NATIONAL INSURANCE COMPANY LIMITED vs VINAY KUMAR SEHGAL

NATIONAL Insurance Company Limited challenges order of District Forum, Jalandhar dated December 31, 1996 in this appeal whereby a direction was given to the appellant to pay Rs. 87,200/- alongwith Rs. 3,000/- damages and Rs. 1,000/- as costs of litigation to the complainant Vinay Kumar Sehgal.

VINAY Kumar Sehgal, approached the District Forum claiming Rs. 99,000/- (Rs. 87,200/- as medical expenses and Rs. 11,800/- special damages). He was working as Divisional Manager of M/s. Northern India Sales Corporation at Jalandhar. The aforesaid Corporation is owned by M/s. Usha International Limited. Since 1986 he had been taking insurance cover (Mediclaim Insurance Policy) from the opposite party, National Insurance Company. The details of the policies taken were mentioned in para 2 of the complaint. Last of the policies taken was on May 19,1989. Thereafter the policy in dispute was taken on July 16,1980 for a year. On December 14,1990 he went to Escorts Heart Institute, Delhi for check up. On the following day surgery was advised, which was actually performed on December 2, 1990 (bye-pass surgery). As per details given in para 3 of the complaint, he spent Rs. 87,200/- on the surgery. Further details of Rs. 86,500/- were given in para 4 of the complaint that for check-up Rs. 1,500/-, for Angiography package Rs. 10,000/- and for surgery Rs. 75,000/- were spent. In fact he had felt pain while on tour on December 12,1990 and had to visit the Escorts Hearts Institute. Since the opposite party avoided making payment of the aforesaid amount, District Forum Was approached with the complaint. The Insurance Company submitted its reply denying its liability. It was alleged that the complainant was suffering from heart disease prior to the issuance of the insurance policy on July 16,1990. He concealed this fact from the Insurance Company before obtaining the policy. Since June 21,1990 he was a known case of heart disease. The complainant fully knew about the existence of this disease when he submitted proposal form for policy in dispute. Thus for valid reason aforesaid the mediclaim of the complainant was repudiated by the Insurance Company. From July 16,1990 to July 15,1991, the complainant was not under the cover of mediclaim policy. Thus, it would appear that on June21, 1990 when he suffered from heart ailment, he was not covered under the policy. Information of repudiation of the claim was given to the complainant on February 14, 1992. Since the claim was repudiated there was no deficiency in rendering service on the part of the Insurance Company. The complainant was playing hide and seek game with the Court. He had no other reason of concealing the fact that his claim already stood repudiated before filing the complaint. Because of the disputed facts and circumstances, the complaint should be relegated to his remedy in the Civil Court. In the complaint no allegations were made regarding repudiation of the claim. The complainant wanted to play fraud on the Insurance Company by obtaining policy concealing the factum of heart ailment. On merits also, similar pleas were taken. The complainant produced his evidence by way of affidavit dated July 25,1996. On behalf of the Insurance Company affidavit of Joginder Singh, Divisional Manager and attorney of National Insurance Company was filed. These witnesses have reiterated the stand taken up in the pleadings referred to above. The District Forum on the material produced passed the impugned order.

Entering into a contract of insurance is outcome of faith and bona fides of the parties and if attempt is made by the insurer to defraud the Insurance Company by concealing material facts about his health, the contract of insurance would be frustrated. This is all has happened in the present case. The Insurance Company vide repudiating the claim relied upon the records of the Escorts Heart Institute from where the complainant had taken the treatment and had spent money, which was sought to be indemnified. Mark A at page 67 of the record is the certified copy of the discharge slip from the Escort Heart Institute where treatment was given. It is significant to be noticed that the history was recorded at the instance of the complainant in the hospital records. In the resume of the history, it was recorded as under : "Sehgal is a 49 years old normotensive, nondiaabetic, exsmoker, pleasant gentleman. He is a known case of ischaemic heart disease since 21.6.1990 when he had inferior wall MI. There was no anticident angina and patient was asymptomatic thereafter. TMT done on 13.12.1990 was strongly positive for reversible ischaemia. CART done on 15.12.1990 revealed severe triple vessel disease with good LV function. In view of his symptomatic status and CART findings, he was advised for surgery."

THIS fact that the complainant was suffered heart attack on June 21, 1990 has been mentioned in the order of repudiation dated February 14,1992 (page 81 of the records). THIS letter was addressed to the complainant. His further letter of March 11,1991 make inference of the discharge certificate issued by the Institute, reference of which has already been made above and which was referred to in the letter of March 19,1991. THIS is a letter of Dr. Prem Nath that the complainant was not filling proper discharge summary and from such summary he had noticed that the complainant had inferior wall Is chaemia on June 21,1990. On that date he was not under cover of Mediclaim policy. There is a letter of the complainant dated August, 14 and 16, 1995 that copy of discharge summary was given to the Insurance Company. An another photocopy was attached and it is the same document of which reference has been made. In spite of this when the complainant filed affidavit before the District Forum as late as on July 25, 1996, he conveniently ignored the factum of suffering heart ailment on June 21,1990 or treatment thereof. There was not even a denial of the allegations of the Insurance Company in this respect made in the reply. When immediately before taking the policy the complainant has suffered heart ailment, it was expected of him to disclose this fact at the time of taking the new policy. There is no evidence produced by the complainant that on June 21, 1990 the complainant was covered under any mediclaim policy. The policy in dispute was taken on July 16,1990 concealing the factum of his previous ailment as referred to above. The repudiation made in the present case by the Insurance Company was bona fide and based on the material collected. Hence there was no deficiency in rendering service on the part of the Insurance Company in repudiating the claim. Rather this repudiation was not challenged in the complaint as such. On the basis of the policy obtained under such circumstances, the complainant is not entitled to any relief. For the reasons recorded above, this appeal is allowed. The order of the District Forum granting compensation is set aside. There will be no order as to costs in this appeal. Appeal allowed.