National Insurance Co. Ltd. vs SURINDER LAL ARORA

THIS is an appeal directed against the order of 30th May, 1992 passed by the State Commission of Uttar Pradesh in Complaint Case No. 117/SC/90.''

THE relevant facts are that the respondent complainant Shri Surinder Lal Arora had taken out a Hospitalisation and Domicialiary Hospitalisation benefit policy from the appellant-Insurance Company on the 9th of February, 1988. This policy was renewed on the basis of a proposal form the insured on the 8th of February, 1989. The respondent complainant underwent a bye pass heart surgery in the Escorts Heart Institute and Research Centre on the 3rd of March, 1989 and remained admitted in the Institute till 13th March, 1989. He made a claim on 10th of April, 1989 on insurer for a sum of Rs. 65,000/-. The appellant-Insurance Company in March, 1990 repudiated the claim on the ground that prior to the taking of the policies the respondent had already been suffering from heart disease and hypertension and that these facts were concealed in the proposal form made by the respondent-complainant. The respondent-complainant thereafter filed a complaint before the State Commission, Uttar Pradesh alleging wrongful repudiation of his claim on his insurance policy and alleging deficiency in service on the part of the appellant-Insurance Company. He asked for relief by way of reimbursement on the expenditure incurred by him with interest at 18% thereon and compensation of Rs. 50,000/-. The State Commission came to the conclusion that the complainant was not having the knowledge of the heart disease prior to the taking of the policy and that the evidence indicated that he was suffering from chest pain only from which it could not be guessed that the chest pain related to the heart disease. It, therefore, directed the appellant to pay a sum of Rs. 65,000/- to the insured with an additional sum@ 12% w.e.f. 20.5.1989 and 18% from 1.8.1992.

After going through the records and after hearing the parties, the facts which emerge are as under: 1) According to the respondent-complainant, he felt chest pain on 13th September, 1988 and was referred by Dr. Sushila Ghatani to the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow (S.P.G. I.M.S.). He was examined in the Institute on 14th September, 1988 where he had to undergo the Treadmill Test. He was under the treatment of Prof. V.K. Kureel, Professor of Cardiology Department in the above Institute from 14.1.1989 till 19.1.1989. In the proposal for renewal of policy submitted on 8th February, 1989 he did not disclose against the relevant column that he was suffering from any heart ailment or a cardiac disease. The respondent-complainant has himself submitted before this Commission a photocopy of the prescription of Dr. Sushila Ghatani of 31.3.1988 which indicates that he was being treated for hypertension and unstable angina.

THE above narration of facts provide adequate evidence that before the renewal of the policy on the 8th of February, 1989, he was having a heart problem for which he had to undergo a Tread mill Test on 27th September, 1988 and was a patient of a Cardiologist in S.G.P.G.I.M.S. Institute at Lucknow during January, 1989. THEse provide reasonable ground to hold that at the time of renewal of policy, the insured had suppressed the material facts regarding the state of his health and the disease/ailments from which he was suffering. The appellant has also produced a letter dated 23 of September, 1989 to the Senior Divisional Manager, National Insurance Co. Ltd., from Dr. S. Radhakrishnan, Asst. Professor, Department of Cardiology of the S.G.P.G.I.M.S., Lucknow, the relevant portion which is reproduced below :

IN reply to your queries about Shri S .D. Arora I wish to clarify the following points as below : 1. Mr. Arora was first registered at our Out Patient on 14.9.88 and was on our follow up till 1.10.88. On this day, based on the investigations, coronary arteiography and bypass surgery (if the need arose) was advised. The patient had his arteriography at the King George Medical College, Lucknow and was referred from this Hospital to Escorts Heart Centre at Delhi in Coronary Bypass Surgery which was done on 3.3.89. Subsequent to this the patient visited our OPD on 13.9.89 and had been advised to be on follow-up. 2. The patient has been a hypertensive for the past 4 years since the day of reporting to our OPD (14.9.88) and had been complaining of angina (chest pain) since 2 years of coming to us. 3. His complaints were found to be relevant to the disease the patient is suffering from. 4. The patient history of onset of symptoms was 4 years (for Hypertension) and 2 years for angina (chest pain)"

This communication of the Assistant Professor of Cardiology of the above INstitute is conclusive; the patient had history of onset of symptoms for Hypertension - four years; and angina (chest pain) for two years. The State Commission in its order has also jioted that Dr. Atul Mehrotra, Heart Specialist, Lucknow has said in his report on 18th October, 1989 that the complainant had been suffering from the angina for the last two years. There is, therefore, conclusive and incontestable evidence that the respondent-complainant had been suffering from angina for 2 years and hypertension for four years prior to September, 1989 and that he was aware of the disease from which he was suffering but nevertheless he had suppressed these material facts in the proposal form not only at the time of taking the policy in 1988 but also at the time of its renewal in February, 1989.

THE appeal, therefore, succeeds. THE order of the State Commission is set aside.

WE, are, however, constrained to observe that we find that there is a widespread tendency to lodge false med-i-claims against the Insurance Companies before the Consumer Forums, especially because no Court fees are payable for processing their complaints before the Consumer Forums. It is essential that such a tendency is firmly curbed and abuse of the Consumer Protection Act is discouraged. It is, therefore, appropriate that the respondent-complainant in this case pays a sum of Rs. 5,000/- as costs to the appellant National Insurance Company Ltd. Appeal allowed.