New India Assurance Co. vs Pradeep Kumar

PRADEEP Kumar, hereinafter referred to as complainant, filled up a Medi-claim Proposal Form dated 2.9.92. On payment of the necessary premium he obtained Hospitalisation Domiciliary Hospitalisation Policy for the period 3.9.92 to 2.9.93. on 23.7.93 the said PRADEEP Kumar lodged a claim under the aforesaid policy claiming compensation amounting to Rs.1,72,680/- being the total expenses incurred by him for his heart operation - Mitral Valve Replacement on 22.4.93 at Escorts Heart Institute and Research Centre, New Delhi. The complainant also submitted Discharge Summary issued by the said hospital on 1.5.93 alongwith a bill amounting to Rs. 1,69,580/- The appellant Insurance Company which was opposite party before the District Forum, referred the case to two Doctors namely, Dr. S.B. Rajpal and Dr. Pran Nath. The said Doctors, vide their reports dated 4.8.93 and 15.10.93 reported that PRADEEP Kumar was a known case of Rheumatic Heart Disease with positive history of Rheumatic fever in childhood. He was having breathlessness and palpitation for the last one year i.e., prior to taking the policy. The said Doctors also reported that the aforesaid PRADEEP Kumar had two/three bouts of Haemaptysis since May, 1992 i.e., prior to the taking of the policy. Based on the Discharge Summary and the aforesaid reports, the Insurance Company repudiated the claim vide its letter dated 4th August, 1993. Thereafter PRADEEP Kumar filed a complaint before the District Forum-I. The case was contested in consideration of the material before it. District Forum accepted the plea of the complainant that he did not have any symptoms prior to taking the policy. He had no knowledge of the existence of the disease at the time of filling the proposal form. It was further held that the Insurance Company failed to discharge the burden of proof that the present case related to fraudulent concealment and suppression of material facts. Accordingly the Insurance Company was directed to pay Rs.1,72,680/-alongwith 15% per annum interest with effect from 4.8.93. Aggrieved by the order the present appeal has been filed by the Insurance Company. Reply has been filed by the respondent. We have heard Mr. Salil Paul Advocate for the appellant and Mr. Rajesh Mahna, Advocate for the respondent.

MR. Paul first invited our attention to the complainant answer in the negative in reply to the question 13(b) of the Proposal Form which, inter alia, required the insured to state whether he had ever suffered from Rheumatic Fever. MR. Paul emphasised that the contract of insurance was based on good faith and if it can be reasonably found that the insured had made a false statement, knowing that the same was false, the contract of insurance was rendered void and the Insurance Company was not liable to pay any amount in terms of the policy. Our attention was next invited to the Discharge Summary prepared by the Escorts Hospital in which it was stated that patient Pradeep Kumar was known case of Rheumatic heart disease. He had a positive history of Rheumatic fever in childhood. He had dyspnea on exertion for the last one year. It would work out to May, 1992 whereas the Medi-claim form was filled on 2.9.92. The Discharge Summary goes on to state that the patient had been admitted NYHA Class-II-III. He had haemoptysis 2/3 times since May, 1992. Based on the aforesaid Medi-claim record and the opinions of the Doctors (Dr. Rajpal and Dr. Pran Nath) the contention of MR. Paul is that the Insurance Company had brought on record material which was sufficient to discharge the onus and the only inference from the above said facts was that the complainant suffered from breathlessness had passed blood alongwith the spyctum from the mouth and has suffered from rheumatic fever in childhood and these facts were known to him at the time of filling in proposal form. He, therefore, contended that the Insurance Company had carefully considered the claim made by the complainant and after ascertaining from the hospital records and views of two well-qualified Doctors, had decided to repudiated the claim and there was no deficiency in service. In the alternative, Mr. Paul contended that in the terms of the policy, there was a ceiling limit on the liability of the Insurance Company and assuming for the sake of arguments, the case having gone in favour of the complainant, that liability in terms of the policy worked out to Rs. 85,250/- in other words even if the case was decided against the Insurance Company on all grounds, the amount to be ordered could not exceed the aforesaid sum worked out in terms of the policy itself.

The contention of Mr. Mahna, on the other hand, is that the complainant appears to have suffered rheumatic fever and this fact was perhaps known to the complainant''s sister and there was no material to show that before die information was given by the sister in the hospital, the complainant was at any stage aware of his having suffered from rheumatic fever at the age of 2 years. Mr. Mahna further submitted that the policy was taken in September, 1992 Breathlessness, which necessitated consultation with the Doctor took place in January, 1993. Under me medical advice, the complainant took Echo test and it was then diagnosed that he suffered from certain heart ailments which needed surgical intervention. Mr. Mahna also emphasised that one can pass blood from the mouth for umpteen reasons and it cannot necessarily be connected with a heart ailment.

AFTER carefully considering the respective submission, we are of the view that the symptoms had come to light before the complainant took the policy. It is not disputed that he was the only person in the family who took the policy as distinguished from the case of a person where several members of me family, if not all, take a Medi-claim policy. We are further of the view that Insurance Company had repudiated the claim after due application of mind and the conclusion reached by the Insurance Company was a bona fide one. Whatever remedy the complainant may have in the Civil Court, there is no case of deficiency in service. We accordingly allow appeal, set aside the order passed by the District Forum-I. As a result the complaint stands dismissed. It will be open to the complainant to have his remedy, if any, in the proper Court. A copy of this order be communicated to both the parties; as well as to the DF-I. Appeal allowed.