DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,<br /> BATHINDA (PUNJAB)<br /> <br /> CC No. 129 of 02.05.2008<br /> Decided on : 05-08-2008 <br /> <br /> Kunal Kumar aged about 6 years minor son of Shri Rajesh Kumar Dubey (aged about 33 years) House No. 3548, Mohalla Serian Wala, Near Mehna Chowk, Bathinda through his father and natural guardian Rajesh Kumar Dubey<br /> <br /> ... Complainant<br /> Versus<br /> <br /> 1.United India Insurance Company Limited having its Registered and Head Office, 24 Whites Road, Chennai 600014 through its Managing Director.<br /> 2.United India Insurance Company Limited having its Branch Office at Khati Bazar, Rampura District Bathinda through its Branch Manager<br /> 3.Opdesh Singal, Insurance Consultant, Singla Street, Rampura Phul, District Bathinda.<br /> ... Opposite parties<br /> <br /> Complaint under Section 12 of the Consumer Protection<br /> Act, 1986.<br /> <br /> QUORUM :<br /> Sh. Lakhbir Singh, President<br /> Dr. Phulinder Preet, Member<br /> <br /> For the Complainant : Sh. Sham Lal Goyal, Advocate.<br /> For the Opposite party : Sh. M.L. Bansal,Advocate.<br /> <br /> O R D E R<br /> <br /> LAKHBIR SINGH, PRESIDENT<br /> <br /> 1. Complainant is a minor. This complaint under Section 12 of the Consumer Protection Act, 1986 (Here-in-after referred to as 'Act') has been preferred by him through his father and natural guardian Sh. Rajesh Kumar Dubey who has no adverse interest against him. Prayer in the complaint is that opposite party be directed to pay him Insurance amount of Rs. 1.00 Lac alongwith interest @18% P.A. from the date when the claim was lodged upto date of payment alongwith bonus and Rs. 50,000/- as compensation on account of mental tension, harassment and botheration.<br /> 2. Version of the complainant lies in the narrow compass as under :-<br /> Medi Claim (Platinum) Insurance Policy for an Insured amount of Rs. 1.00 Lac for each of the family members of Sh. Rajesh Kumar consisting of him, his wife Seema Rani, Kunal Kumar complainant and minor daughter Miss Kajal was purchased on 19.7.07. Cover Note No. 041815 was issued after receiving premium of Rs. 5034/- by the opposite parties. Policy was valid from 19.7.07 to 18.7.08. All the family members were enjoying good health and were duly checked by opposite party No. 3 who is authorised agent of opposite parties No. 1 & 2. Premium was accepted by the opposite parties after being fully satisfied in all respects. Assurance was given that in case of any disease to any family member full Insurance amount would be paid. Policy has not so far been cancelled. Complainant had fallen ill. He was taken to the doctors of Escorts Heart Institute and Research Centre, New Delhi on 26.7.07. A sum of Rs. 2300/- was deposited as registration fee cum first consultation charges and Pediatric Echo charges. Thereafter he remained admitted in the hospital from 1.8.07 to 8.8.07. During this period, subaortic membrane resection (pediatric surgery) was done on 3.8.07. A sum of Rs. 1,71,844/- was charged by the hospital vide bill No. 07/MBB3-HO1323/Ca/IH002706 dated 8.8.07. His registration number in the hospital was 00313473, IPD No. IP 00195137 whereas his Bed No. was DLWD 05-516. He was attended by Dr. Krishna Subramony Iyer and S. Radha Krishnan in that hospital. After recovery, claim No. 200404/48/07/0000257 was lodged by him with opposite parties No. 1 & 2 through opposite party No. 3 probably in the month of October, 2007. Opposite party No. 3 had obtained his signatures on some printed forms and blank papers. Claim was repudiated by opposite parties No. 1 & 2 vide letter No. Medi Claim/TPA/2008 dated 22.2.08 on the ground that it was a Congenital Disease. He alleges that contents of the documents/forms were not read over to him and signatures were obtained on them in routine. He assails the repudiation of the claim as illegal, arbitrary and unjustified. He (his guardian) was not informed by opposite party No. 3 that claim would be rejected in case of Congenital disease. Moreover, he is not so literate that he could understand the meaning of Congenital disease. Hence, there is deficiency in service on the part of the opposite parties.<br /> 3. On being put to notice, opposite parties filed their version taking legal objections that complainant has no cause of action to file the complaint, this Forum has got no jurisdiction to entertain it; complainant has not come with clean hands; complaint is bad for mis joinder of parties and non-joinder of necessary parties and that it has been filed to humiliate and harass them. On merits, they admit that Medi claim policy was purchased. As per facts, medical history and discharge summary, it is clear that complainant was suffering from some disease 2-3 years prior to the filling the proposal form and taking the policy. This fact was concealed. From the record, it transpired that complainant had taken some treatment at Bathinda but no document in this regard has been produced. Complainant was having Congenital disease which is an exclusion as per clause 4.1 under the scope of cover under the policy. Since complainant was suffering from Congenital heart disease much prior to the date of policy, claim has been rightly repudiated. Opposite party No. 3 is only Insurance agent of opposite parties No. 1 & 2 and he was not competent to do medical check up of any person. Checking could be done only by competent doctor on disclosure of history to him. Complainant has left blank Annexure A & B of proposal form. Had he disclosed the true history, no policy could be issued. Infact complainant was fully aware about his ailment and about the previous treatment taken by him from Bathinda. It has been clearly mentioned in the medical record of Escort Heart Institution that complainant had taken the treatment at Bathinda since the age of 2-3 years. They deny that claim has been arbitrarily and illegally repudiated. Similarly they do not admit the remaining averments in the complaint.<br /> 4. In support of his averments contained in the complaint, complainant has produced in evidence affidavits of Sh. Rajesh Kumar Dubey (Ex. C-1 & Ex. C-6), photocopy of Insurance Policy (Ex. C-2), photocopy of letter dated 22.2.08 (Ex. C-3), photocopy of bill cum receipt (Ex. C-4), photocopy of bill (Ex. C-5), photocopies of Identity Cards (Ex. C-7 to Ex. C-9), photocopy of OPD Record (Ex. C-10), photocopy of discharge summary (Ex. C-11), photocopy of blood reports (Ex. C-12), photocopies of Radiology reports (Ex. C-13 to Ex. C-15) and photocopy of OPD record (Ex. C-16).<br /> 5. In rebuttal, on behalf of the opposite parties affidavit of Sh. Balwinder Singh, Divisional Manager (Ex. R-1), photocopies of letters dated 22.2.08 (Ex. R-2 & Ex. R-3), photocopy of settlement intimation note (Ex. R-4), photocopies of letters dated 15.2.08 and 14.1.08 (Ex. R-5 & Ex. R-6), photocopy of claim processing sheet (Ex. R-7), photocopy of OPD record (Ex. R-8), photocopy of discharge summary (Ex. R-9), photocopy of Blood Report (Ex. R-10), photocopy of bill dated 8.8.07 (Ex. R-11), photocopy of receipt dated 8.8.07 (Ex. R-12), photocopy of ECG film (Ex. R-13), photocopy of letter dated 20.10.07 (Ex. R-14), photocopy of Insurance Cover Note No. 041815 (Ex. R-15), photocopies of proposal details (Ex. R-16 to Ex. R-19), photocopy of Individual Health Insurance (Ex. R-20) and photocopy of policy (Ex. R-21) have been tendered in evidence.<br /> 6. We have heard learned counsel for the parties. Besides this, we have gone through the record and written brief of arguments submitted on behalf of the complainant.<br /> 7. Some facts do not remain in dispute in this case. They are that Medi-claim (Platinum) Insurance Policy was purchased for the entire family of Rajesh Kumar i.e. for him, his wife Seema Rani, son Kunal and minor daughter Miss Kajal. Proposal details of each of them were submitted to opposite party No. 3 and copies of them are Ex. R-16 to Ex. R-19. Ex. R-18 pertains to the complainant. Insurance Cover Note dated 19.7.07 was issued copies of which are Ex. C-2 & Ex. R-2. Insurance was valid from 19.7.07 to 18.7.08. Intimation regarding the disease of the complainant and the treatment got provided to him from Escorts Heart Institute & Research Centre, New Delhi (Here-in-after referred to as 'Escorts Delhi') was given to the Insurance Company by the father of the complainant on 20.10.07 as is clear from Ex. R-14. Letter dated 20.2.08 copy of which is Ex. R-3 was sent to the father of the complainant intimating that they are closing the claim concerning the complainant as No Claim as according to TPA letter the disease of the complainant was Congenital disease and claim is not payable as per Exclusion Clause 4.1. Claim has been repudiated vide letter dated 22.2.08 copies of which are Ex. C-3 & Ex. R-2. The effective part of it is reproduced as under :-<br /> “We are thankful to you for your choosing united India's Platinum Health Policy for your family effective from 19.7.07 to 18.7.08. On receipt of claim papers of Master Kunal Kumar, it has been found that he was admitted to the Escort Heart Institute & Research Centre, Delhi with Acyanotic Congenital heart Disease and was operated on 3.8.07. As the disease for which the treatment was taken in found to be a 'Congenital Disease' which is a exclusion 4.1 under the scope of cover. As such your claim is not tenable and hence repudiated”<br /> 8. Contention of the learned counsel for the complainant is that complainant and/or his guardian were not made aware about the contents/terms and conditions of the policy before it was purchased. He was never informed that claim can be rejected in case of Congenital disease. This argument is not tenable. Complainant himself is relying upon the copy of the Insurance Cover Note in which it has been made clear that Insurance is subject to the terms and conditions of the policy of the opposite Insurance Company. Moreover with the cover note, opposite Insurance Company had attached proposal forms of all insured and prospectus of the policy. Copy of the policy is Ex. R-2. In such a situation, it does not lie in the mouth of the complainant that he was not aware about the contents of the policy and the fact that claim can be rejected in case of Congenital disease.<br /> 9. Mr. Goyal, learned counsel for the complainant vociferously argued that complainant was hale and hearty at the time when policy was purchased. Under the instructions of opposite parties No. 1 & 2, opposite party No. 3 had checked the complainant and all his family members. Thereafter premium was received after full satisfaction and after completing all the necessary formalities. Moreover complainant and his guardian were not aware about any illness of the complainant prior to the issuance of the policy in question. Complainant was not suffering from any disease at the time of submitting the proposal form.<br /> 10. Mr. Bansal, learned counsel for the opposite parties countered the arguments of the learned counsel for the complainant by submitting that complainant through his guardian/father concealed the material facts of his health while submitting the proposal form. Infact complainant was suffering from Congenital disease and when insured is suffering from this disease, claim is not payable as per Exclusion Clause 4.1 of the Policy. Accordingly claim has been rightly repudiated by the opposite Insurance Company.<br /> 11. We have considered the respective arguments.<br /> 12. Admittedly Insurance Policy was purchased on 19.7.07. Complainant had fallen ill on 26.7.07 and was admitted in Escorts Delhi on 1.8.07 and he remained admitted till 8.8.07. As per Ex. C-4 a sum of Rs. 2300/- was deposited with this hospital on 26.7.07 and after treatment Rs. 1,71,844/- were charged by this hospital from him vide bill dated 8.8.07 copy of which is Ex. C-5. Material question for determination is as to whether claim has been rightly repudiated by the opposite Insurance Company ? Insurance Policy was purchased by the complainant and his family members through opposite party No. 3 who is an authorised agent of opposite parties No. 1 & 2. There is nothing on the record that opposite party No. 2 is Physician and he has been authorised by opposite parties No. 1 & 2 to medically examine the persons who offer to purchase Insurance Policies. Hence plea of the complainant that opposite party No. 3 had checked him and his family members appears unfounded and baseless. Copy of the relevant proposal detail concerning the complainant is Ex. R-18. Question No. 12 a) and 13 mentioned in it and the answers to them are reproduced as under :-<br /> Questions Answers<br /> “12.a) Are you in good health and free from physical and mental Yes<br /> disease or infirmity or medical complaints ? <br /> <br /> <br /> 13. Have you ever suffered from any of the disease/illness ? No <br /> If yes, give details. <br /> a) any nervous, mental or psychiatric disease '<br /> b) slipped disc or other spinal disorder or ' <br /> (fainting episode, blackout, fit) paralysis or any kind '<br /> c) high blood pressure, heart disease, including ischaemic ' <br /> heart disease, other circulatory disorder etc.(rheumatic fever) ' <br /> d) fistula, piles, hernia, varicose veins ' <br /> e) any disease of the bones or joints including rheumatic disease ' <br /> f) disease of uterus, ovaries or breast or any specific ' <br /> gynaecological disorders ' <br /> g) any respiratory of all allergic disease ' <br /> h) any disorder of the stomach, ulcer, bowel or gall bladder, ' <br /> kidney stones etc. '<br /> i) any cancer, malignant growth, boil, cyst or wound etc., which '<br /> does not heal or improve despite treatment ' <br /> j) any other complaint requiring specialist's consultation or '<br /> surgical or hospital treatment or investigations ' <br /> k) any complaint or tendency that may necessitate such ' <br /> consultation or treatment in the future ' <br /> l) any dimness of vision/cataract ' <br /> m) any disease of ears or difficulty or interference with hearing '<br /> n) diabetes or any urinary diseases ' <br /> o) any other illness or disease or accident or operation sustained No” <br /> by you. <br /> <br /> Copy of the Discharge Summary issued to Escorts Delhi concerning the complainant is Ex. R-9 in which Resume of his History has been given as under :<br /> “Master Kunal Dubey is a 5 year old male child who is a case of acyanotic congenital heart disease. He is 1st in birth order and is a product of full term normal vaginal delivery (twin) delivery with birth weight of 2.25 Kg. Child has symptoms of recurrent chest infection and palpitations since 2-3 years of age. There is history of excessive sweating on exertion. He has been evaluated at Bathinda. Echo done there showed Subaortic stenosis with mild AR. He was further evaluated at EHIRC on 26.7.07. Echo done here revealed Subaortic membrane, left ventricular outflow tract gradient max 56/30 mean mmHg, normal ventricular function and mild AR.” <br /> When this resume of the history is considered, no other conclusion can be arrived at than the one that complainant through his guardian while submitting the proposal for Insurance concealed the material fact about the health of the complainant as he was found to be case of Acyanotic Congenital Heart Disease. He was having symptoms of recurrent chest infection and palpitations since the age of 2-3 years. He had history of excessive sweating on exertion. Not to speak of this, he was evaluated at Bathinda. Echo done there showed Subaortic Stenosis with mild AR. Hence complainant through his guardian suppressed the matter regarding the health of the complainant which was material to be disclosed. In view of the history of the complainant given by Escorts Delhi it cannot be said that complainant or his guardian was not aware about the congenital disease from which he (complainant) was suffering or that he was hale and hearty at the time of purchasing the policy. Accordingly, claim has been rightly repudiated as per Exclusion Clause 4.1 according to which Insurance Company is not liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured person in connection with or in respect of all Congenital disease (Internal and external)<br /> 13. In the light of the discussion made above, crux of the matter is that no deficiency in service on the part of the opposite parties is proved. Hence, complaint is dismissed. Parties are left to bear their own costs.<br /> Copy of this order be sent to the parties concerned and file be consigned.<br /> Pronounced :<br /> 05-08-2008 (Lakhbir Singh )<br /> President<br /> <br /> <br /> (Dr.Phulinder Preet) <br /> Member<br /> 'iki' <br /> <br />