STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 08.02.2018
Date of final hearing: 15.05.2023
Date of pronouncement: 14.07.2023
First Appeal No.214 of 2018
IN THE MATTER OF:
Umed Singh son of Ram Diya, resident of Village Jattal, Tehsil and Distt. Panipat.. ....Appellant
Versus
Star Health and Allied Insurance Company Ltd. having its Branch Office at 1668/7, Vij Complex, 2nd Floor, Opp. I.B. College, G.T. Road, Panipat through its Manager/Sub Division Manager.
…..Respondent
CORAM: Naresh Katyal, Judicial Member
Argued by:- Sh. S.S. Ghangas, counsel for the appellant.
Sh. Ravinder Arora, counsel for respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
Challenge in this appeal No.214 of 2018 has been invited by complainant to the legality of order dated 19.12.2017 passed by District Consumer Disputes Redressal Forum-Panipat (In short “District Commission”) in complaint case No.180 of 2015.
2. Complainant had taken Medi-Claim Health Insurance Policy (Optima Insurance Policy No. P/211112/01/2015/000456) from opposite party, for himself, and for his family members. Sum assured under policy was Rs. 3 lacs and its period was from 06.05.2014 to 05.05.2015. Premium amount was Rs.10,315/-. It is pleaded that complainant was entitled to benefits of policy, for any type of disease during its period. In September, 2014 he suffered pain in Heart at his house. He was brought at Dr. Ravindra Maternity and General Hospital-Panipat and hospitalized there. He spent more than Rs.23,000/-. He was advised by doctor of said hospital to consult Heart Specialist from Metro Heart Institute Faridabad, who weekly visits at Panipat. On 29.10.2014, he was admitted in Sir Ganga Ram Hospital-Delhi for treatment. Concerned Doctor conducted several tests and advised him for ‘Open Heart Surgery’. Accordingly, Open Heart Surgery for ‘Aortic Valve Replacement’ was done on 31.10.2014. He remained hospitalized in Sir Ganga Ram Hospital and discharged on 06.11.2014. He spent Rs. 2,47,000/-being package charges for 8 days bed charges, intensive care monitory investigation etc. After discharge; he approached OP for payment of claim and submitted required documents. Complainant’s claim was repudiated by order dated 26.06.2015. It is alleged that his claim was illegally rejected; it amounts to deficiency in service of OP and thus complainant has filed complaint.
3. Upon notice, insurer/respondent raised contest. In defence; it is pleaded that: complainant has no locus standi; there was no deficiency in service of OP. It is pleaded that: as per discharge summary of complainant issued by Sir Ganga Ram Hospital-Delhi; he was treated for severe Calcific Aortic Stenosis and Hypertension and was known case of Diabetic Mellitious Type-II since six (6) years. He was admitted with complaint of Giddiness and Breathlessness for past four months and Diagnosed for past four months. ECHO Report dated 29.10.2014 revealed concentric Left Ventricular Hypertrophy with Severe Aortic Stenosis with Aortic Valve showing Trileaflet, Sclerosed Calcified with grading valve of PG 67 mmHg with confirms Chronic long standing Aortic Valve disease and it cannot occur within 4-5 months from inception of policy. It is pleaded that: this ailment comes in the category of pre-existing disease, as such, complainant’s claim is not payable. It is pleaded that: complainant has not disclosed material facts of his ailments, while first time proposing insurance with company/OP and thus violated condition No. 7 of insurance policy held by him, as per which; if there is any misrepresentation/non-disclosure of material facts whether by insured person or any other person acting on his behalf, then company is not liable to make any payment in respect of any claim. It is pleaded that complainant’s claim has been repudiated under Section 7 of insurance policy and same was intimated vide repudiation letter dated 11.05.2015. On these pleas dismissal of complaint has been prayed.
4. Parties to this lis led evidence, oral as well as documentary.
5. On subjectively analyzing the same; learned District Consumer Commission-Panipat vide order dated 19.12.2017 has dismissed the complaint.
6. Feeling aggrieved; complainant has filed this appeal.
7. Learned counsel for parties has been heard at length. With their able assistance; record too has been perused.
8. Learned counsel for the complainant/appellant has urged that reasoning adopted by learned District Consumer Commission is erroneous, legally as well as factually. There has been no concealment of any material facts by complainant at the time of obtaining health insurance policy. Discharge summary of Sir Ganga Ram Hospital, Delhi reflects that complainant was not suffering from severe Calcific Aortic Stenosis at the time of obtaining insurance policy. On these submissions learned counsel for complainant has urged for acceptance of appeal.
9. Per contra, learned counsel for respondent/OP has supported the impugned order dated 19.12.2017 passed by learned District Consumer Commission-Panipat by urging that it is outcome of proper appreciation of facts and evidence. It is urged that there was active concealment of material facts (pre-existing ailments) by complainant while obtaining health insurance policy. It is urged that the type of ailment, of which complainant was diagnosed, cannot be termed to carry past history of 4-5 months.
10. Admittedly, Family Health Optima Insurance Policy (Ex.R-1) was issued by OP/respondent in names of Umed Singh, Ratna Devi and Ravi Kadyan. Its currency period was 06.05.2014 to 05.05.2015. Sum insured under this policy was Rs.3,00,000/-. Initially, complainant-Umed Singh, aged 47 years had obtained medical treatment from Dr. Ravindra Maternity and General Hospital at Panipat. Ex.R-2 is Colour Doppler ECHO Cardio Report dated 03.09.2014. It reflects following summary and comments:-
“LV & LA Dilated, Concentric LVH, All other chambers normal.
Mild Global Hypokinesia of LV.
Mild LV Systolic (LVEF 50%), Diastolic Dysfunction Present.
Severe Aortic Stenosis (PG67 mmHg), No Valvular Regurgitation.
No Vegetation/Clot/Thrombus. No Pericardial Pathology.”
Thereafter, complainant landed in Sir Ganga Ram Hospital, Delhi on 29.10.2014. Discharge summary is Ex.R-3 wherein under head “Clinical Summary” following observations has been recorded:-
“Mr. Umed Singh, 47-year-old male, is a known-Diabetic, Hypertensive patient, presented with a history of episodic giddiness on exertion/rest since 4 months. He also has history of breathlessness on exertion since 4-5 months. He came to Sir Ganga Ram Hospital for evaluation and management. Coronary Angiography performed at SGRH, revealed normal Coronaries.”
Discharge summary (Ex.R3) recites that: Complainant was diagnosed as sever Calcific Aortic Stenosis Moderate to severe Left Ventricular Dysfunction, Diabetes Mellitus Type II and Hypertension. He was operated for Aortic Valve Replacement (21 mm ON-X Bileaflet Mechanical Heart Valve) and discharged on 06.11.2014 in stable condition. Discharge summary Ex.R-3 reflects that complainant was treated by Cardic Surgeon namely Dr. Sumir Dubey at Sir Ganga Ram Hospital.
11. Above, evidence reflects that medical treatment of complainant at Dr. Ravindra Maternity and General Hospital-Panipat and at Sir Ganga Ram Hospital-Delhi was during the currency of health insurance policy period. Insurer has repudiated the claim of complainant by relying upon documents Ex.R-6. It is a letter dated 09.05.2015 of Dr. M.M. Rathina Sabapathy of Chennai directly addressed to M/s Star Health and Allied General Insurance Company Ltd. Chennai. Following is text of integral part of this letter Ex.R-6:-
“I have perused the medical records relating to the above insured patient. I give below my opinion.
Thank you for referring a claim of Umed Singh Age 47 years who got admitted in Sir Ganga Ram Hospital-New Delhi admitted on 29/10/2014 for the treatment of severe Calcific Aortic Stenosis, Moderate to severe Left Ventricular Dysfunction, Diabetes Mellitus Type II Hypertension. I have gone through the complete records of this claim admission, investigations and complete treatment details.
As per submitted documents, discharge summary, Echo; it is chronic long standing Arotic Valve Disease with Valvular changes.”
12. If, diagnose of ailment of complainant and eventual medical treatment which he obtained from Sir Ganga Ram Hospital-Delhi so mentioned in his discharge summary Ex.R-3 is given a conjoint reading with document/letter Ex.R-6 of Dr. M.M. Rathina Sabapathy of Chennai, then obviously it is deciphered that: contents of both correlates with each other. In opinion of this Commission; the learned District Consumer Commission-Panipat has grossly erred in law while relying upon medical opinion Ex.R-6 of Dr. M.M. Rathina Sabapathy of Chennai. Reasons are obvious. Firstly, Dr. M.M. Rathina Sabapathy was not the treating doctor of complainant. Secondly, burden of proof in this regard lay upon insurer alone as it is the specific fact so alleged, in its written version. Curiously enough, absolutely nothing has been brought on record in evidence by insurer/OP that complainant-Umed Singh had obtained any prior medical treatment from any hospital, with regard to ailments, before initially landing in Dr. Ravindra Maternity and General Hospital-Panipat and eventually landing in Sir Ganga Ram Hospital-Delhi with history of breathlessness and giddiness on exertion since last 4-5 months. There is no evidence on record that complainant was a Cronic Diabetic and Hypersensitive patient. With the type of history presented by complainant at Sir Ganga Ram Hospital-Delhi on his landing there; he appropriately obtained medical treatment. It was required on behalf of insurer to prove expressly by leading explicit evidence that complainant had long history of Giddiness, Breathlessness, Diabetic and Hypersensitive. The insurer/OP could not unveil the mystery behind this particular aspect through any tangible evidence. As a legal corollary so flowing, it cannot be taken on mere supposition that complainant had pre-existing disease of nature and type, of which he obtained medical treatment from Sir Ganga Ram Hospital-Delhi. Hence, it is held that if, there is no evidence by insurer/OP in that arena which could have non-suited the complainant, then, assertion of complainant that he suffered Breathlessness and Giddiness since last 4-5 months i.e. during currency of policy has to be accepted at legal pedestal, particularly when it is supported by hospital’s discharge summary Ex.C-9. Discharge summary does not recite that: complainant’s ailments had long history and it was not mere 4-5 months old ailments.
13. It is trite to say that wherever such an exclusionary clause is contained in a policy, it would be for the insurer alone to show that the case falls within the purview of such clause. In case of ambiguity, the contract of insurance has to be construed in favour of insured. Reliance in this regard can be placed on judgment of Hon’ble Supreme Court in case titled as “National Insurance Co. Ltd. Vs. Vedic Resorts and Hotels Pvt. Ltd.” (Civil Appeal No.4979 of 2019 decided on 17.05.2023, and also on decision of Hon’ble Apex Court in case titled as “National Insurance Company Limited vs. Ishar Das Madan Lal” (2007) 4 SCC 105.
14. While applying the legal dictum of afore cited judgments to the facts of this appeal, “it is held that insurer, having miserably failed to bring on record any cogent and tangible evidence, to prove its pleaded fact that insured/beneficiary (Sh. Umed Singh) had pre-existing aliments of Cronic Long Standing Arotic Valve Disease which cannot occur within 4-5 months from inception of policy. In view of above; it is held that reasoning adopted by learned District Consumer Commission-Panipat does not stand with the test of correctness in legal parlance and thus unsustainable. Complainant’s claim has been wrongly rejected. There was no fundamental base before the insurer/OP to repudiate complainant’s claim. As a legal corollary, so flowing, it is also held that: impugned order dated 19.12.2017 is legally unsustainable. It is accordingly set aside. Resultantly, complainant’s complaint is accepted/allowed.
15. In opinion of this Commission, complainant’s claim is payable. He has spent Rs. 2,47,000/- on his treatment which is reflected from certificate dated 12.11.2014 (Ex.C-12) of Sir Ganga Ram Hospital. Health Insurance Policy had a coverage limit of Rs. 3,00,000/-. Expenses incurred by complainant fall under limits of insurance cover. Consequently, OP respondent is directed to pay Rs. 2,47,000/- to complainant with interest at the rate of 6% p.a. from the date of order (19.12.2017) passed by District Consumer Commission-Panipat. In addition, complainant is also held entitled for a sum of Rs.20,000/- on account of harassment, mental agony and litigation expenses. Amount awarded under head of harassment mental agony and litigation expenses will not carry any interest. OP/respondent is directed to comply with these directions within a period of three months from the date of this order.
16. With above observations, this appeal is allowed. Impugned order dated 19.12.2017 passed by learned District Consumer Commission-Panipat is set aside. Respondent/OP is directed to strictly comply with the directions issued in preceding paragraph (No.15) within the time frame mentioned in it.
17. Application(s) pending, if any stand disposed of in terms of the aforesaid judgment.
18. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
19. File be consigned to record room.
Date of pronouncement: 14thJuly, 2023
Naresh Katyal
Judicial Member
Addl. Bench-II
