NATIONAL INSURANCE COMPANY LIMITED vs NEELAM RANA

THIS is an appeal filed against order dated 1.3.2004 passed by District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (for short hereinafter referred to as District Forum) in Complaint Case No. 686 of 2002-Smt. Neelam Rana wife of Sh. S.S. Rana resident of House No. 712, Sector 22-A, Chandigarh v. The National Insurance Company Limited, SCO No. 85-86, Sector 17-D, Chandigarh through its Branch Manager, vide which the complaint was partly allowed and the National Insurance Company Limited (for short hereinafter referred to as the Insurance Company) was directed to pay to the complainant Rs. 27,072/- with interest @ 6% per annum w.e.f. 10.3.2000 till payment along with Rs. 1,000/- as costs of litigation.

THE respondent/complainant took a Medical Insurance Policy from the Insurance Company through its Manager in Sector 17-D, Chandigarh being policy No. 548904 for a sum of Rs. 50,000/- for the risk period from 30.8.1999 to 29.8.2000. At the time of taking the policy, Smt. Neelam Rana was enjoying best of her health. She, however, suffered a severe pain in her abdomen on 30.9.1999 and was taken to General Hospital, Chandigarh where ultrasound test was performed and multiple small H.E.S.C. Pas was diagnosed in her gall bladder which moves "C" change of posture. She was admitted to the General Hospital on 7.10.1999 and operation was performed on her on 8.10.1999. After surgery, she was advised to go Echo Cardiography at Heart Care Centre, Sector 35, Chandigarh, which was undertaken. Smt. Neelam Rana was discharged from the hospital on 11.10.1999 and was referred to the PGIMER, Chandigarh. She was taken to PGIMER, Chandigarh the same day where she was thoroughly checked by the doctors. Echo was again taken besides other tests and she was advised to undergo Hematology test at Chandigarh Clinical Laboratory Pvt. Ltd., which was got done. On 3.11.1999, she suffered severe pain in the gall bladder and was taken to PGIMER, Chandigarh, where she was admitted and after conducting various tests and x-ray examination, she was discharged on 5.11.1999 after prescribing certain medicines etc. On 20.12.1999 at about 10.00 p.m., the complainant suffered severe pain. She took some tablets and on getting no relief, was taken to Dr. Nirmaljit Kaur Sachdeva in Sector 15, Chandigarh where she remained admitted till the evening of 20.12.1999. Dr. Nirmaljit Kaur Sachdeva advised her to undergo operation of removal of gall bladder. She was taken to G.M. Nursing Home, Sector 34, Chandigarh where she was operated upon for removal of gall bladder and was discharged on 31.12.1999.

On all these treatments, the respondent/complainant spent a sum of Rs. 27,072/-. She filed a claim on 10.1.2000 along with details of events. The claim was registered by the Insurance Company as Claim No. 48/85/99/192 but no action was taken. A legal notice dated 8.5.2000 was served but there was no response. The Insurance Company, however, sent to the complainant letter dated 1.8.2002 posted on 3.8.2002 and received by the complainant on 5.8.2002. The said letter repudiated the claim of the complainant on the plea that the disease was pre-existing and was excluded from the terms and conditions of the policy. The complainant filed the complaint praying that the O.P. be directed to pay Rs. 27,072/- with interest @ 18% per annum from its due date besides a sum of Rs. 50,000/- as compensation towards harassment and Rs. 10,000/- as litigation expenses.

THE Insurance Company appeared and filed written statement and took a plea that the complainants suffered from disease, which were pre-existing at the time of issuance of medical insurance policy and as such the claim was excluded under the terms and conditions of the policy. A plea of limitation was also raised and it was contended that the claim petition is barred by limitation. THE plea of limitation was repelled by the District Forum. It was held that the date of repudiation letter was 1.8.2000, which was despatched on 3.8.2000 and received by the complainant on 5.8.2000. THE complaint could be filed on or before 4.8.2002 but it was filed on 5.8.2002 and according to the contention of the appellant, technically, the complaint was filed belatedly by one day for which the complainant had not moved any application seeking condonation of delay. The learned Counsel for the respondent/complainant pointed out that undoubtedly the complaint was to be filed on or before 4.8.2002 but the said date happened to be Sunday, a closed holiday for the District Forum and as such the complaint was filed on the next opening day i.e., 5.8.2002. The calendar for the year 2002 was consulted and its perusal showed that 4.8.2002 happened to fall on Sunday and as such the complaint was rightly filed on 5.8.2002 and the same was not barred by limitation even by a day.

COMING to the merits of the case, the District Forum has categorically recorded a finding that the complainant/respondent Smt. Neelam Rana was in best of her health when she had submitted the proposal for issuance of Medical Insurance policy and the same was issued by the appellant-Insurance Company to her. Since she was not suffering from any disease at the time nor had any such symptoms, her case did not fall under any of two exclusionary Clauses Nos. 4.0 and 4.1 of the policy of insurance, which excluded such claims and which have been extracted in the impugned order in para 5. The District Forum referred to para No. 2, on merit, of the written statement wherein the plea raised was about the cover note being given to the complainant and later on policy wherein the detailed terms and conditions were stipulated were sent to the complainant. The case of the complainant was that policy was never delivered to her by the appellant and the District Forum held that since the policy of insurance had not been delivered to the complainant in continuation of the issuance of cover note, the complainant could not be presumed to know the exclusionary Clause Nos. 4.0 and 4.1. The District Forum held the repudiation of the claim of the complainant on the basis of exclusionary clauses, prima facie, illegal and it amounted to deficiency in service. Apart from it, there is no reliable material on record to show that the complainant was in the know of such symptoms regarding the gall bladder at the time of submitting the proposal for issuance of policy of insurance. The appellant relied on the affidavit of Shri Sunil Aggarwal, Asstt. Divisional Manager whose affidavit is a verbatim copy of the written statement filed by the appellant Insurance Company. The proforma of the Medical Insurance policy, which has been annexed with the affidavit showing the exclusionary Clauses 4.0 and 4.1, does not categorically show that the policy had in fact been sent to the complainant and the complainant was in the know of exclusionary clauses contained in the policy of insurance. Moreover, the District Forum has referred to the affidavit of the complainant in which a clear and categorical stand was taken that the complainant did not have any pre-existing disease relating to her gall bladder. The District Forum, in our considered opinion, rightly allowed the complaint and awarded compensation. We find no merit in this appeal, which is dismissed with costs, which we quantify at Rs. 300/-.

COPIES of this judgment be sent to the parties free of charge. Appeal dismissed.