Kapil Kumar Aggarwal vs National Insurance Co. Ltd.

THIS is an appeal by the complainant against the dismissal of his complaint by the District Forum, Udham Singh Nagar vide order dated 21.12.2004.

THE facts giving rise to the case under hand are that the complainant took a mediclaim policy from the opposite party/Insurance Company for himself, his wife Smt. Sarla Aggarwal and his son Puspa Kumar Aggarwal for Rs. 1,00,000, 50,000 and 50,000 respectively, for which he paid the premium of Rs. 2,646 to the Insurance Company. THE Insurance Company issued cover note No. 794455 which was valid from 28.10.2001 to 27.10.2002. It is alleged that on 21.2.2002 the complainant felt severe pain in Right Lower Limb and he was admitted in Saroj Hospital, Delhi where angiography was conducted and it was revealed that there is complete blockage in right poplileal artery. THE complainant was operated upon in Apollo Hospital, Delhi and he was discharged from Apollo Hospital, Delhi on 26.2.2002, which was informed to the Insurance Company on 27.2.2002. On 9.8.2002 the Insurance Company asked the complainant to submit a certificate of the Apollo Hospital, Delhi in which the full description of the disease of the complainant should be given. It is further said that on 9.8.2002 the complainant submitted the claim form along with bills of Rs. 95,634.71. On 29.8.2002 the complainant submitted the certificate issued by the doctor of Apollo Hospital. It is alleged that in spite of repeated requests, his claim was not paid and on 7.1.2003 the Insurance Company repudiated the claim of the complainant on the ground of non-disclosure of relevant facts. THEreafter he filed the complaint before the learned Forum. The Insurance Company filed written statement before the learned Forum and admitted the issuing of policy. The claim was repudiated for non-disclosure of material facts. In para 12, it is said that the complainant did not disclose his prior illness in the proposal form. In para 16, it is alleged that the complainant has committed breach of the policy conditions and said that on 21.10.1998 the complainant took mediclaim policy No. 351157 from United India Insurance Co. Ltd., in which he mentioned that he was hale and hearty whereas he was suffering from diabetes and heart disease, which he suppressed in the proposal form which is violation of the policy conditions, therefore, the complainant is not entitled to any claim.

The Learned Forum after taking the evidence of the parties and hearing them dismissed the complaint, against which order the complainant has filed the present appeal.

WE have heard the learned Counsel for the parties and gone through the records. The proposal form Annexure-1, paper No. 19 is available on record. At page 6 of this proposal form, it is clear-cut mentioned "Open Heart Surgery in 1998-1999". This proposal form was filled on 24.10.2001. The policy cover note is filed which was issued on 29.10.1999 in the joint name of complainant, his wife and son. In the column of Special Terms, it is written that the insurance is subjected to fresh medical certificate submission. Thereafter, this was a renewed mediclaim policy as alleged. The Echocardiography Report of the complainant has been filed which is dated 14.12.1999 issued by Apollo Hospital which is signed by Dr. P.K. Ghosh. In this report, the results of tests are mentioned. The complainant in para 4 of his complaint has mentioned that he undergone a surgical operation at Apollo Hospital, Delhi which was successful. The complainant was discharged on 26.2.2002 and advised for further checkup and the complaint informed the office of the opposite party on 27.2.2002 about the said medical treatment and claimed the amount incurred on medical expenses and this information was received by the opposite party on 28.2.2002. The complainant has specifically alleged that he did not suppress any material fact in the proposal form. This fact is also evident from the proposal form wherein it is clearly written as said above, "Open Heart Surgery in 1998-1999". The complainant filed his affidavit dated 16.12.2004 before the learned Forum and in paras 1 and 2 of the affidavit said that the first policy No. 501626 was issued for the period from 28.10.1999 to 27.10.2000 and the cover note of the said policy was filed as Annexure-2 of the affidavit, wherein the opposite party asked to submit new medical certificate and then the complainant got himself medically examined and submitted his medical certificate dated 14.12.1999, which is Annexure-3 of the affidavit. This certificate was filed before the learned Forum. This fact was not denied anywhere by the opposite party/Insurance Company.

THE learned Counsel for the Insurance Company argued that the complainant concealed the material fact at the time of filling the proposal form but there is no evidence on record to prove the allegations of the Insurance Company that the complainant suppressed any material fact. THEre is no rebuttal of the affidavit of the complainant from the side of the Insurance Company. THE complainant clearly mentioned in the proposal form that he underwent an open heart surgery in 1998-1999 and submitted the fresh medical certificate to the Insurance Company as per the requirement of the policy. THE learned Forum erred in not considering the evidence as discussed above. In view of what has been said above there was definitely deficiency in the services of the Insurance Company in repudiating the claim of the complainant and the order of the learned Forum dismissing the complaint is not correct and is liable to be set aside. As such the appeal is fit to be allowed for the claim amount of Rs. 95,634.71 along with interest @ 9%. ORDER The appeal is hereby allowed. The order dated 21.12.2004 is hereby quashed. The complaint is also allowed. The Insurance Company is hereby directed to pay a sum of Rs. 95,634.71 to the complainant along with interest @ 9% payable from the date of complaint i.e., 17.5.2003 till the actual date of payment. In the circumstances of the case, costs shall be easy. Appeal allowed.