Haryana

Kurukshetra

54/2017

Sarbati Devi - Complainant(s)

Versus

UIIC - Opp.Party(s)

PArdeep Budhwar

13 Feb 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

                                                     Complaint Case No.54 of 2017.

                                                     Date of institution: 03.03.2017.

                                                     Date of decision:13.02.2019.

Sarbati Devi wife of Sh. Ram Kishan, resident of House No.4840/5, Model Town, Jhansa Road, Thanesar, Tehsil Thanesar, District Kurukshetra.

                                                                        …Complainant.

                        Versus

United India Insurance Company Ltd., Railway Road, Opposite Gol Bank, Kurukshetra, through its Branch Manager.

….Respondent.

Before:      Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Trikha, Member.

Present:     Sh. Pardeep Budhwar, Advocate, for the complainant.   

                Sh. Paras Manocha, Advocate for the OP.

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Sarbati Devi against United India Insurance Company Ltd., the opposite party.

2.            Brief facts of the present complaint are that the complainant obtained two family medi-claim policies bearing No.110702/48/14/06/00000309 on 24.09.2014 for the sum assured of Rs.2,00,000/- valid for the period w.e.f. 24.09.2014 to 23.09.2015  and the policy No.1107022815P107210057 for the sum assured of Rs.7,00,000/- valid for the period w.e.f. 24.09.2015 to 21.09.2016.  It is alleged that unfortunately, the complainant fell ill and she was suffering from SAH ruptured and epileptic attack and on 12.12.2014, she was shifted to Apna Hospital, Kurukshetra but due to serious condition, she was referred to P.G.I., Chandigarh.  It is further alleged that the complainant received treatment from P.G.I., Chandigarh where she was operated upon on 27.12.2014 and she was discharged on 06.01.2015.  The complainant spent Rs.1,90,000/- on her treatment.  It is further alleged the complainant lodged the claim with the Op and submitted all the necessary documents but the Op repudiated the claim of complainant vide letter dt. 30.09.2016.  The said repudiation of claim is wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of Op and prayed for acceptance of complaint with the direction to Op to pay an amount of Rs.1,90,000/- alongwith interest @ 18% p.a. and further to pay Rs.1,00,000/- as compensation for harassment and mental agony as-well-as Rs.11,000/- as litigation charges. 

3.            Upon notice, the OP appeared before this Forum and contested the complaint by filing reply raising preliminary objections with regard to locus-standi; maintainability; cause of action; that the complainant has concealed the true and material facts from this Forum.  The true facts are that the complainant and her husband Ram Kishan got insured with the Op w.e.f. 24.09.2014 to 23.09.2015 vide policy No.110702/48/14/06/00000309.  The claim of complainant stands repudiated and the husband of complainant was duly informed vide letter dt. 12.09.2016. The claim was repudiated as the assured Sarbati Devi was under treatment and was admitted in PGIMR and was a known case of psychiatric treatment since many years with history of HTN, whereas the policy was in its first year and as such, the claim was not payable as per terms and conditions of the policy.  There is no deficiency in service on the part of Ops.  On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

4.             The complainant tendered into evidence affidavit, Ex.CW1/A and documents Ex.C1 to Ex.C15 and thereafter, closed the evidence.

5.           On the other hand, learned counsel for the Ops tendered into evidence affidavit, Ex.RW1/A and documents Ex.R1 to Ex.R12 and thereafter, closed the evidence on behalf of Ops.

6.             We have heard the ld. Counsel for both the parties and perused the record carefully and minutely.

7.             It is pertinent to mention here that during the course of arguments, the counsel of complainant tendered medical bills Mark-1 to Mark-54 and medical tests Mark-A and Mark-B.  Learned counsel for the complainant contended that the complainant obtained medi-claim policies in question from the Op on 24.09.2014 and 24.09.2015.  On 23.09.2014, the Op has taken a medical test of complainant, copy of medical test is Mark-A and Mark-B.  On 12.12.2014 due to sudden attack, she was admitted in Apna Hospital, Kurukshetra.  Due to serious illness, she was referred to P.G.I.Chandigarh on 12.12.2014, but the attendant of complainant got her admitted in Alchemist Hospital, Panchkula and she remained there upto 16.12.2014.  The complainant was again admitted in P.G.I. Chandigarh on 16.12.2014 and discharged on 06.01.2015.  The counsel of complainant contended that the complaint spent Rs.1,90,000/- on her treatment including transportation charges etc., copy of treatment record and medical bills are Mark-1 to Mark-54 and Ex.C1 to Ex.C15.  He further contended that the Op repudiated the claim of complaint on the ground of pre-existing disease on 30.09.2016, copy of repudiation letter is Ex.C6.  The said repudiation of claim is wrong and illegal.  He further contended that at the time of taking the policies, the complainant was fit and medical test was done by the Op.  The complaint of complainant may please be allowed.  The counsel of complainant placed reliance upon the order dt. 03.10.2006 passed by Hon’ble National Commission in case titled as Praveen Damani Vs. OIC bearing revision petition No.1696 of 2005 and order dt. 02.04.2014 passed by Hon’ble High Court of Punjab and Haryana in case titled as Star Health & Allied Insurance Co. Ltd. Vs. The Chairman, Permanent Lok Adalat bearing CWP No.3356 of 2014.

8.             On the other hand, learned counsel for the Op contended that the claim of complainant was rightly repudiated because the complainant was admitted in P.G.I. Chandigarh on 28.01.2013 and discharged on 03.02.2013, copy of admission and discharge is Ex.R7.  The complainant suppressed her illness in the proposal form, Ex.R1.  In the proposal form, the complainant also mentioned that she was of good health at the time of taking the policies in question.  The complainant has suppressed the pre-existing disease, so, the claim of complainant was rightly repudiated by the Op.  The counsel of Op placed reliance upon the case law cited in 2009(4) CLT page 398 titled as Satwant Kaur Sandhu Vs. NIA (SC); order dt. 28.07.2014 passed by Hon’ble National Commission in case titled as Smt. Paramjit Kaur Vs. LIC bearing revision petition No.1308 of 2013; order dt. 28.11.2014 passed by Hon’ble National Commission in case titled as Manju Bhattacharya Vs. Senior Manager, LIC bearing revision petition No.1367 of 2014 ;2012(2) CLT page 591 titled as LIC of India Vs. Kulwant Kaur (Hon’ble State Commission Haryana) and 2012(20 CPR page 76 (NC) titled as NIC Vs. Mehboob Khan (NC).

9.             We have seen the treatment record of the complainant, Ex.C14 whereby it is clear that the complainant was admitted in P.G.I. Chandigarh on 20.12.2014 with the problem of SAH.  According to WIKIPEDIA, copy of which is Mark-C, “Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space-the area between the arachnoid membrane and the pia mater surrounding the brain.  Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever and sometimes seizures.  SAH may occur as a result of a head injury of spontaneously, usually from a ruptured cerebral aneurysm.  Risk factors for spontaneous cases included high blood pressure, smoking, family history, alcoholism and cocaine use.  Females are more commonly affected than males.  It is a form of stroke and comprises about 5 percent of all strokes”.  It is a sudden attack which is also supported by the report of P.G.I. Chandigarh, Ex.R7 in which Dr. Priti Arun, Professor, Deptt. Of Psychiatry, Govt. Medical College & Hospital, Sector-32B, Chandigarh has taken the view “The psychiatric conditions for which she was treated in Department of Psychiatry, GMCH 32, Chandigarh does not lead to Subarachnoid Heamorrhage”.  So, it means that the claim of complainant was wrongly repudiated by the Op because the medical test of complainant was done by the Op and the treatment which was given to the complainant in P.G.I. Chandigarh w.e.f. 16.12.2014 to 06.01.2015 is not pre-existing disease.  We can rely upon the order dt. 30.01.2014 passed by Hon’ble Madras High Court in case titled as Manivasagam Vs. NIC bearing W.A. (MD) No.956 of 2011 wherein in para No.8 of this order it is mentioned that “It is the admitted case of the petitioner that he is suffering from hypertension and diabetes.  If the treatment is relating to hypertension and diabetes, then it is pre-existing disease an no claim can be made.  However, in the report, it is stated that the petitioner was suffering from Coronary Artery Disease and surgery was done.  Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued.  Therefore, the claim apparently is rejected on the misconception”.  We can also rely upon the order dt. 27.02.2015 passed by Hon’ble State Commission, Punjab in case titled as Ashwani Joshi Vs. Reliance General Insurance bearing first appeal No.1671 of 2012, wherein in para No.12 and 13 of the said order, Hon’ble State Commission, Punjab has taken the view on relying upon the view of Hon’ble Supreme Court and Hon’ble Delhi State Commission.  In para No.12 of the said order, it is mentioned that “Moreover, the Supreme Court in its judgment dt. 10.10.1995 recorded in Biman Krishan Bose Vs. United India Insurance Company, in Civil Appeal No.3438 of 1995 had stated: that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the insurance company.  Moreover hypertension is not a material disease which is fatal in itself”.  In para No.13 of the above-said order, it is mentioned that “Similarly, the Hon’ble Delhi State Consumer Disputes Redressal Commission, in case of Life Insurance Corporation of India Vs. Sudha Jain, 2007(2) CLT 423, had drawn the conclusions in para 9 and had stated as under. 

        “Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is fully of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” 

           We have also perused the treatment record of P.G.I.Chandigarh, Ex.R10 wherein the brief history of the complainant is that “K/C/O psychiatric disorder with hypertension”.  So, the hypertension is not pre-existing disease, this is a routine illness.  The authorities submitted by the counsel of Op are not disputed but the same are not applicable to the facts of instant case because in the present case, the complainant has suffered a sudden attack, which is SAH i.e. mentioned above in WIKIPEDIA.  So, the said disease is not pre-existing disease.  Hence, in the facts and circumstances of the case, we are of the considered view that the Op has wrongly repudiated the claim of complainant and the Op is deficient while rendering services to the complainant.                                                  

10.            Thus, as a sequel of above discussion, we allow the complaint and direct the Op to pay Rs.1,90,000/- to the complainant and further to pay Rs.20,000/- as lump sum compensation on account of harassment, mental agony including the litigation charges.  Let the order be complied with within 30 days from the date of preparation of copy of this order, failing which, the complainant shall be entitled interest @ 9% p.a. from the date of order till its realization.  A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.            

Announced in open court:

Dt.:13.02.2019.

  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Trikha),           (Neelam)       

Member                             Member.