ORIENTAL INSURANCE Company Limited vs RAJINDER SINGH

-THIS is an appeal by the Oriental Insurance Company Ltd. against the judgment and order of the District Forum dated 20. 4. 2001 by which the complaint of complainant Rajinder Singh was allowed in the following terms: "next question for determination is as to how much amount the complainant is entitled to recover. The complainant has placed on file a number of bills. Some of the bills are of Gurmail Medical Hall. Even the investigator in the report has mentioned that the said bills are forged. Any how the record shows that the complainant got the treatment from C. M. C. Final bill of the C. M. C. Ex. A64 is on the file showing that the complainant incurred total expenditure of Rs. 64,438 in C. M. C. Hospital. That amount is payable to the complainant. Bills, Ex. 99,111 and A. 120 are for Rs. 5,238 each. Said bills relate to the medicine which was purchased from Chandigarh during admission of the complainant in the hospital. Genuineness of the said bills cannot be disputed. As such said amounts are also payable. In addition to the same bill Ex. A. 191 of Avon Medicose shows that the medicine worth Rs. 10,788 were purchased by the complainant after his dicharge from the hospital on prescription given by Dr. D. R. Rajan, as such the said amount is also payable. Bill A. 189 for Rs. 8,688 of Avon Medicose is also on the file through which the medicines were purchased after discharge on the prescription of Dr. Rajan. As such the amount of the said two bills have also to be allowed. Total amount of the above said bills comes to Rs. 1,01,628. Therefore, the complainant is entitled to recover the said amount. The claim of the complainant was repudiated on 28. 10. 1999. As such, the opposite party is directed to pay an amount of Rs. 1,01,628 along with interest @ 9% per annum w. e. f. 28. 10. 1999 till the date of actual payment. Compliance of the order be done within one month of the receipt of this order. Copy of the order be sent to the parties. "

BRIEF facts are that the complainant had taken a medi-claim policy from the appellant Insurance Company for the period 12. 3. 1998 to 11. 3. 1999 in the sum of Rs. 2. 50 lacs. According to the complainant, he fell ill and he was admitted in the CMC, Ludhiana on 13. 7. 1998 (wrongly mentioned in the impugned order as 18. 3. 1998) and was discharged from the said hospital on 8. 9. 1998. According to him, he had spent Rs. 2,88,125 on medical treatment and medicines in the hospital. The claim was lodged but the same was repudiated primarily on the ground that prior to the taking of the policy the complainant was suffering from hypertension and renal problems. After appreciating the evidence, etc. on the record the complaint was allowed as aforesaid. Hence, the present appeal. The points for determination, in this case, are, (i) whether there is anything on the record to show that the complainant respondent was suffering from hypertension/renal problems at the time he took the policy? and (ii) whether he had any knowledge about the alleged disease?

In the discharge summary issued by CMC, Ludhiana in the column of ''history'' it is mentioned that "this is 38 years old man and not a known hypertension or renal failure patient". In the final diagnosis, though it is mentioned that there is chronic renal failure and hypertension, but the fact remains that it was not a known case of hypertension or renal failure as has been mentioned in the ''history''. It is the case of the appellant Insurance Company that under Clause 4. 1 of the policy it would not cover all diseases/injuries which are pre-existing when the cover incepts for the first time. According to the appellant, whether a patient has the knowledge of the disease or not is immaterial; mere pre-existence of a disease prior to the taking of the policy would disentitle the insured from claiming under the medi-claim policy.

WHILE interpreting Clause 4. 1 of the policy, National Commission in a recent judgment Praveen Damani v. Oriental Insurance Co. Ltd. , IV (2006) CPJ 189 (NC)=2007 (1) CPC 141, observed in paragraph 18, 19 and 20 as under: "18. The District Forum also relied on Clause 4. 1 of the policy which states that it is not material whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the Insurance Company to disown the liability.

If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4. 1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc. prior to 11. 8. 2000. Since there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the complainant that he was thoroughly checked up by the Doctors who were nominated by the Insurance Company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.

In view of the above discussion and from the records available before us, in our opinion, the complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed. "

In view of the above, Clause 4. 1 of the policy would mean not only that the disease should be pre-existing at the time of the taking of the policy but the insured must have the knowledge of the same. The knowledge can be attributed to the insured if he had taken some treatment in a hospital or anywhere else or was taking some medicines for that disease prior to the taking of the policy or some other evidence akin to that. In the present case, there is no such evidence that the insured had the knowledge of the disease as he had been taking some treatment prior to the taking of the policy.

RECENTLY, we had no occasion to consider a similar point in Appeal No. 1616 of 2002, New India Assurance Co. Ltd. v. Commander (X) (P) Kamaldeep Singh Sandhu, I (2008) CPJ 34, decided on 17. 5. 2007, where after taking the view as taken by the National Commission in Praveen Damini''s case (supra) we had decided the case against the Insurance Company. For the foregoing reasons, we find no infirmity in the order of the District Forum which we uphold. The appeal is dismissed. No costs. Appeal dismissed.