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Judgment
The present revision petition has been filed against the judgment dated 17.08.2016 of the Haryana State Consumer Disputes Redressal Commission, Panchkula ("the State Commission") in Appeal no. 528 of 2016.
The facts of the case as per the respondent/ complainant are that the respondent requested for compensation on account of death of her son Ravi Kumar who obtained a policy no. 179603061 for Rs.5.00 lakh. At the time of issuance of the policy he was examined by the doctors of the petitioner/ opposite party and no abnormality was found. Unfortunately he fell ill and expired on 16.07.2013 in PGI MS Chandigarh. Her claim was repudiated on 31.03.2014 without any reasonable ground.
In reply, the petitioner admitted the policy but alleged that medical examination of the deceased life assured (DLA) was not conducted by any doctor at the time of obtaining the insurance policy. As per form no. 3816 which was received from PGI Chandigarh, the DLA was suffering from Idiopathic Dilated Cardiomyopathy since February 2013, whereas the insurance policy commenced from 28.05.2013. He remained admitted to PGI MS, Chandigarh from 06.05.2013 to 28.05.2013 for this treatment. As the previous disease was not disclosed his claim had been rightly repudiated.
The District Consumer Disputes Redressal Forum, Rohtak (''the District Forum'') vide its order dated 25.04.2016 while allowing the complaint observed as under:
"After going through the file and hearing the parties it is observed that the claim of the complainant has been repudiated by the opposite parties on the ground that at the time of proposal of policy, the life assured was suffering from Idiopathic Dilated Cardiomyopathy. But to prove its contention opposite parties have placed on record only copy of certificate of hospital treatment, but the alleged document is not supported with the affidavit of the doctor concerned. Moreover there is no proper address of the life assured on the alleged document and there are so many over writings/ cuttings on the dates and other particulars, i.e., name of doctor to whom history was reported and in the case summary column and the cuttings are not attested by the doctor concerned. Hence, the same cannot be read into evidence. No other treatment record of life assured prior to taking the policy has been placed on record by the opposite parties.
In view of the facts and circumstances of the case it is observed that opposite parties shall pay the sum assured under the policy no. 179603061, i.e., Rs.5.00 lakh along with interest 9% per annum from the date of filing the present complaint, i.e., 23.05.2014 till its actual realisation, other benefits under the policy, if any, and shall also pay an amount or Rs.3500/- as litigation expenses to the complainants maximum within one month from the date of decision failing which the awarded amount shall carry further interest @ 12% per annum from the date of decision. Complaint is allowed accordingly."
Aggrieved by the order of the District Forum, the petitioner/ opposite party filed an appeal before the State Commission. The State Commission while dismissing the appeal has observed as under:
"This argument is of no avail. There is no cogent evidence to prove that he (DLA) was suffering from any ailment before obtaining the insurance policy. As per history of the DLA, it cannot be presumed that he was having this ailment keeping in view expressed by Punjab State Commission, Chandigarh in Joginder Kaur and Others vs Life Insurance Corporation of India and Another - 2001 (3) CLT) 633 and Life Insurance Corporation of India and Anr. Vs Raj Kumar Sharma - II (2013) CPJ 60. When OP has failed to prove that DLA was suffering from above said ailment the claim cannot be repudiated. Impugned order passed by the District Forum is well reasoned, based on law and facts and cannot be disturbed. Hence, the appeal fails and the same is hereby dismissed."
Hence, the present revision petition.
I have heard the learned counsel for the petitioner. He contended that the claim of the respondent was repudiated on 31.03.2014 on the grounds that the deceased Ravi Kumar was suffering from Idiopathic Dilated Cardiomyopathy and he had taken treatment from PGIMER Chandigarh since February 2013.
The State Commission had not appreciate the fact hat the life assured was suffering from Idiopathic Dilated Cardiomyopathy prior to the date of filling the proposal form and the said fact was duly established by the certificate of hospital treatment issued by PGIMER, Chandigarh.
The claim was repudiated on the ground of suppression of illness at the time of presenting the proposal. The respondents were aware of the same and that is why they did not raise any objection to the finding in the repudiation letter regarding the deceased suffering from Idiopathic Dilated Cardiomyopathy from February 2013, i.e., prior to the submission of the proposal form and inception of the policy.
I have gone through the repudiation letter of Death Claim under policy no. 179603061 in the name of Ravi Kumar. It was repudiated on the grounds that as per 3816 received from PGI Chandigarh deceased life assured was suffering from Idiopathic Dilated Cardiomyopathy since February 2013. This fact was not disclosed in the proposal form.
I have carefully gone through the medical certificate placed on record. The following columns are relevant to the case on hand:
What at the time of admission, was a. The nature of his complaint
b. The duration of the complaint as reported by him?
In April 2013, patient developed, cough, breathlessness with pinkish sputum, swelling feet and abdominal distension
What was the diagnosis arrived at in the hospital Idiopathic Dilated Cardiomyopathy
Was there are any other disease or illness which preceded or co-existed with the ailment at the time of the patient''s admission into the hospital? If so what was it? Please give detail stating.
a. History reported
b. Date when such was first observed by patient
c. By whom treated
NIL April 2013
Was he she treated in this hospital or any other hospital on any previous occasion either as an inpatient or an outpatient If so, please state:
a. Date of 1 st admission or fist time treatment as an outpatient
b. Date of discharge and condition on discharge
c. Nature of ailment
Yes. As an indoor patient (a) 6.5.13 - First Adm.
-Second adm.
(b) (11.6.13)Date of second discharge
(c)Idiopathic Dilated Cardiomyopathy
(11) Patient had developed cough and SOB in February 2013 was evaluated and treated elsewhere. In May 2013 patient got admitted in PGIMER, Coronary Angiography showed normal _______. MUGA Scan showed very low ejection fraction. He was diagnosed as a case of Dilated Cardiomyopathy was again hospitalised in June 2013 and discharged. Final admission was on 7 th July 2013 with refractory cardiogenic shock. Pt. expired on 16.07.2013 at 1030 p m".
As per the medical certificate, the patient Ravi Kumar had developed Cough, breathlessness in February 2013. He then again developed cough, breathlessness with pinkish sputum, swelling feet and abdominal distension in April 2013, but was treated elsewhere. Hence, it belies the stand of the petitioner, that Ravi Kumar had taken treatment from PGIMR Chandigarh from February 2013. He first came to PGIMR in May 2013 for treatment of his cough and breathlessness which he had developed in April 2013. It is only after his admission and after undergoing extensive tests in the hospital at PGIMR, Chandigarh was he diagnosed as suffering from Idiopathic Dilated Cardiomyopathy. The petitioner has failed to place on record the treatment record of Ravi Kumar from February 2013 to May 2013 when he was admitted in PGI. In fact they have even failed to mention the hospital or doctor from where he had taken treatment before May 2013. They have also failed to give any evidence that Ravi Kumar was aware and was in the knowledge of the fact that he was suffering from Idiopathic Dilated Cardiomyopathy in February 2013 and that he intentionally concealed this fact in the proposal form. On the other hand, in the complaint, the complainant has clearly stated that at the time of making proposal the insured Ravi Kumar was in good health and a good sportsman. They have further stated that it is only after taking the insurance policy that he fell ill.
The Hon''ble Supreme Court in Mrs Rubi (Chandra) Dutta vs M/s United India Insurance Co. Ltd., 2011 (3) Scale 654 has observed:
"Also, it is to be noted that the revisional powers of the National Commission are derived from Section 21 (b) of the Act, under which the said power can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view than what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the Courts below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. In this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21 (b) of the Act has been transgressed. It was not a case where such a view could have been taken by setting aside the concurrent findings of two fora."
In view of the above, I find that the petitioner has failed to adduce any evidence that Ravi Kumar was suffering from Idiopathic Dilated Cardiomyopathy since February 2013, and that he was well aware of his disease. The petitioner has also filed to identify the hospital and doctor from whom he was taking treatment for the same. No treatment record for the period prior to May 2013 has been placed on record. He only came to PGIMR in May 2013 where after extensive tests were conducted he was diagnosed as suffering from Idiopathic Dilated Cardiomyopathy. Hence, they have failed to prove that he had intentionally suppressed his illness which was within his knowledge.
In view of the above, we find that no jurisdictional or legal error or misrepresentation of facts have been shown to us which calls for interference in the exercise of powers under Section 21 (b) of Act. The order of the State Commission does not call for any interference nor does it suffer from any infirmity or erroneous exercise of jurisdiction or material irregularity. Thus, the present revision petition is dismissed.