ABHISHEK JAIN vs Hdfc Standard Life Insurance Co. Ltd.

THE present Revision Petition has been filed before this Commission under Section 21(b) of the Consumer Protection Act, 1986 against the impugned order dated 12.6.2013 in Appeal No. 1571 of 2010 passed by the State Consumer Disputes Redressal Commission (in short, ''State Commission''). The State Commission allowed the appeal of the Appellant filed against the order in Consumer Complaint 162 of 2008 dated 24.6.2010 passed by the District Consumer Disputes Redressal Forum (in short, ''District Forum''). The brief facts of the case are: On 10.1.2006 and 5.6.2006 the Complainant, Mr. Abhishek Jain, purchased 2 life insurance policies, under Policy Plan HDFC Young Star. The death benefit was of Rs. 5,00,000 each and Rs. 5,00,000 for Extra Health Rider Benefit as a yearly premium. Those policies were issued after proper pathological test and examination by panel of doctors. Suddenly, in the month of June 2007, the Complainant suffered a stroke and the entire right half of the body got paralysed. Hence, the Complainant, submitted claim of Rs. 5,00,000 under each policy, before the HDFC Standard Life Insurance, under the Extra Health Rider Benefit and under Critical Illness. The OP repudiated the claim and declared both the policies as ''null and void''. OP offered only a surrender value for Rs. 1,62,612 under policy No. 10487172 and Rs. 1,52,125.78 under policy No. 10628082 vide its letter dated 17.1.2008.

THE Complainant made several correspondence with the OP, which did not yield any result. Hence, the repudiation of the claim of the Complainant was arbitrary. Complainant, at the time of taking policy, was not suffering from or was aware of Becker''s Muscular Dystrophy (BMD). Hence, the OP has committed deficiency in service. Hence, filed a complaint before the District Forum. The District Forum allowed the complaint and directed the OP to pay Rs. 5 lacs, under each policy, along with interest @ 9% p.a. and Rs. 1,500 as costs.

AGAINST the order of District Forum, the OP filed a First Appeal 1571/2010, which was allowed by the State Commission.

HENCE , aggrieved by the order of State Commission, the complainant preferred this revision. We have heard the Counsel for both the parties. Counsel for the complainant argued that the complainant was not suffering from BMD. He has drawn our attention to the discharge summary, Exhibit -1, which does not mention about BMD, hence, the complainant was not suffering from BMD, prior to taking of the policy. Whereas, rival arguments were advanced on behalf of OP. The Counsel drew our attention to Exhibit -R/7, in which it clearly mentions about the disease BMD. The Exhibit -7 was verified by Sh. V.C. Vyas, Manager Administration, whereas the Exhibit -1, produced by the Complainant, did bear any verification, but bears the signature of Resident doctor. Therefore, as per the Counsel for OP, the Ex -1, is a forged one, and not a genuine one. He further contended that in the instant matter, the Complainant had got done DNA Diagnostic Test, on 21.9.2004 and Muscle Biopsy Test on 29.11.2004. According to both tests, the Complainant was suffering from Becker''s Muscular Dystrophy and the same facts were concealed intentionally by the Complainant, under the proposal forms, dated 16.1.2006 and 5.6.2006 just to take undue advantage of OP and fraudulently obtained both the policies. Therefore, both the policies produced by the Complainant were declared null and Void legally and the claim asked under Critical Illness Benefit Claim was repudiated. Therefore, the repudiation is correct and there is no deficiency.

THE important question which swirls around is, which is the genuine document, either Exhibit 1 produced by the complainant or Exhibit -7 produced by the OP? We have requisitioned the original file from District Forum, also summoned Mr. V.C. Vyas, Manager (Administration), OP -1 for appearance before this Commission on 22.7.2014. We have perused the Exs -1, 2, 3 and Ex -7 available on record of file of District Forum. Exhibit -7 is a discharge summary which was issued by Mr. V.C. Vyas on which he appended his signature and affixed seal, while issuing it to the OP. On his appearance, before this Commission on 22.7.2014, we have verified his signatures.

TO arrive at a conclusion, we have collectively perused the three documents, the Ex -1, Ex -7 and Ex -3. (A) The Exhibit -3 is a Discharge Summary issued by Bombay Hospital and Medical Research Centre, Mumbai, which revealed that, the Complainant took treatment from Dr. B.S. Singhal, a Neurologist. The Complainant was admitted there from 27.6.2007 to 29.7.2007. The relevant notes in Exhibit -3 are as below:

Diagnosis: Left Hemiplegia/Right Basal Ganglia Haemorrhagic Infarct (Cardioembolic)

History and clinical findings:

A 27 year old gentleman was transferred from Rajasthan with h/o sudden onset L sided, weakness of 8 days duration. He had one month back h/o transient weakness with facial deviation on the L side that recovered in 24 hrs.

(B) Exhibit -R7 is a copy of Discharge Summary which was issued to the OP. It was issued to the OP, after 2 -3 months of discharge and certified by Mr. Vyas of Jaipur Hospital, some of its relevant part is reproduced as follows:

Final diagnosis: F/c muscular dystrophy? Becker''s Cardio embolic stroke -right basal ganglia Haemorrhagic infarct -left hemiplegia

Past History: Patient is a F/c muscular dystrophy clinically appearing to be Becker''s v. LGMD. Biopsy findings were consistent with muscular dystrophy. Dystrophinstaining was patchy and irregular. Genetic analysis did not show the deletions found in becker''s muscular dystrophy. No h/o HTN, DM. TB, Asthma

xx.......xx

Hospital Course: This 27 years old male, diagnosed case of muscular dystrophy with cardiomyopathy.

About 20 days back, he had facial deviation which recovered spontaneously in about 10 days.

xx...........xx

In the last portion, Ex -7 also shows that,

Investigation done outside (25.10.2006), Muscle biopsy on 29.11.2004 and DNA Diagnostic test (21.9.2004).

(C) Exhibit No. R -1: It is the Discharge Summery of Jaipur Hospital, which was issued at the time of discharge to the complainant on 26.7.2007. Some of its relevant part is reproduced as follows:

Final diagnosis: Cardio embolic stroke -right basal ganglia Haemorrhagic infarct -left hemiplegia.

Past history: No h/o HTN, DM. TB, Asthma

xx.......xx

Hospital Course: This 27 years old male, about 20 days back, he had facial deviation which recovered spontaneously in about 10 days.

xx.........xx

On careful analysis of the paras (A), (B) and (C) supra, it is very pertinent to note that, there is similarity between the Ex -1 and the Ex.3 whereas, Ex -7 is totally different. It is evident that there was deliberate attempt to insert few lines in Exhibit -7, so that, it will show that the patient was a case of Muscular Dystrophy..!!

FURTHER , it is very important to note that, in the both the Ex -1 and Ex -3, there is no mention of anything about investigation done outside, muscle biopsy and DNA Diagnostic test. The common medical practice is that, the discharge summary is issued at the time of discharge only, with the signature of concerned doctor or the duty doctor who makes all the entries as per records. While the 2nd discharge summary, the Ex -7 was obtained by OP, after long time, it was issued by Mr. Vyas, which reveals some additions in the Final diagnosis, past history, Investigation outside. Mr. Vyas, the then Manager (Admin) and Liaison of Jaipur Hospital, who has verified and put his seal and signatures. It is very surprising to note that, Mr. Vyas, a responsible officer of Jaipur Hospital did not mention the date or time of issue. Therefore, such document appears to be vague and issued with intention to help the Insurance Company. It can be created at any time. Hence, the discharge summary which was issued to the patient at the time of discharge, is a valid one. Another point is that the patient was referred to Bombay Hospital, the Neurologist Dr. B.S. Singhal also examined and treated the patient/complainant also did not mention anything about muscular dystrophy either in his findings or in the past history. We don''t think that a Super Specialist, like Dr. Singhal, a Senior Neurologist, will ever fail to diagnose muscular dystrophy in the complainant.

WE have searched through the web and from standard medical books on Neurology about the Muscular Dystrophy (MD). It is a genetic disorder, that weakens the muscles that help the body move. People with MD have incorrect or missing information in their genes, which prevents them from making the proteins they need for healthy muscles. Because MD is genetic, people are born with problem/MD weakens muscles over time, so children, teens, and adults who have the disease, can gradually lose the ability to do the things. Thus, it has no relevance with the Left Hemiplegia/Right Basal Ganglia Haemorrhagic Infarct, (Cardioembolic) which the complainant suffered. Therefore, on the basis of entirety of facts and in such circumstances, we are of considered view that the benefit of doubt should go to the complainant. The OP was wrong, who disbelieved the first discharge summary and repudiated the claim of the complainant. It is deficiency of service. Hence, we accept this Revision Petition and set aside the order passed by the State Commission and restore the order of the District Forum. Parties are directed to bear their own costs.