New India Assurance Co. Ltd. vs VIMAL CHAND JAIN

THIS appeal is by opposite party, the New India Assurance Company Ltd. against the order dated 23.10.2002 passed by the District Consumer Disputes Redressal Forum, Damoh in Case No. 31/2001 allowing the complaint of the respondent and directing the appellant-Insurance Company to reimburse the treatment expenses incurred by the respondent, under a mediclaim policy taken out by the latter from the former on 26.11.2001.

RESPONDENT-complainant had under-gone heart surgery at Apollo Hospital, Hyderabad on 6.2.2002. The claim of the respondent was repudiated by the appellant-Insurance Company mainly on the ground of suppression of pre-existing heart ailment. However, no evidence as to this pre-existing heart ailment could be adduced by the appellant-Insurance Company. As per discharge summary prepared at the time of discharge of the respondent-patient at the said hospital, it is clearly recorded that the respondent aged 61 years was found having exertional angina grade II with dyspnoea on exertion grade I from one month. Known hypertensive from one month. It cannot be thus said that the ailment existed on or before the date of taking out of the policy and that there was any wilful suppression on the part of the respondent as to the existence of any such ailment. It is true that on examination certain arteries of respondent were found blocked 60% to 99%. It could be thus argued that this blockage must have existed or developed much before the respondent took out the policy in question. Even if that was so, there is no evidence on record to show that the respondent was aware of any such development and wilfully suppressed the same while taking out policy. Learned Counsel for appellant has submitted a prospectus applicable to mediclaim insurance policies laying down certain conditions. Our attention was particularly drawn towards Clause 4.1 which thus read as follows : "4.1. Such diseases which have been in existence at the time of proposing this insurance. Pre-existing condition means any injury which existed prior to the effective date of this insurance. Pre-existing condition also means any sickness or its symptoms which existed prior to the effective date of this insurance, whether or not the insured person had knowledge that the symptoms were relating to the sickness. Complication arising from pre-existing disease will be considered part of that pre-existing condition."

A careful reading of the aforesaid clause would show that the insured should have the knowledge about some symptoms of the pre-existing disease although he may not know that the symptoms are relating to that sickness. Even otherwise, these conditions do not seem to have been attached with the insurance certificate issued to the complainant. This document does not even find part of the record of the Forum below and obviously the appellant has not submitted the same for consideration of the Forum. The burden of proving the alleged suppression was on the appellant who has however failed to discharge the same and, therefore, this appeal must fail and is dismissed with cost of Rs. 1,000/-. Appeal dismissed with costs.