HARJEET SINGH BEDI vs NEW INDIA ASSURANCE COMPANY

THIS is an appeal against the judgment and order dated 11.11.1993 passed by the District Consumer Forum, Kanpur Nagar in Complaint No. 145 / 92. Facts of the case stated in brief are that the complainant got himself insured for Hospitalisation and Domicilliary Hospitalisation Benefit Policy. Under this policy if a person falls sick during the continuance of the policy then the entire expenses borne by the person is to be reimbursed by the Insurance Company. For the first time the complainant took insurance policy for a period of one year from 1.7.1988 to 30.6.1989. Thereafter it was further renewed from 18.7.1989 to 17.7.1990 and was again renewed in continuation from 18.7.1990 to 17.7.1991 ..For this policy he had paid a premium of Rs. 1,575/- per annum. It was further alleged that the complainant felt some pain in his chest on 8.3.1991 and he was admitted in the District Hospital, Gorakhpur for treatment. He was told that he had some heart problem and for further investigation and treatment he was admitted in Escorts Heart Institute and Research Centre, New Delhi on 7.4.1991. During his treatment he had spent a sum of Rs. 59303.70 for which the information was sent to the Insurance Company, the opposite party and a claim was put forward. THIS claim was repudiated on the ground that the claim is not correct in view of the question No. 10. A copy of the repudiation letter dated 14.10.1991 has been filed. It was alleged by the opposite party that he had suppressed the material facts and was aware of the disease before taking the policy. According to the complainant he never knew about his illness before he took the policy and for the first time he came to know about his illness on 8.3.1991. He had also indicated to the complainant that he has not taken any leave from his department prior to this date. It was a sudden development and the claim has been repudiated on the surmises.

THUS on his illness the complainant claimed a sum of Rs. 59,303.70 on account of expenses incurred by him and a sum of Rs. 10,000/- as damages. In the written version of the opposite party, it has been alleged that the complainant had suppressed the illness and has not disclosed the correct facts. Insurance is done on the presumption that the insured person is giving correct information. On the basis of the discharge summary report dated 15.4.1991 which was issued by Escorts Heart Institute and Research Centre, New Delhi, it was written in the "resume of history" that the complainant is suffering from ''angina'' (heart ailment) from the last 4 years. This angina has reached in the 3rd stage. It was further alleged that the opposite party took an opinion from their Doctor T.N. Singh, Chest Specialist and he, vide his report dated 5.9.1991, has mentioned that the complainant was using special medicines and must have been aware of this disease before taking the policy. Accordingly, the opposite party should repudiate the claim.

On the basis of evidence on record and hearing the learned Counsel of both parties, the learned District Consumer Forum has come to the conclusion that the complainant had suffered from this disease before and must be aware about the existence of this disease before taking the policy. It has further been alleged that the complainant had given wrong facts and has not disclosed the correct history while taking the policy.

AGGRIEVED against the order of the District Consumer Forum, the complainant has filed this appeal and challenged the correctness of the order passed by the learned District Consumer Forum, Kanpur Nagar. We have heard learned Counsels for the parties and perused the facts on records. The only question that arises for consideration in this case is whether at the time of renewing the policy from 18.7.1989 to 17.7.1990 the complainant knew about his disease ''angina'' which has caused him heart trouble and took treatment in Escorts Heart Institute, New Delhi. According to the complainant he has no indication of the disease from before as he has taken the policy twice before the present one. It has further been argued by the learned Counsel of the appellant that the terms of policy relied upon by the opposite party do not apply in present case and the certificate issued by Dr. T.N. Singh is not correct as the same has been issued on the basis of presumption and is based on the report made by Escorts Heart Institute at the time of discharge. The discharge summary given by Escorts Heart Institute, New Delhi is before us and it shows that the complainant was admitted on 7.4.1991 and he was discharged on 15.4.1991. Dr. Naresh Trehan, the leading Cardiologist was the consultant and invasive surgery was done on 8.4.1991. In this report it has been written that there was no history of ''angina''. On the basis of this report Dr. T.N. Singh in his report dated 5.9.1991 has mentioned that the disease of ''angina of effort and hypertension for which the insured was hospitalised is chronic in nature and was in existence from the last about 4 years, as is stated in the discharge summary report dated 15.4.1991 given by Escorts Heart Institute under the heading of ''Resume of History''. In Clause ''B'' it has been reported by the same doctor that it was definitely possible that the insured was aware of his disease of angina of effort and hypertension and was taking medicines. This report is not based on the clinical examination and previous history given to Dr. T.N. Singh by the complainant. He has given report on the basis of discharge summary report made by Escorts Heart Institute, New Delhi. He has not stated on what basis he found the complainant to be aware of the disease and in fact he also uses the word ''possible'' in his report. It is suggested that the Doctor concerned has merely given his report on the basis of certain observations made in the discharge summary report of Escorts Heart Institute. In this summary report, it is correctly mentioned that effort angina was there for the last 4 years but according to the statement of complainant he had no symptom of this disease ever before and he never consulted any doctor nor he took any leave from his office for this illness. The Insurance Company could have got the information from the office of the complainant as to whether he had taken any leave from his employer on the ground of this illness. Whether he was granted any leave for the treatment for this specific illness. It is common knowledge that the patient of Dyspnoea (breathlessness) also suffers from these symptoms while taking strain. If a patient is suffering from the problem of asthma, eosinophilia then the same symptoms will also appear. It is very difficult to differentiate between this group of ailments such as eosinophilia, cardiac problem etc. Only a thorough medical examination can bring out the real cause. For bringing out the actual condition of the heart ailment Electric Cardiogram and treadmill test are conducted. Treadmill test is done under stress condition and it will give a clear picture as to be whether a person is suffering from heart ailment or not. Some time E.C.G. does not reveal the true picture. Because in many cases even after the heart attack this disease does not appear on E.C.G. Doctor has also not applied this method to detect the heart ailment before renewal of policy. This test could have been done only in the hospital or the place where these facilities are available. It was very easy for the Insurance Company to have enquired from the employer about the leave taken and then should have contacted the hospital concerned to know the illness. The Insurance Company does take all these exercises, at the time when the claim is forwarded to them. In the present case it appears that nothing could be extracted by the Insurance Company from the employer as there was nothing abnormal and contrary to the version of the complainant. No enquiry was made from the Escorts Heart Institute from where his discharge summary report was made, about the possibility of this disease having been in the knowledge of the complainant. The summary report itself said that the disease has reached in the advanced stage. No person suffering from this disease will wait till a precarious condition is reached and any tragedy could happen. The patient who is in the knowledge of such dangerous disease which can be fatal at any time will not risk his life and will go for treatment at an earlier stage of time. It is not possible to believe that the complainant know about his disease prior to the consultation in the District Hospital, Gorakhpur on 8.3.1991. The complainant would not have taken risk specially when he had an insurance in the previous year also and could have recovered the entire amount which he would have spent for the treatment. It could not be said that the complainant took the policy to get himself operated upon and to pass on the financial burden on the Insurance Company. The last insurance started from 18.7.1990, but for the first time that the complainant come to know about his disease was on 8.3.1991, i.e. about seven and a half months after. If the complainant intentionally gave wrong particulars to the opposite party then he could have got himself treated much earlier than 8.3.1991 specially soon after the policy was renewed. Thus the case taken up by the opposite party that the complainant knew about his extreme condition of the heart for the last 4 years could not be believed and the same is not supported by any cogent evidence and simply based on the surmises and inference of facts drawn by Dr. T.N. Singh. Moreover answer to question No. 10 of questionaire has been relied upon by the Insurance Company as well as condition No. 1 of the hospitalisation or Domicilliary Hospitalisation Benefit Policy does not apply in the present case. This condition is a exclusionery clause. It lays down that during the first 30 days from the commencement date of policy this condition shall not apply if a panel of medical practitioners constituted by the Company for this purpose found that the insured could not have known about the existence of the disease or developed any symptom before the time of making the proposal of insurance to the Insurance Company for renewal. Moreover, there is a provision added to this sub-clause that this condition shall not apply in the case of insured person having been covered under this scheme by any of the Insurance Company for a continuous period of 12 months preceding without any break. This clause accordingly goes to say that if a person is continuously insured in the previous 12 months without any break this exclusionary clause shall not apply. This covers the first initial period of 30 days also. Therefore, answer to question No. 10 loses its importance. Moreover, question No. 10 in the proposal form only required information of any knowledge of any possible existence or presence of any illness, sickness etc. which requires medical attention in the immediate future. The answer of complainant was ''no'' to this question. The words of this question No. 10 are also relevant to consider "that the insured had the knowledge of any positive existence of any disease at the time of making the proposal". This means the person who is going to be insured has definite knowledge of that particular disease existing in his body. If a person has a disease in his body but he does not know about it then no knowledge of the disease can be attributed to him. It is a common knowledge that cancer, a deadly disease, does not give any indication in the beginning and only comes to surface when it reaches advanced stage. The cases shows that when a number of organs in the body are damaged only then normal life of a person is affected and then only the symptoms of this deadly disease of cancer, which is a silent killer, are manifested and a person only then knows the existence of this particular deadly disease. No person will like to take risk of life when he knows about the existence of a tumour and will get it removed at the earliest, lest it later develops into the cancer and further damages the body. Similar is the case with a heart patient. The case are there that only one single massive heart attack is sufficient to kill a person. Arteries get blocked internally but the patient does not know about the condition of the heart and when the condition reaches its peak the heart attack takes place causing immediate death. There are number of persons who have never complained of heart problem or heart attack earlier but a single stroke ends their life. Thus the contention of the opposite party that the complainant knew about his disease for the last 4 years cannot be relied upon.

THE finding to the contrary of the learned District Forum is not correct and the learned District Forum has not correctly interpreted and assessed the evidentiary value of the summary report and the report of Dr. T.N. Singh. THE Clause 1 of the policy have also not correctly interpreted as well as question No. 10 and its answer. THE entire evidence has to be taken into consideration. No case can be decided merely on the basis of report which merely states about the possibility of a disease without knowing the history of the person concerned. The appeal is liable to be allowed and the complainant is to be reimbursed with the expenses of Rs. 59,303.00 which he incurred. He is also entitled to damage on account of mental tension etc. which he had to suffer on account of wrong repudiation of claim on surmises based'' on the doctor''s summary report in which no definite conclusion has been given and the word ''possible'' has been used. Insurance Company had also not analysed the case in its correct perspective and has driven the complainant to approach the District Forum. Therefore the complainant is entitled for recovery of Rs. 59,303/- and compensation of Rs. 10,0007- and the complainant will get interest at the rate of 18% p.a. in the form of damages on Rs. 59,303/-. The interest shall be payable from expiry of three months of submission of the claim till the date of payment. ORDER The appeal is allowed and the case of complainant is decreed for Rs. 59,303.00 against opposite party on account of medical expenses, incurred by him alongwith interest in the form of damages at the rate of 18% p.a. from the expiry of three months from the date of submission of claim till payment. He shall also get a sum of Rs. 10,000/- as compensation alongwith interest at the rate of 18% p.a. till the date of payment to the complainant. The complainant will also get Rs. 1,500/- as costs of the appeal. Let the orders be complied with by the opposite party within a period of six weeks from today. Let the copies of this order be issued to the parties as per rules. Appeal allowed.