MRS. NEENA SANDHU, MEMBER

1.         This is an appeal filed by the complainant against order dated 16.12.2008 passed by District Consumer Disputes Redressal Forum-I, UT, Chandigarh (for short hereinafter to be referred as District Forum) passed in complaint case No.852 of 2008.

2.       Briefly stated the facts of the case are that the complainant No.1 (Lakhwinder Singh) working as Deputy Manager of OP No.3 (HFCL Infotel Limited) who secured a Group Medi-claim Insurance Policy from OPs No.1 & 2 (United India Insurance Company Limited) under which its employees and their dependents were covered for various medical expenses incurred by them on their treatment.  The complainant No.2 i.e. Gurbachan Kaur is the mother of complainant No.1 Lakhwinder Singh and she is dependent upon her son Lakhwinder Singh. The complainant No.2 being a patient of hypertension felt chest pain on 10.1.2006 and was immediately taken to Government Medical College and Hospital, Sector-32, Chandigarh from where she was referred to P.G.I, Chandigarh. On 11.1.2006 complainant No.2 was admitted in the PGI, Chandigarh where the complainant No.1 incurred total expenses of Rs.1,20,525/- on her treatment and in the month of February, 2006 the original bills were submitted to OP No.3 for claim.  The correspondence was started between the OP No.3 and OP No.1 through letter annexure C-12 stated their inability to accept the liability. Thereafter the complainant No.1 made a representation to OP No.3 for illegal and wrongful rejection of the claim. OP No.3 wrote a letter to OP No.1 for reconsideration of the claim but the OP No.1 vide their letter annexure C-14 finally stated that in view of facts explained in Annexure C-12 they were unable to reconsider the claim.  The above said act of OP amounts to deficiency in service. Hence, the complaint was filed.

3.        Reply was filed by OPs No.1 & 2 and they pleaded that the complainant No.2 was a hypertension patient for the last six years and having chest pain for the last 4-5 years. Dr. N.P. Singh, medical expert gave the opinion that as per the medical record, the complainant No.2 was having stable angina for the last 4-5 years and which was confirmed in Angiography. It was pleaded that vide letter dated 11.4.2006, OP No.3 was informed by the answering OPs that due to pre-existing disease, the claim of the complainant was repudiated. It was further pleaded by the answering OPs that as per clause 4.1 of the terms and conditions of the policy, the answering OPs would not be liable to make any payment in connection with or in respect of such diseases which have been in existence at the time of proposing this insurance.  Hence, it was pleaded by the answering OPs that there was no deficiency in service on their part and prayed for dismissal of the complaint. 

4.       Reply was filed by OP No.3 and pleaded that it was the duty of OPs No. 1 & 2 to make the payments and to follow the necessary procedure as required under the contract.  It was further pleaded that there was no relief claimed against it, and as such the complaint qua it is liable to be dismissed.  Hence, it was pleaded that there was no deficiency in service on its part and prayed for dismissal of the complaint.

5.       The parties led their evidence in support of their contentions.

6.       The District Forum dismissed the complaint as the complainant No.2 was suffering from pre-existing disease prior to taking the policy in question and she has suppressed the material information about her health at the time of taking the policy.

7.          Aggrieved by the order passed by the learned District Forum, the present appeal has been filed by the complainant and submitted that there is no question of fraudulent suppression of material fact in any document by the complainants as question and answer form was never got filled from the complainants. Neither Dr.N.P.Singh nor the Forum had taken into consideration clarification sought by the insurance company from Dr.Y.P.Sharma, Head of Cardiology Department of PGI, Chandigarh which specifically states that there is no history of pre-existing angina. The policy in question is not specific, it is employee welfare scheme where his dependents are also covered and how can the question of concealment in such a policy arise. Moreover the policy in question is of year 2000 and renewed thereafter from time to time and no one will wait for four years to go in for treatment where life is at stake. Question of having fraudulent intention does not arise in the present case. The suppression and concealment conclusion and knowledge of existence of angina are without any basis rather based on surmises and conjectures. The action of OPs No.1 and 2 rejecting the claim under the medi-claim policy is clearly illegal, arbitrary and against the settled principles of law and as such rejection of the claim is not sustainable. It is submitted that chest pain can be one of the most difficult symptoms to interpret and chest pain does not always signal a heart attack. Patient when have no knowledge about such a disease and she was never given any treatment in the past. There is no element of fraud, misrepresentation and concealment of any fact at any point of time. There is no history of any such treatment which may indicate pre-existence of the disease. It is submitted that once the insurer is getting premium for more than six years and when claim is lodged for reimbursement the same cannot be declined on the ground of pre-existing disease. The learned District Forum had failed to appreciate the evidence/facts on record. Hence, it is prayed that the impugned order passed by the learned District Forum may kindly be set aside and the appeal may kindly be allowed.

8.       We have heard Sh.P.S.Dhaliwal, Advocate for the appellant, Sh.Nitin Grover, Advocate for the respondent No.1 & 2, Sh.Sukhbir Singh, Advocate has appeared on behalf of respondent No.3.

9.       After hearing the learned counsel for the parties and perusal of the record, admittedly the complainant and his mother were covered under the Group Medi-claim Insurance Policy which was duly issued by OPs No.1 and 2 as due to sudden chest pain, the complainant No.2 was hospitalized. The complainants filed a claim for the expenses incurred for the treatment taken by the complainant No.2 as per policy. The OPs repudiated the claim on the ground of suppression of pre-existing disease The learned District Forum has also dismissed the complaint on the ground of suppression of material facts at the time of taking the policy in question by not disclosing that the complainant No.2 was suffering from pre-existing disease.

10.     A perusal of the out patient card of Government Medical College and Hospital, Sector 32, Chandigarh dated 10.1.2006 shows that the complainant No.2 came with the problem of chest pain and was admitted in the hospital for a day and then was referred to PGI, Chandigarh for further investigation and treatment by cardiologist, where the complainant No.2 was thoroughly examined and the observation made by the Cardiologist of PGI, Chandigarh are as under :-

“Patient was a known hyper-tensive for last 5-6 years on regular treatment. She only had symptoms of angina on 10.1.2006 for which she underwent evaluation in PGI when she was diagnosed to have single vessel coronary artery disease and underwent CAB on 18.2.2006.”

The total expenses incurred by the complainants for the treatment came out to Rs.1,20,525/- and the original bills were submitted by the complainants to the OP No.3. The same were forwarded to OPs No.1 and 2 for reimbursement of the expenses incurred by the complainant but the OPs No.1 and 2 repudiated the claim on the ground of suppression of material facts. The question for consideration before us is whether the appellant/complainant was suffering from pre-existing disease, the non-disclosure of which tentamounts to suppression of material facts.  After the perusal of the reports issued by the Cardiologist of renowned institute i.e. PGI, Chandigarh, we have come to the conclusion that admittedly there was no history of previous treatment of angina. Moreover as per the medical research there are various medical conditions causing chest pain and the chest pain is not the only signal for heart related diseases. It has been disclosed by the complainant while taking the policy that the complainant No.2 is hyper tensive and as per settled law that the maladies like diabetes, hyper tension being normal wear and tear of life cannot be termed as concealment of pre-existing disease. Moreover, as per the contention of the appellant that at the time of issuing this policy, the respondents never asked for medical history from the complainant and no medical tests were conducted. So, there is no question of any concealment of material facts as the respondents have never sought any medical declaration form from the complainants. Even we agree with the contention made by the learned counsel for the complainant at the time of arguments that even for the sake of presumption. If, we presume that the disease is pre-existing for the last 4-5 years as per reference to the alleged history we are of the view that no one will remain without treatment when the one’s life is at stake and in this case there is no history of any such treatment which may indicate that there is a pre-existing disease.

11.     We are of the view that the learned District Forum has wrongly observed that there is a pre-existing disease as respondents have failed to prove on record that the complainant had taken any treatment for the chest pain and before chest pain on 10.1.2006 the complainants were aware of this fact that complainant No.2 is suffering from disease. Although as per the opinion sought by the company from medical expert Dr.N.P.Singh, the complainant No.2 was having angina for the last 4-5 years when angiography was done. The report given by the Cardiologist of PGI, Chandigarh which is a independent body does not confirm that complainant was suffering from chest pain in the last 4-5 years. We are of the view that the opinion of super specialist of PGI specializing in Cardiology shall prevail over the report of doctor having degree of M.D (Medicine). Moreover Dr. N.P.Singh has not given his opinion after examining the patient physically but merely going through the case history (documents) provided by the respondents No.1 and 2. Taking these facts into consideration, we are of the opinion that there is no suppression of material fact as complainant was not aware of any pre-existing disease. Our view is supported by the order passed by Hon’ble National Commission in the case titled as Life Insurance Company of India & Ors. Vs. Paria Pally Sujatha & Ors. 1(2010) CPJ 106(NC). “Consumer Protection Act, 1986 – Section 21(b) – Life Insurance – Suppression of material facts – No evidence produced in support – Ex gratia payment made by insurer – complaint dismissed by Forum – allowed by State Commission – no interference required in revision.”

Hence, we are of the view that the complainant is entitled to the expenses incurred by him on the treatment to the tune of Rs.1,20,525/-.

12.     The objection taken by the Ops that the complaint is time barred by limitation is also base less. It is pertinent to mention here that the OPs No.1 and 2 repudiated the claim on 11.4.2006. On the representation made by the complainant vide letter dated 11.12.2006 for the settlement of the claim, the OPs after taking the opinion of Dr.N.P.Singh refused to reconsider the claim of the complainants vide its letter dated 29.8.2007 and the complaint was filed well in time. With the above discussion, the appeal is allowed and OPs No.1 and 2 are directed

1)       To pay Rs.1,20,525/- along with interest @ 7% from the date two months after the filing of the documents for the claim till realization.

2)       To pay Rs.5,000/- as litigation expenses.

This order be complied by the OPs No.1 and 2 within one month from the date of receipt of copy of this order failing which interest @ 12% shall accrue.

13.          Copies of this order be sent to the parties, free of charge.

Pronounced.

7^th April, 2010.