  that  there was no material  to show  that the complainant  was suffering  from any pre disease  illness or hyper tension  and  there was also not  suppression  of the fact on the part of the complainant.  The learned District Consumer Forum, Nagpur  also  reached to the  conclusion  that   the  exclusion  clause will not be  attracted  and  complainant  was entitled  for  total  sum of Rs. 3,00,000/- as insured in the Happy  Floater Policy. The learned District Consumer Forum, Nagpur  thereby partly allowed the  complaint  and directed  the O.P.  to pay  balance amount of Rs. 1,87,500/- with interest  at the rate of 9% and also  to pay compensation  of Rs. 5,000/- towards mental and physical harassment  caused to the complainant.  Against this impugned order dated 17/01/2012 passed by the learned District Consumer Forum, Nagpur ,the present appellant has come up in appeal.

 5.         We have heard Mr. Rahate, learned advocate for the appellant and  Mr. J.S. Bamrah, learned advocate for the respondent/complainant. We have also gone through the written notes of argument filed by appellant as well as respondent and both appellant and respondent have reiterated the contentions raised in the pleading.

 6.         The foremost  contentions  raised by  Mr. Rahate, learned advocate for the  appellant  before us  is that  the learned District Consumer Forum, Nagpur  has not properly  appreciated  the fact that  the complainant  was known  case of  hyper tension  since one year prior  to the  period of policy. Secondly , the learned District Consumer Forum, Nagpur  has also not properly appreciated  the exclusion clause  Nos. 4.1 & 4.3 on the  basis  of  the claim  of the complainant  came to be repudiated.  Mr. J.S. Bamrah , learned advocate for the respondent  has strongly  rebutted  this contention. However,  before  dealing  with  the contentions  which were  advanced  by the learned advocate  at the  bar  it would  be  useful to deal with  the letter  to repudiation  dated 31/08/2010 about which  there is no dispute  between  the parties.  It is also  not in dispute  that there was  exchange  of  correspondence  on this aspect  between  the complainant  as well as  appellant –Oriental  Insurance Company Ltd. Coming  now back  to the letter  of repudiation  dated 31/08/2010 the  appellant – Oriental  Insurance Company Ltd.  had given  reason for  Repudiation  that  as per  pre  authorization  form the patient –Mr. Amulya Sinha  who was  father  of the complainant  was  known case  of  the hyper  tension  since  one year prior to the  policy.  The record  shows that  the complainant had  given reply  to the  Oriental  Insurance Company from time to time  and more particularly on 02/02/2011  denying the stand  of the  Oriental  Insurance Company. The respondent /complainant  had  pointed  out  that  prior  to  being  admitted  in  the Wockhardt Hospital , Nagpur  on 01/04/2010 his father  namely  Mr.  Amulya Sinha was examined  by Dr.  Nikhil Balankhed  of G.T. Memorial  Hospital  and  the prescriptions  also  do not show  that  he was suffering  from hyper tension  since last one year.  The respondent  has also stated  in the reply  that  his father  was  keeping good  health  till he  consulted  Dr. Nikhil Balankhed  on 28/08/2009 in the O.P.D. where medicines were prescribed  after taro medical examination. The respondent  also  clarified  that he had  no  availed  of any claim  in the previous  policy  and  had also paid  premium  for the Floater Policy  which was  for the  period  from 20/06/2009 to 19/06/2010. Admittedly, The Family Floater Policy  was issued   for first time on 20/06/2009 for  sum of Rs.  3,00,000/- and  the father of the complainant  had also  under   gone  medical treatment  during this  period.  However,  Mr. Rahate, learned advocate for the  appellant  has placed   much  emphasis on the  exclusion clause  in the terms  and conditions  of the insurance  policy  and so  it would be  convenient  to deal with   the same and they read as under.

Exclusion Clause No. 4.1:-Any ailment /disease/injuries/health  conditions which are  pre-existing (treated /untreated , declared/not declared  in the proposal form), when  the cover  incepts  for the first item are excluded  for such insured  person  upto 4 years  of the  policy  being  in force continuously. For  the purpose of applying this conditions, the date of inception of the policy taken from the Company shall be  considered, provided the renewals have been continuous and without  any  break in period.  This exclusion  will also apply to any complications  arising from pre-existing  ailments/diseases and such  complications  shall be considered as a par of  the pre-existing  health condition or  disease.

 Exclusion Clause No. 4.3.:- If  the continuity of  renewal is not  maintained with the Company then subsequent  cover  shall be treated  as fresh policy  and clause 4.1 shall apply unless agreed by the Company and  suitable endorsement passed on the policy. If the sum insured  is enhanced subsequent to the inception of the policy , the exclusion  No. 4.1 will apply afresh for the  enhanced portion of the sum insured  for the purpose  of this section. 

 7.         Mr. Rahate, learned advocate for the appellant  has submitted  that  above exclusionary  clause  comes  into  play if the patient  suffers  from any pre existing  ailment  which is  not declared  in the proposal  form  prior to  the inception  of the policy. At the cost of repetition it may be stated that the claim was also repudiated on this count.  Mr. J. S. Bamrah, learned advocate for the respondent  has   vehemently  challenged  this aspect and  we have  already  referred  to the  correspondence  which  took place between  the complainant  and  respondent.  Mr. J.S. Bamrah, learned advocate for the respondent  has submitted that  the  Oriental  Insurance Company had not  placed  on record any documents  which would  go to show that  the father of the complainant  was  a  known  case of  hyper tension.  Mr. J.S. Bamrah, learned advocate for the respondent  has  submitted that  the appellant  had  also not placed  on record any  affidavit  of the  person who  filled the  claim  form nor any medical  case  papers  have been placed  on record to show that  the father of the complainant  was a known  case of a  hyper tension  as mentioned  in the letter of repudiation.  We have  also  considered the documents  placed on record  and pleadings  and  they show that  Mr. Amulya Sinha  complained   of  muscular pain  and heaviness  in shoulder  and so he consulted  Dr. Nikhil  Balankhed  on  28/10/2009 and thereafter Dr. Nikhil Balankhed  again referred him  to  Wockhardt Hospital. It is  necessary to point out that  the appellant – Oriental  Insurance Company  has not placed  on record  any  other  medical  record or  medical papers  to show that  Mr. Amulya Sinha was suffering  from hyper tension  since one year  prior  to inception  of Family  Floater Policy  due to which  he  would become disentitled  for the benefit  of the Family Floater Policy  for which  he  had already paid  the premium. On this aspect Mr. J.S. Bamrah , learned advocate has also  heavily  relied upon  the series  of judgments. At the outset  Mr. J. S. Bamrah  learned advocate  has relied  upon one judgment  of Maharashtra  State Commission, reported in 2013(1)ALL MR (Journal)1 in the case of  Star  Health and Allied  Insurance  Company Ltd. Vs. Anil Chandrant Argade. In that case  also  the facts were  quite similar  and insurance claim  was repudiated  on the ground   of  pre- existing disease  relating to heart  which was  also  congenital. It was  observed  that  there was no material  to demonstrate  that  the  disease  was  pre-existing and so the repudiation  was not accepted.  Mr. J.S. Bamrah, learned advocate for the respondent has also  relied upon  another  judgment  of Hon’ble National  Consumer Commission in the case of New India  Assurance  Company Ltd. Vs. Rakesh Kumar, reported in III(2014) CPJ 340 (NC).  In that case also  the claim was repudiated  but the  O.P. did not   produce any  evidence  to show that  the complainant  was  suffering  from hyper tension. It was observed  by the  Hon’ble National Commission  that  people  can live  for months, even  years without  knowing   about disease  and  repudiation  was not justified. On this count  alone  when  concealment  was not  established. Here in the present  case also  before us  there was no material  to  draw any  inference  that  there was  concealment  of facts relating  to the  illness. In the present  case before us   appellant – Oriental Insurance Company had also  not  laid  any other  evidence  nor  examined any medical  expert  on this aspect and so  no such  inference  can be drawn .  In the same way Mr. J.S. Bamrah, learned advocate for the respondent  has also  relied upon  another  judgment  of the  Hon’ble National Commission in the case of Ravindra Singh Bindra Vs. National  Insurance  Co. Ltd. , reported in I (2017)CPJ 498 (NC). Here also  the  facts were  identical.  Mr. J.S. Bhamrah, learned advocate for the respondent has also relied upon one   judgment of the Hon’ble National Commission in the case of Bajaj Allainz Life Insurance  Company Ltd.  Vs. Sowbhagyalaxmi  and other, reported in  2013(2) CPR 137 (NC). In that case  also  it was observed  that  pre existing  ailment  must be proved  from medical reports. We find that  the facts in the present  case  before us are squarely  covered  by the facts in the judgments  on which  reliance  has been placed  by  Mr. J.S. Bamrah, learned advocate for the respondent  We have also find that  the learned District Consumer Forum, Nagpur  have also  elaborately   dealt with this aspect  and  has rightly given  findings  that  the exclusion  clause  is not  attracted  and  so we find  no material  to disturb  or  interfere  with  the said findings.

 8.         Lastly it is submitted by  Mr. Rahate, learned advocate for the appellant  that  the terms  and conditions  in  any  contract of  insurance  had to be  strictly    construed  to  determine the  extent  of  insures  liability.  On this aspect  he has relied  upon the judgment  of  Hon’ble Apex Court  in the case of  M/s Suraj Mal Ram  Niwas  Oil Mills (P) Ltd. Vs. United  India  Insurance Company, reported in  2011(1) ALL MR 453  and  Deokar Exports Pvt. Ltd. Vs. New India  Assurance  Company Ltd., reported in  I (2009) CPJ 6 (SC). We have  gone  though  both these judgments  on which  reliance  has been placed  by  Mr. Rahate, learned advocate  for the  appellant   and there can be  no dispute  regarding  this proposition   which is  firmly settled.  In view of  the discussion  already  held above, we feel  that  these  judgments relied upon  by the learned  advocate  for the  appellant  will not  go to  help  the case of the appellant.  In the light  of the aforesaid discussion  we are unable  to  accept  the  contentions of the appellant that  the learned District Consumer Forum, Nagpur  has not  appreciated  the evidence  in  the proper  perspective or  has given  findings  which were  erroneous  in nature.  As such by way of  sequel , we proceed to pass the  following order.  

ORDER

i.          The appeal is hereby  dismissed.

ii.          No order as to cost in appeal.

iii.         Copy of order be furnished  to both the parties, free of cost.​