P T G MENON vs C V RAJAN

THIS is a case wherein a senior citizen was denied the mediclaim benefits by the Insurance Company on the assumption that he had not disclosed relevant information to the Insurance Company about the pre-existing disease while obtaining the policy.

MR. O. P. Kingar, a retired employee of Hindustan Aeronautics Ltd. Bangalore, had obtained a family mediclaim policy No. 4867040000735 on 22. 2. 1993 for a period of one year from 22. 2. 1993 to 21. 2. 1994 from New India Assurance Company Ltd. , by paying an annual premium of Rs. 4,680. The complainant was admitted to Apollo Hospital, Madras on 2. 3. 1993 as he had suffered chest pain and was discharged on 10. 3. 1993 after he underwent certain procedures. Thereafter a claim form was submitted to the opposite party (the Insurance Company) claiming the actual expenses incurred i. e. , Rs. 78,157 on 12. 4. 1993. The Insurance Company repudiated the claim. Hence, the insured, Mr. Kingar filed the complaint before the District Forum claiming a sum of Rs. 1,20,157. Case of the complainant: Mr. Kingar had planned to visit his brother-in-law in UK in the month of April 1993. Accordingly, he went to HAL Hospital for medical check-up, Chest X-ray, ECG, etc. on 4. 2. 1993. The results were found within the normal limits. On 8. 2. 1993 the complainant went to the British High Commission at Madras for visa. The New India Assurance Company''s agents approached the complainant''s son Mr. Rakesh Kingar for group insurance to get Income-tax rebate for filing the return upto March, 1998. The proposal and the premium were accepted by the opposite party. At that time Mr. Kingar was in good health. On 25. 2. 1993 Mr. Kingar had little chest pain and went to HAL Hospital and the CMO of the HAL referred the petitioner to Apollo Hosital, Madras for check-up. The petitioner was admitted in Apollo Hospital on 2. 3. 1993 for investigation which revealed ''recent on set of angina'' (it was recent angina not existing earlier) and angioplasty was performed on the petitioner. The opposite party was informed of the above development. The petitioner was discharged from the hospital on 10. 3. 1993. The petitioner submitted the claim papers for the treatment obtained at Apollo Hospital to the opposite party. No reply from the opposite party was received for about five months in spite of constant followup Mr. Kingar sent a letter dated 10. 9. 2003 under Registered Cover to the opposite party for immediate settlement of the claim. The petitioner received a letter dated 16. 9. 1993 from the opposite party asking the petitioner to submit an authority letter to the effect that the petitioner has no objection if any hospital, including HAL Hospital furnishes whatsoever details sought by the Insurance Company. The certificate has already been signed by the petitioner at the time of taking the policy and it was a part and parcel of the policy. This was done by the opposite party only to harass the petitioner. On 19. 1. 1994 a letter was received from the Insurance Company repudiating the claim under different clauses. The original letter on the basis of which the claim was repudiated has never been produced either at District Forum or at the State Commission in spite of giving sufficient opportunity to the opposite party. The opposite party was shown the original letter from HAL''s Chief Medical Officer and copies of this letter and reports were sent to the opposite party, which shows that everthing was normal as on 4. 2. 1993. A letter was sent by the petitioner to the opposite party with the remarks of the Chief Medical Officer of the HAL stating that the X-ray and the ECG taken on 4. 2. 1993 were all within normal limits. The opposite party did not respond at all. Then the petitioner approached Jayamahal Consumer Protection (JCP) Society for help. A letter was sent by the JCP Society to the Divisional Manager of opposite party requesting him to settle the claim immediately as the matter has been delayed for one year. Since no reply was received from Divisional Manager, the JCP Society has written a letter to the Chairman of the opposite party requesting him to instruct the Divisional Manager to settle the claim at the earliest. The JCP Society sent a reminder to the Chairman of the opposite party. Another reminder was also sent to the Chairman of the opposite party requesting him to take action. Thereafter, on 5. 7. 1994, a case was filed in District Consumer Forum. Ultimately the judgment was delivered on 27. 3. 1998 by the District Forum, dismissing the complaint.

Aggrieved by the decision of the District Forum the complainant filed an appeal before the State Commission. The State Commission affirmed the order of the District Forum and dismissed the appeal. Dissatisfied by the order of the State Commission Mr. O. P. Kingar has come up with the revision petition. Submission of the learned Counsel for the revision petitioner :

(i) Learned Counsel Mr. Adalkha submitted that on the day the ProPosal form was filled, Mr. O. P. Kingar was hale and hearty. Accordingly, for the Part of the ProPosal form under the heading chest Pain or coronary insufficiency or myocardial infarction, he had said ''no''. Question No. 3 is not relevant. Hence, he has not suPPressed anything from the Insurance ComPany and there is no question of non-disclosure.

(ii) The Policy had the following exclusion clauses amongst others: the comPany shall not be liable to make any Payment under this Policy in resPect of any exPenses whatosever incurred by any Insured Person in connection with or in resPect of-Any disease other than those stated in Clause 2. 1. 1. 3 contracted by the Insured Person during the first 30 days from the commencement date of the Policy. This exclusion shall not however, aPPly if in the oPinion of Panel of Medical Practitioners constituted by the ComPany for the PurPose, the Insured Person could not have known to the existence of the disease or any symPtoms or comPlaints thereof at the time of making the ProPosal of insurance to the ComPany.

(iii) It is true that the Policy holder under went hosPitalization within first 30 days of the commencement of the Policy. The Insurance ComPany did not aPPoint any Panel of medical Practitioners to Prove their contention that the comPlainant was having knowledge of existence of the disease or the symPtoms thereof.

(iv) On 25. 2. 1993 the comPlainant felt Pain in the chest, and, accordingly Dr. P. Mohan Rao had referred him to the APollo HosPital with the following letter: "dear Dr. Girinath, i herewith refer Mr. O. P. Kingar, a retired officer of HAL, who is suffering from Ischaemic Heart Disease. I request you to kindly examine him and do the needful. "

(v) On 26. 2. 1994 Dr. P. Mohan Rao, Chief, Medical Services, HAL HosPital, Bangalore had isued a certificate that ''the ECG and the X-ray chest of Mr. O. P. Kingar done on 4. 2. 1993 were within normal limits''. Further Radiology and Imaging Science DePartment of the same hosPital had certified on 4. 2. 1993 that ''ct Ratio Normal and no abnormality''.

(vi) He finally submitted that there was no question of withholding any information from the Insurance ComPany. Subsequently, the comPlainant''s son informed the New India Assurance ComPany Ltd. about the admission of his father in APollo HosPital during the first week of March, 1993 and during the next week they submitted the claim statement to the Insurance ComPany duly enclosing the medical rePorts and bills. After a laPse of five months, the Insurance ComPany rePudiated this claim. Submissions of the learned Counsel for the resPondent No. 1:

(i) The learned Counsel for the Insurance ComPany, Ms. Pankaj Bala Verma, submitted that the comPlainant withheld vital medical information from the Insurance ComPany - that he suffered Ischaemic Heart Diseases (IHD) Prior to the taking of the insurance Policy. She Produced the original letter addressed by Dr. P. Mohan Rao, Chief of Medical Services, HAL HosPital, Bangalore dated 29. 12. 1993 to the Assistant Manager, New India Assurance ComPany Ltd. The extract of the letter is reProduced below: "i would like to inform you that according to the records available with us Mr. O. P. Kingar, Retd. , Factory Manager of HAL, has undergon check-uP on 4. 2. 1993 and ECG, Chest X-ray and blood test were done on the same day. He was subsequently referred to APollo HosPitals, Madras for management of Ischaemic Heart Disease. "

(ii) It is crystal clear that Mr. O. P. Kingar was suffering from IHD and he was referred to the APollo HosPital for management of the same disease. She submitted that the District Forum has gone through the facts of the case and the evidence in great detail and has rightly rejected the comPlaint. Thereafter order of the District Forum has been rightly affirmed by the State Commission. The oPerative Portion of the State Commission''s order reads as follows: "the Commission after considering the facts came to the conclusion that "after reassessing the entire materials in the light of the arguments advanced by the learned Counsel on both sides and on the basis of the judgment Passed by the District Forum, we are of the oPinion that the order Passed by the District Forum does not suffer from any infirmity. Hence, the revision Petition deserves to be dismissed. "

Findings:

THE State Commission, in Para 7 of its order, has stated that "we have been taken through the order of the District Forum. The District Forum in its order has clearly stated that the letter Ex. D3 written by Dr. Mohan Rao on 29. 12. 1993 to the Insurance Company clearly revealed that the complainant had undergone check-up on 4. 2. 1993 and ECG, Chest X-ray, blood test were conducted before getting the said policy. It also further observed that on the basis of the said report, the complainant got himself admitted to the Apollo Hospital where he was checked by the doctor in the said hospital. In spite of these materials which were in his knowledge, the complainant had deliberately suppressed them at the time of obtaining the mediclaim policy. The Insurance Company at the time of repudiating the claim has fully considered the claim of the complainant by applying its mind on the basis of the materials available to them. We are of the view that the letter dated 29. 12. 2003 should be read along with the certificate issued by the very Dr. P. Mohan Rao on 26. 2. 1994 wherein he has categorically stated that "the ECG and the X-ray Chest of Mr. O. P. Kingar done on 4. 2. 1993 are within normal limits. " An extract of the letter dated 29. 12. 1993 is reproduced below for ready reference: "i would like to inform you that according to the records available with us Mr. O. P. Kingar, Retd. Factory Manager of HAL, has undergone check-up on 4. 2. 1993 and ECG, Chest X-ray and blood test were done on the same day. He was subsequently referred to Apollo Hospitals, Madras for management of Ischaemic Heart Disease. (Emphasis added)"

The word subsequently is very relevant. Hence, it is apparent that insured person was subsequently referred to the Apollo Hospital, Madras. This is again borne by the letter dated 25. 2. 2003 written by Dr. P. Mohan Rao, addressed to Dr. M. R. Girinath, Cardio Vascular Surgeon, Apollo Hospital, Madras.

HENCE on the date on which the family insurance policy was taken, the complainant he was not suffering from IHD. Moreover on 8. 2. 1993 Mr. Kingar had also obtained a visa to visit the United Kingdom. Hence, we find no reason to disbelieve the version of the petitioner.

ACCORDINGLY, the Revision Petition is allowed and the orders passed by the lower Fora are set aside. The Insurance Company i. e. , New India Assurance Company Ltd. , (respondent) is directed to pay Rs. 78,157. 45 with interest @ 6% per annum from the date of the complaint till date of payment to the complainant/revision petitioner. We also award Rs. 10,000 as compensation and costs to be paid by the respondent (Insurance Company ). Revision Petition allowed.