NATIONAL INSURANCE CO. LTD. vs Balkhandi Lal Sharma

THIS revision petition has been filed against the concurrent decisions of the lower Fora awarding compensation of Rs. 1.00 lakh towards medical claim insurance policy issued by the petitioner to the respondent -complainant. The petitioner assails the order passed by the State Commission on two grounds, (i) the report of the investigator Dr. R.K. Kakker dated 13.7.2001, wherein he has mentioned about certain treatment undergone by the petitioner since 2.11.2000, whereas the policy was issued on 28.1.2000 for one year and on 27.1.2001 which was further renewed for one more year. Dr. Kakker has filed this report without prejudice. However, he has not chosen to file any affidavit in support of his contentions made in this report. He also quoted the letter of Dr. Jayant Gupta addressed to Dr. Kakker, which reads as follows: Yours specific queries regarding - (i) occurrence of ischaemic heart disease in short span of 11 months,

(ii) management during general anaesthesia including pre, per, post -operative care.

I beg to say that I will not be able to recall details of the exact management carried out without consulting hospital records and notes. It is, however, unusual for ischaemic heart disease to develop in a short span of time because of process of arterial blockage is generally slow and occurs over the span of several years/ decades; symptoms like angina, unstable angina, heart attacks can occur suddenly on this baselines atherosclerotic process.

THIS letter is not supported by any affidavit. Further, this letter clearly states that this was issued without going through the hospital records and notes. It is not disputed by the learned Counsel for the petitioner that the mediclaim policy was issued only after medical test especially after a particular age. In this case, the insured was 69 years old and the amount claimed by him is not very big. The amount claimed was for Rs. 44,658 for the first policy and Rs. 52,234 for the renewed policy for undergoing certain procedure relating to prostrate glands, Carcinoma of Bladder. It is not his case that the patient was advised CABG as he was suffering from IHD and, therefore, he had taken the insurance policy and tricked the Insurance Company to issue policy and subsequently presented a fat bill for indemnification. The main contention of the Insurance Company is that he has taken this policy by not disclosing the material facts like IHD.

IN our view, the learned Counsel for the petitioner has not placed any new arguments other than those, which were submitted before the lower Fora. No material facts were suppressed by the complainant. The report of Dr. Kakker and Dr. Gupta do not have any evidentiary value as they have not filed any affidavits. We cannot take them into consideration while arriving at any decision in this case. In fact in this case the renewal cheque was returned to the complainant only on 10.1.2002, just few days before the expiry of the renewed policy.

IN view of the concurrent finding of the Fora below and the facts of the case, we do not wish re -analyse the facts once again which have been analysed in great detail. Further, no new points have been urged by the learned Counsel for the petitioner, which were not urged before the Fora below.

IN Praveen Damani v. Oriental Insurance Co. Ltd., IV (2006) CPJ 189 (NC), Revision Petition No. 1696 of 2005, decided on 3.10.2006, the National Commission paid special attention to the Exclusion Clause -4.1'' of the Medical Claim Policy as under: It is not relevant whether the insured person had knowledge of the existence of a disease or not. If symptoms of the disease existed before the effective date of insurance and even if the insured person was not aware of these symptoms, the insurance company was not liable to pay any claims arising out of the condition. If this interpretation of the Exclusion Clause was to be accepted, then, the insurance company would not be liable to pay any claims whatsoever, because most people suffer from symptoms of diseases without the knowledge of the same. The National Commission noted that: "The policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre -existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence, they cannot be made liable to suffer because the insurance company relies on their Exclusion Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the medi -claim policy as every human being is born to die and diseases are perhaps pre -existing in the system totally unknown to him which he is not aware of."

It further held: "In hindsight, everyone realizes much later that the symptoms were indicative of a disease. But common people are not at all familiar with the medical knowledge and so they cannot diagnose their own diseases. If they were expected to be so aware of their medical condition at all times, there would be no use of insurance policies."

THE ratio of the case quoted (supra) is squarely applicable to the case on hand. Accordingly, we do not see any material irregularity or jurisdictional error in the order passed by the State Commission warranting our intervention under Section 21(b) of the Consumer Protection Act, 1986. Therefore, this Revision Petition is dismissed There shall be no order as to cost. R.P. dismissed.