NATIONAL INSURANCE CO. LTD. vs AJAY RAJORA

This revision petition has been filed under section 21(b) of the Consumer Protection Act, 1986 against the impugned order dated 12.03.2008, passed by the Delhi State Consumer Disputes Redressal Commission (hereinafter referred to as ''the State Commission'') in First Appeal No. FA-08/95, "National Insurance Company Ltd. versus Ajay Rajora", vide which, while dismissing the appeal, the order dated 19.11.2007, passed by the District Forum in consumer complaint No. 484/2006, filed by the present respondent/complainant, allowing the said complaint, was upheld.

The respondent/complainant had obtained a medi-claim insurance policy for the period from 14.07.2005 to 13.07.2006 from the petitioner / opposite party (OP) for an insured sum of 1,50,000/-. It is stated in the consumer complaint that at the time of obtaining the said policy, he was in good health and without any medical complaint of any kind. He met with an accident on 22.09.2005, when he slipped down from the staircase in his house, causing injuries to his back and spinal cord. He took rest for 5 days under the impression that the injury will heal itself, but when his condition became unbearable, he consulted Dr. Harsh Bhargava of Indraprastha Apollo Hospital on 27.09.2005. On the same day, MRI scan was done at the Mahajan Imaging Centre, after which he was put on medication. Since his condition did not improve, he again approached the said Doctor on 05.10.2005 and was advised admission in the Hospital for surgery. However, the complainant continued on conservative line of treatment, but when his condition did not improve, he consulted a super-speciality hospital on 14.02.2006, where also, he was advised immediate surgery. Thereafter, he again approached Dr. Bhargava and was advised that surgery was the only viable alternative. The complainant was operated at the Apollo Hospital on 21.03.2006 and incurred a sum of 1,43,310/- on his treatment. The surgery is commonly known as Diaminplant 12mm Metronics. The complainant informed the OP vide notice dated 03.04.2006 and asked them to make payment of 1,43,310/-, being the actual expenses on surgery and also demanded 1,01,000/- as liquidated damages. On the failure of the OPs to make such payment, the consumer complaint in question was filed, seeking directions to the OPs to pay actual expenses of 1,43,310/-, 1,01,000/- as liquidated damages and 25,000/- as litigation expenses.

The complaint was resisted by the OP insurance company by filing a reply before the District Forum in which they stated that at the time of obtaining the insurance policy, the complainant had concealed his pre-existing disease of ''aging process'' from the company. Under clause 4.1 of the Policy, the pre-existing condition of disease was to be reported to the insurance company before taking the policy. The company was, therefore, not liable to pay the claim in question. Further, the complainant had made a false story that he met with an accident on 22.09.2005, when he slipped down from the staircase in his house. In fact, when the complainant met Dr. Harsh Bhargava of 27.09.2005 for the first time, he did not disclose about any fall from the staircase. The certificate issued later by Dr. Harsh Bhargava on 23.03.2006 mentions about the said fall, but the said certificate was false. The OP insurance company, further stated that as per the MRI scan report of Mahajan Imaging Centre, the findings were suggestive of primary lumber canal stenosis with a broad-based posteriorcentral disprotrusion at L-4-5 level which shows that the above process is a result of aging process. The condition stated in the MRI scan could not have been due to fall in the staircase.

The District Forum, after taking into account the averments made by the parties, allowed the consumer complaint and directed the insurance company to pay the demanded sum of 1,43,310/- alongwith interest @9% p.a. from the date of the repudiation of the claim and to further pay a sum of 5,000/- as compensation and 2,000/- as litigation cost. Being aggrieved against the said order, the OP filed appeal before the State Commission, and the said appeal having been dismissed vide impugned order, the Insurance Company is before this Commission by way of the present revision petition.

During hearing before me, the Ld. Counsel for the petitioner insurance company has drawn attention to the prescription dated 27.09.2005, made by Dr. Harsh Bhargava of Indraprastha Apollo Hospital, saying that there was mention of severe back-pain for the last 5 years in the same, but nothing had been stated about the alleged fall from the stair-case. The MRI scan report dated 27.09.2005, also did not mention about the accidental injuries. In the prescription made on 17.03.2006, it was stated that the patient needed immediate surgery, but there was no mention of any fall or accidental injuries. In the discharge summary issued by the Hospital on 22.03.2006, it has been mentioned for the first time that the complainant had a fall from stairs and sustained injuries to his back. The Ld. Counsel argued that since the mention of fall from stairs, had been made in the discharge summary only and not in any of the prescriptions issued earlier, the story of having fall from the stairs, was not correct and hence, the claim was not payable.

The Ld. Counsel for the respondent, however, stated that there was no material on record to say that the complainant was suffering from any pre-disease. It had been mentioned in the first prescription dated 27.09.2005 that he had pain for the last 5 days, which was a result of fall from the stairs only. The Ld. Counsel argued that the concurrent findings given by the consumer fora below should be maintained and the present revision petition should be dismissed.

I have examined the entire material on record and given a thoughtful consideration to the arguments advanced before me.

The basic issue that merits consideration in the matter is whether there has been any concealment of a pre-existing disease from the insurance company, at the time of obtaining the policy in question. There is no evidence on record that the complainant suffered from any disease, or that he failed to disclose any material information about his health condition from the insurance company. The term ''aging process'' cannot be described as disease by any stretch of imagination. The policy in question is known as ''Hospitalisation and Domiciliary Hospitalisation Benefit'' policy. The chain of events on record including the prescription issued by Dr. Harsh Bhargava and the MRI scan report of Mahajan Imaging Centre reveals clearly that the condition of the patient required surgery upon him. The said surgery was conducted at the Inderprastha Apollo Hospital and an amount of 1,43,310/- was spent. It has been made clear that the patient had continuous pain in the back that was radiating to both the lower limbs. The pain used to get worsened on standing and got decreased during rest. The MRI scan also showed lumber canal stenosis and finally, the surgery had to be performed after obtaining two sets of medical opinion. Under these circumstances, it is not understood how the insurance company denied the payment of claim under the policy to the complainant.

The claim made by the complainant has been allowed by the District Forum and the said order has been duly confirmed by the State Commission in appeal. It is a settled legal proposition that at the stage of revisional jurisdiction, interference in the concurrent findings of the consumer fora below should be made only, if there is a patent error of jurisdiction or miscarriage of justice in any manner. This view has been taken in the case, " Rubi (Chandra) Dutta Vs. United India Insurance Co. Ltd. (2011) 11 SCC 269, " by the Hon''ble Supreme Court. The facts and circumstances on record in the present case do not justify any interference at the revisional stage, because there is no illegality, irregularity or jurisdictional error in the said orders passed by the consumer fora below. It is held, therefore, that there is no merit in this revision petition and the same is ordered to be dismissed. The orders passed by the District Forum and the State Commission are upheld. There shall be no order as to costs.