Sri Kamal De, President
The present case arises over repudiation of Complainant’s claim by the OPs in respect of his health insurance policy.
In short, case of the Complainant, is that he took a mediclaim policy from the LICI in the year 2011 and staked a claim with the Insurer for an operation that was done on his right leg at Vellore in the year 2013. It is alleged that the OP Insurer repudiated his claim most arbitrarily and illegally vide a letter dated 16-01-2015. Hence, the case.
OP Nos. 1&2 contested the case by filing WV, whereof they denied all the material allegations of the Complainant. It is the case of the OP LICI that the Complainant availed of the policy in question suppressing the fact that he underwent operation on his left leg prior to availing of the policy in question. So, the claim of the Complainant was rightly repudiated for suppression of material fact. It is the further case of the OP LICI that the treating doctor of a Cuttack based hospital, where the Complainant underwent operation restricted the latter from playing outdoor games. However, in utter defiance of such advice, the Complainant played football and sustained injury on his right leg. So, according to the OPs, the Complainant himself is responsible for the injury on his right leg and the LICI cannot be held responsible in any manner to foot his medical bills. The OPs, thus, prayed for dismissal of the present case.
Points for consideration
- Whether the claim of the Complainant has rightly been repudiated by the OP Insurer, or not?
- Whether the insured complainant is entitled to get claim, if so, to what extent?
Decision with reasons
Ld. Lawyer for the OP Nos. 1&2, drawing our attention to the Discharge Summary of CMC, Vellore dated 07-12-2013, has stated that the Complainant suffered similar injury in his left knee in the year 2008, for which he underwent left knee ACL reconstruction in Cuttack in the year 2010. It is also contended by the Ld. Lawyer that the Complainant was duly cautioned by the treating doctor of Cuttack based hospital, who operated his leg knee, from playing outdoor games. Yet in defiance of said advice, he played football and suffered a fall because of which he experienced difficulty in running and walking on uneven surfaces. It is alleged that the Complainant took the LICI health insurance policy being no. 499580346 in the year 2011 suppressing all the above facts notwithstanding it was obligatory on the part of the Complainant to disclose such material fact about his past injury while filling up the proposal form. Thus, he contended that the Complainant availed of the aforesaid policy in question with an ulterior motive for unlawful gain. According to the Ld. Lawyer, the Insurer has done no wrong by repudiating the claim of the Complainant over withholding of material fact from the Insurer and prayed for dismissal of this case in liminie.
Admittedly, the Complainant suffered some injury in his left knee in the year 2008 for which he underwent operation at Cuttack. The present claim relates to right knee arthroscopic ACL reconstruction of the Complainant which was done at CMC Vellore on 04-12-2013.
Now the question remains, whether non-disclosure of past injury of left knee by the Complainant while filling up the proposal form can be construed as material suppression of fact in the present case, or not.
It is the truism of law if one otherwise leads normal and healthy life in the near proximity of obtaining an insurance policy, he is not supposed to disclose the normal wear and tear of human life. Disease that can be easily detected by subjecting the insured to basic tests like blood test, ECG, etc., the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person. The previous injury to the left knee of the Insuree occurred when he had a fall while playing football. It was nothing but an accidental injury. There is nothing on record to show that the Complainant was facing any difficulty in leading normal and healthy life or discharging his duties and daily chores like any other person at the time of obtaining the policy in question or the previous injury aggravated in any way giving rise to the present discomfort on his right knee and most importantly, the past injury had any relation with the present injury. It is clearly stated in the discharge summary of CMC, Vellore dated 07-12-2013 that the Insuree was facing difficulties in running and walking on uneven surfaces for the past six months and that he was apparently well till six months back. In fact, it is stated in the discharge summary in unequivocal terms that following ACL reconstruction in the year 2010, the Complainant was alright. Thus, it can reasonably be surmised that the previous operation that was done on the left knee of the Insuree had got no bearing on the health of the Complainant. There appears to be no co-relation between the previous injury that the Complainant suffered in the year 2008 on his left knee vis-à-vis the present injury that he suffered on his right knee in the year 2013. Although the OP Nos. 1&2 have taken a plea that the treating doctor of the Cuttock hospital cautioned the Complainant against playing football, we do not come across any documentary proof in support of such contention.
Although the OP Insurer has sought to pick hole over the claim of the Complainant for non-disclosure of past history of injury that the Complainant suffered in the year 2008, one wonders, how the same would have any adverse impact on the eligibility of the Complainant to insure his right knee.
Ld. Advocate for the OP Nos. 1&2 has placed reliance on some decisions of the Hon’ble National Commission, viz., 2015 (1) CPR 280 NC, 2015 (3) CPR 538 NC, 2014 (4) CPR 729 (NC) and 2015 (4) CPR 492 (NC), where the Hon’ble Commission has put due emphasis on the virtue of good faith between an Insurer and an Insuree.
No one denies the necessity of full-fledged disclosure about past ailment(s), if any, by a prospective customer while applying for an insurance policy. However, as we find that the factum of non-disclosure of past injury by the Complainant in the present case cannot be construed as material suppression of fact, in our considered opinion, the afore-mentioned decisions do not aid the cause of the OPs in anyway. Disease that can easily be detected by subjecting the insured to basic tests like blood test, ECG, etc., may be termed as pre-existing disease. The Insured, however, is not supposed to disclose such disease that occurs in course of normal wear and tear of human life and such a person should not be branded as a diseased person.
We, thus, hold that the decision of the OP Insurer as well as its TPA to repudiate Complainant’s claim does not stand on sound lucidity and is not tenable in the eye of law. As an Insurer, OPs do have a legitimate right to put every claim under stringent scrutiny, but that does not in any way give it the right to reject a claim over trifle matters. Rejection of claim cannot be the be all and end all of any Insurer. If it cannot desist itself from such self-destructive temptation, people would ultimately lose faith in the insurance sector as a whole. Needless to say, if that indeed happens, they would be left with no or very little business.
It would be seen from the photocopies of bill/voucher/money receipts on record that the Complainant incurred a sum of Rs. 64,735/- towards his treatment. As against this, the Complainant has sought for a sum of Rs. 2,00,000/- as insurance benefit together with compensation and litigation cost to the tune of Rs. 85,000/- and Rs. 60,000/-, respectively. It appears that the Complainant derived at such figure (insurance benefit) after taking into consideration the bank interest over the expenditure incurred by him. Any person of reasonable prudence would find it hard to appreciate as to how the bank interest would become Rs. 1,35,265/- over a principal amount of Rs. 64,735/- within a year. We feel, one should be reasonable in one’s approach while staking monetary relief before a Court of Law. On the other hand, it is stated by the OP Nos. 1&2 in their W.V. that under normal circumstances the Complainant would be entitled to get a sum of Rs. 59,400/- HCB for (ADB Rs. 2,200/- x 9 days) = Rs. 19,800/- plus other surgical benefit Rs. 2 x 2,200 x 9 = Rs. 39,600/-. The compensation figure, as calculated by the OP Nos. 1&2, appears to be quite reasonable and as such, we hold that the Complainant would be entitled to get Rs. 59,400/- as insurance benefit. Besides, in the facts and circumstances of the case, we also allow compensation and litigation cost in favour of the Complainant.
Consequently, the complaint case succeeds.
Hence,
ORDERED
that C. C. No. 93/2015 be and the same is allowed on contest against the OP Nos. 1&2 and ex parte against the OP No. 3. OPs are directed to reimburse Rs. 59,400/- in full and final settlement of the claim of the Complainant. Besides, the OPs are further directed to pay compensation and litigation cost to the tune of Rs. 10,000/- and Rs. 5,000/-, respectively. Non-compliance of this order by the OPs within 40 days hence would entail the Complainant to put it on execution in accordance with law and in that event, OPs would be liable to pay an amount of Rs.50/- per diem till full and final payment of the decreetal amount.
