National Insurance Co. Ltd vs Kawaljit Singh

The present Revision Petition, under Section 21(b) of the Consumer Protection Act, 1986 (for short "the Act") has been filed by the Opposite Parties in the Complaint, against the order dated 24.04.2017, passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (for short "the State Commission") in Appeal No.712 of 2016.

It is argued that the petitioner does not dispute its liability to pay to the insured, the amount under the policy. It only disputes its liability to the extent that it is liable to pay only 50% of the insured sum and not 100% of the insured amount. It is submitted that in this case the insured was suffering with a pre-existing disease, which is abundantly clear from his discharge summary of the year 2009-2010. It is submitted that medical record of Master Jasnoor Singh clearly shows that he was admitted in PGI Chandigarh from December 2009 to April 2010 and the treatment was also obtained from PGI Chandigarh from 24.05.2014 to 19.07.2014 for the same disease.

It is further submitted that al-though this fact is admitted by the District Forum and, accordingly, in terms of the policy, District Forum had awarded 50% of the insured sum. The State Commission in the impugned order has totally ignored the said fact and on the basis of conjectures and surmises granted 100% of the insured sum to the insured. It is submitted that said order is liable to be set aside as it totally ignores the fact which stand proved on record. It is submitted that petitioner does not dispute its liability to pay under the relevant policy.

Notice of the revision petition was issued to the respondent. Counsel for the respondent has not disputed the fact that insured master Jasnoor Singh had underwent treatments for the same disease, for which insurance claim has been made, in the year 2009-2010. As regards to this fact, the District Forum has held as under:

""There is no dispute between the parties regarding admission of Master Jasnoor Singh son of complainant Kawaljit Singh in the hospital for treatment".

Despite the aforesaid finding of fact, the State Commission has opined as under:

"We are of the opinion that normally the disease as suffered by the complainant's son cannot be taken as pre-existing disease as some ailments can spend decades lurking in the body of an individual until they suddenly spring up in life. Many persons have diseases that one is having without his knowing. The diseases remain dormant in the body for years. Some illnesses have incubation period of anywhere from years to decades. Some diseases wait in body for decades before striking. As per certificate given by the doctor no date for his pre-existing disease suffered by the complainant's son was given. There is no mention that his son was suffering from pre-existing disease. As per the discharge summary, there is only mention that Symptomatic since May 2009."

It is apparent that based on its opinion, the State Commission had upset the findings of fact which was based on the admitted facts. Even otherwise, the document showing the treatment of Master Jasnoor Singh clearly states that disease was symptomatic in the year 2009. Therefore, it is apparent that disease, for which claim has been sought, had manifested itself in the year 2009 and, therefore, findings of the State Commission is clearly based on its personal view, conjectures and surmises and, thus, patently illegal and perverse. Findings of the State Commission to the effect that disease had manifested in the year 2009 and was lurking inside is not based on any medical opinion or any document on record. These findings are, therefore, set aside.

Since the insured was suffering from pre-existing disease for which claim has been made in terms of the insurance contract, he is entitled to 50% of the insured sum. The order of the District Forum to this effect is hereby upheld.

Revision Petition stands disposed of, with no order as to costs.