DATE: 17-10-2014

ORDER

This appeal is directed against the Order dt. 10-01-2014, passed in Case No. 291/2013 by the Ld. District Forum, South 24 Parganas, by which, the complaint has been allowed with certain reliefs.  Being aggrieved by and dissatisfied with the same, the OPs thereof have preferred this appeal.

The case of the Complainant, in short, is that he had taken a mediclaim policy being no. P/191117/01/2012/003335 dt. 07-02-2012, named, ‘Senior Citizens Red Carpet Insurance Policy’, from the OP insurance company for an amount of Rs. 1 lakh, on payment of a premium of Rs. 4,908/-, which has since been renewed for the period from 18-02-2013 to 17-02-2014.  One of the conditions of the policy was that the Insured should declare pre-existing disease, if any, in the preceding 12 months from the date of policy.  He told the Intermediary (Agent) of the Insurance Company, Mr. Sandipan Sen about fitment of Pacemaker in his heart on 11-11-2011, which, however had not been noted in the initial policy therein, but, however, duly noted in the renewed policy dt. 18-02-2013.  On 02-11-2012, morning, he suffered from fever and visited Dr. Swagata Chowdhuri at Apollo Clinic, who prescribed some medicines and advised him admission in the hospital, if condition worsens.  As his condition became acute at the dead of night on 02-11-2012, he was admitted to RSV Hospital on 03-11-2012 at 3.35 a.m., where he was treated by the same physician for 08 days and was discharged therefrom on 11-11-2012, for which an expense of Rs. 61,648.34 was incurred, and the hospital authorities intimated the insurance company seeking cashless letter on his admission.  After discharge, he received a letter dt. 06-11-2012 from the insurance company denying the cashless benefit, where it was stated that there is non-disclosure of pre-existing disease at the time of inception of the policy with remarks (PPI done in 11-11-2011), to which he replied by letter dt. 20-12-2012 denying the allegation of non-disclosure of pre-existing disease stating that he was hospitalized due to acute ‘PNEUMONITIS’, having no connection with the pacemaker fitment.  As such, the contention of the insurance company is not tenable/vague and non-maintainable and the same is not in consonance with the terms and conditions of the ‘Senior Citizens Red Carpet Insurance Policy’.  Accordingly, the case.

         On  behalf of the OPs, the case is that the Complainant was admitted at RSV Hospital, Kolkata on 03-11-2012, and prior to it, he was examined by Dr.  Swagata Chowdhuri of Apollo Clinic on 02-11-2012, who stated that the Complainant was having Hypertension (HT,) COPD (Chronic Obstructive Pulmonary Disease), Bronchiectesis in both lungs - mainly left lower lobe.  Further, the Discharge Certificate of North Frontier Railway Hospital, where he was treated earlier, diagnosed him with having CHD (Complete Heart Block), and PPI (Permanent Pacemaker Implantation) done on 11-11-2011.  It is, thus, clear from all such medical papers that the present ailment of the Complainant existed prior to inception of the policy.  Therefore, it is a pre-existing disease.  Accordingly, the claim of the Complainant was repudiated by the OPs, which was again reviewed on the basis of a representation dt. 06-03-2013 by the Complainant, and it was found that he had long-standing disease, even prior to inception of the policy and it is a case of pre-existing disease, and the repudiation invoking Exclusion Clause No. 1 was in order.  So, the complaint be dismissed.

         It is to be considered in this appeal as to whether the impugned order, favouring the Respondent, is required to be interfered with in any manner, or not.

Decision with reasons

Ld. Advocate for the Appellants has submitted that the initial prescription of Dr. Swagata Chowdhuri of Apollo Clinic dt. 02-11-2012 indicates that the Respondent has already a history of HTN along with COPD, and Bronchiectasis indicated.  But, in the Proposal Form for the Policy, filled up on 07-02-2012, there is no indication whatsoever of such diseases i.e. HTN and COPD and that although all information related to past ailment(s) has to be properly/correctly mentioned in the said form, the Complainant answered in the negative.  Furthermore, the Certificate issued by Dr. Swagata Chowdhuri, also in the pad of Apollo Clinic, which has been issued on 07-02-2013, shows that MRI of the Respondent was not done as he was already having pacemaker.  The Exclusion Clause No. 1 clearly states that pre-Existing Disease as defined in the policy, is to operate as a bar until 48 months of continuous coverage have elapsed, since inception of the first policy with the Company.  COPD relates to lung disease, pacemaker indicates heart disease.  The history sheet of RSV Hospital, Kolkata, where the Respondent was admitted under Dr. Swagata Chowdhuri, also contained history of IHD? (Ischemic Heart Disease) and PPM (permanent pacemaker) in situ.  He was earlier treated at the Railway Hospital, where he was admitted on 10-11-2012 and discharged on 14-11-2012 and was diagnosed as Int.CHB (Complete Heart Block) and PPI (permanent pacemaker implant) done on 11-11-2011.  All these clearly go to show that the Respondent has intentionally suppressed such vital material facts while taking the insurance policy.   So, the Respondent has caused breach/violation of policy condition in this sphere by not disclosing his previous disease and treatment, which would have eliminated the prospect of issuance of mediclaim policy in his favour.  He has mentioned that the impugned judgment, in this respect, is a horrible one, it was such a short order, with short discussion/reasoning, and absolutely a perverse one and not tenable under the law.  Further, what is the unfair trade practice, as stated by the Ld. District Forum, at all in this matter?  It is a damaging order, bad in law, where cumbersome amount have been doled out to the Respondent.  He has referred to certain decisions of the Hon’ble National Commission, reported in I (2013) CPJ 606 (NC), III (2013) CPJ 684 (NC), III (2013) CPJ 650 (NC), and II (2014) CPJ 67 (NC).

The Respondent, in person, has submitted that he has not suppressed any material fact, as alleged.  In fact, the hospital discharge certificate of the North Frontier Railway Hospital dt. 14-11-2011, that diagnosed him having Int. CHB and PPI having been done on 11-11-2011, was submitted by him to the insurance company.  Not a single column of the proposal form was filled up by him, but the same was filled up by the Intermediary (Agent) of the Insurance Company, Mr. Sandipan Sen.  So, he cannot be held responsible for suppression of material fact.  Perhaps, the insurance company diluted the matter, only for its own interest, so as to repudiate a genuine and bonafide claim, bypassing the main disease, for which he was admitted at the RSV Hospital, Kolkata i.e. pneumonitis.  The specific final diagnosis by the hospital in the discharge certificate will also go to show that it was ‘left lower lobe pneumonitis, septicemia & septic shock, bronchiectasis, asthma’.  No medical paper is there to indicate otherwise, like sufferance from COPD, HTN, etc.  In fact, the concerned physician, Dr. Swagata Chowdhuri has further communicated by issuing one certificate dt. 06-03-2013 that the Respondent had to be admitted in the hospital in acute condition due to severe attack of pneumonitis, not for any other disease like COPD/HTN at the crucial time.  All these, unnecessary dogmas and pleas have been raised by the insurance company vastly in order to appease their own aggrandizement, in order to nullify a genuine claim by hook or crook.  He used to lead and is still leading a normal life.  Most interesting fact is that the instant policy is meant for, senior citizens only, and glorified with the name and style ‘Senior Citizens Red Carpet Insurance Policy’ where red carpet is shown at the time of making a policy and  black carpet at the time of settling a claim.  They have no sympathy to the insured, more so towards a senior citizen.  The impugned order of the Ld. Forum is perfectly in order.

There is no gainsaying of the fact that the Respondent had COPD connected with HTN, along with pacemaker implantation in his heart.  But, a crucial factor involved in this case is that the treatment meted out to him was not in anyway connected with the above.  He presented himself with shortness of breath and fever with chills at RSV Hospital, Kolkata and the Discharge Certificate does not in any way indicate that he was having anything related to COPD, HTN, etc., and the final diagnosis also goes in favour of the Respondent.  The tenacity to anyhow repudiate a claim invariably defeats the very purpose of taking an insurance policy.  It appears, the same is done by concerned officials to please their higher authorities with a self-centric objective of christening their career prospects.  In the process, they don’t bother to leave helpless policyholders fend for themselves.  There is nothing wrong in the findings of Ld. District Forum, by which the complaint has been allowed.  However, it appears, out of exuberance, the Ld. Forum below has given out disproportionate compensation in its order and accordingly, the same is modified to the extent as appended below.

In the result, the appeal success in part.

Hence,

ORDERED

that the appeal be and the same is allowed in part against the Respondent without cost.  The impugned order is modified to the extent that the Respondent will be entitled to his claim of Rs. 61,646.43 which is to be paid by the Appellants within a period of 45 days hence, along with interest @ 9.5% from the date of repudiation i.e. 26-02-2013 till full payment.  Respondent will also be entitled to a litigation cost of Rs. 5,000/- as per the impugned order.  Other compensation/costs being awarded in the order stand deleted.

         Sri Jagannath Bag.                Sri Debasis Bhattacharya.

                MEMBER                                 MEMBER