NEW INDIA ASSURANCE CO. LTD. vs Arun Krishan Puri

THE complainant/respondent had taken medi claim policy from the petitioner/opposite party since 1997 and the policy was effective from 22.8.2001 to 21.8.2002 for a sum of Rs. 2,20,000. On 12.7.2002, the complainant had chest pain and after ECG, he was referred to B.B.C. Heart Care Centre, Jalandhar. The complainant in fact went to Sir Ganga Ram Hospital, New Delhi on 13.7.2002 and he was treated there by Dr. Vinod Sharma and Dr. O.P. Yadav. He was operated upon on 17.7.2002 for coronary heart by -pass surgery and was discharged on 22.7.2002. The complainant submitted a claim for Rs. 1,35,000 for the operation and hospitalization. The said claim was not settled and the complainant approach District Forum.

THE District Forum, after analysis of material placed before it by both the parties came to the conclusion that except for a report from Dr. Harish Nagpal, who was working in the Insurance Company, the opposite party was not able to produce any evidence to establish that the complainant was suffering from heart disease. It was also stated that Dr. Harish Nagpal did not document the photocopy of the papers of Sir Ganga Ram Hospital to authenticate his own report. On the contrary, the complainant had produced a document Annexure -I in which Doctor In -charge of Sir Ganga Ram Hospital had written that the disease is of recent origin. The District Forum relied upon authorities stating that onus lies on the Insurance Company to prove that the insured had pre -existing disease at the time of taking medical policy. Accordingly, the claim put forward by the complainant was granted to the extent of Rs. 1,35,000 with 12% interest thereon from date of repudiation till realization as also Rs. 1,000 as compensation for mental agony. This order was challenged before the State Commission.

THE State Commission examined the matter with reference to the plea of the Insurance Company regarding concealment of pre -existing disease. The State Commission found that the sole question, which was required to be decided was whether the complainant/respondent was suffering from Angina or heart disease prior to his taking policy in 1997 or not. The State Commission took into account the discharge summary issued by Sir Ganga Ram Hospital, Annexure -A3. Another discharge summary, Annexure A -10 produced by the complainant/respondent and certificate, Annexure A1 of Dr. Ganesh Shiv Nani. The State Commission came to the conclusion that the Investigator, Dr. Harish Nagpal was hired by the opposite party and he was never treating doctor of respondent/complainant; that insofar as the Angiography in the year 1999 is concerned, not much value can be attached to the said aspect because the same was done much after respondent/complainant had taken the policy in the year 1997 and as regards allegation of sufferance of Angina on exertion off and on since 1996, there was no evidence on record to prove the same by way of any statement of the treating doctor or any prescription slip. Therefore, it was held that the opposite party had failed to establish that the respondent/complainant was suffering from pre -existing disease, which he concealed from the opposite party. The repudiation of claim was considered as deficiency in service and the appeal was dismissed with cost of Rs. 2100. This order is subject matter of challenge before this Commission. We have heard the learned Counsel appearing on behalf of the petitioner who has submitted before us that the original record from Sir Ganga Ram Hospital could not be produced as the same has been destroyed. A certificate to this effect has been filed. He, however, submitted that Dr. Ganesh Shiv Nani has identified his signatures at the end of page 2 of the discharge summary issued by Sir Ganga Ram Hospital. He, therefore, submits that the petitioner has been able to establish through the said discharge summary that the complainant/respondent was suffering from Angina on exertion off and on since 1996 and that his coronary angiography was done in 1999 which revealed severe triple vessel coronary artery disease and he was advised CABG but he deferred surgery. Insofar as this discharge summary upon which reliance is placed by the petitioner, we would like to mention that the discharge summary has been prepared on 22.7.2002. The Investigator, Dr. Harish Nagpal did not take copies of hospital record on the basis of which, this discharge summary was prepared and more particularly clinical summary, which could have authenticated the observations, made in the discharge summary. Secondly, no record whatsoever in relation to Angina on exertion off and on since 1996 and that his coronary angiography was done in 1999, which revealed severe triple vessel coronary artery disease were placed before the Fora. Thirdly, the discharge summary has not been verified by Dr. Ganesh Shiv Nani, who has only identified his signatures at the bottom of second page of the discharge summary. Dr. Ganesh Shiv Nani has categorically stated in the certificate that he cannot verify the discharge summary. In the absence of verification of the discharge summary by any doctor who had treated or issued the discharge summary, no reliance can be placed on the same. The discharge summary shows that Dr. O.P. Yadav is Cardiac Surgeon and Dr. Vinod Sharma/S. Dhawan are Cardiologist. The discharge summary further shows that the patient was referred to Dr. Vinod Sharma/S. Dhawan, Sr. Consultant Cardiologists for further followup. No affidavits of the said doctors were filed. Besides this, the complainant had filed Annexure A -1, wherein Dr. Ganesh Shiv Nani had categorically stated that the ailment suffered by respondent/complainant had recent onset and this Annexure was duly signed by Dr. Ganesh Shiv Nani and his stamp was also affixed thereon. In addition, in the operation notes dated 17.7.2002 signed by Dr. O.P. Yadav of Sir Ganga Ram Hospital, it was merely stated that the complainant was having angina and currently he was NYHA Class III Symptomatic. There is no reference whatsoever to chronic Angina on exertion off and on since 1996 and that his coronary angiography was done in 1999, which revealed severe triple vessel coronary artery disease but on the contrary it states that angiography was performed on 15.7 2002, and it was a case of severe triple vessel coronary artery disease with normal L.V. function.

IN the light of the aforesaid material on record, the conclusion arrived at by the District Forum and State Commission is well founded and does not call for any interference in exercise of revisional jurisdiction under Clause (b) of Section 21 of the Consumer Protection Act, 1986. In view of this, the revision is hereby summarily rejected with no order as to costs.