National Insurance Co. Ltd. vs MUKESH BHARGAVA

CLAIM of the respondent against medi-claim policy for a sum of Rs. 1,00,000 could not be settled by the appellant for want of documents required to be furnished by the respondent as the appellant doubted the correctness of the statement given by the respondent at the time of taking the policy as to the pre-existing disease.

HOWEVER, vide impugned order dated 31.10.2001, the District Forum has directed the appellant to pay the insured amount of Rs. 1,00,000 along with interest @ 9% and Rs. 1,000 as cost of litigation. Feeling aggrieved the appellant has preferred this appeal.

The case of the respondent before the District Forum was that he had a medi-claim policy obtained from the appellant for a sum of Rs. 1,00,000 and the same was valid w.e.f. 27.8.2000 to 26.8.2001. On 15.10.2000 when he was travelling in a train from Madras to Bangalore he felt pain in the chest although he had no previous history of such type of ailment. He got himself examined in Bangalore at Wockhardt Hospital and Heart Institute. He remained admitted in the said hospital from 15.10.2000 to 21.10.2000 and he made payment of Rs. 22,995.50. On return to Delhi on 22.10.2000 he was admitted to Malhotra Heart Institute, Lajpat Nagar, New Delhi for open heart surgery and operation was performed on 28.10.2000. He remained admitted in the said hospital from 22.10.2000 to 4.11.2000 and he made payment of Rs. 2,02,313 at the said hospital. Respondent filed a claim with the appellant on 22.1.2001 but on one excuse or the other his claim was not finalised.

STAND of the appellant before District Forum was that the claim was referred to Dr. A.K. Batra for investigation and assessment of the claim and Dr. A.K. Batra required some additional documents before giving his opinion and respondent was asked to file those documents and information and since he failed to give necessary information his claim could not be settled. Furthermore, the respondent had withheld information regarding pre-existing disease as he had told the doctor that he had been suffering from breathlessness for many years though he was never hospitalised or diagnosed as a heart patient or undergone any operation. In medical terminology such a disease was referred as "Dyslipidemia". We have taken a view that unless the patient or insured is hospitalised or undergoes an operation for some particular disease but otherwise leads a normal and healthy life is not supposed to disclose the factum of normal and day-to-day minor problems of life. In such type of cases where the patient suffers sudden heart attack without any past history of having suffered any disease, being hospitalised or operated upon, he is neither supposed nor expected to know as to the medical terminology of the disease like problem of breathlessness. The contention of the Counsel for the appellant that in the opinion of doctor of the appellant that the above referred disease is not detected unless the Lipid Profile Test is done and since the respondent has failed to produce the report of the Lipid Profile Test he cannot avail the benefit. Even if it is so it was not the ground for repudiation of the claim though the respondent has produced the document showing Lipid Profile Test conducted upon him.

IN view of the foregoing reasons we do not find any infirmity so far the direction to pay Rs. 1,00,000 towards insured amount is concerned but substitute the rate of interest by way of lumpsum compensation of Rs. 15,000 which shall include the cost of litigation, as in such type of cases the interest is not awardable as Hon''ble Supreme Court has taken view in Sovintorg (INdia) Ltd. v. State Bank of INdia, New Delhi, II (1999) CPJ 4 (SC)=VI (1999) SLT 545=(1999) 6 SCC 406, that unless and until there is contract between the parties as to the payment of interest or there are strong equitable grounds, interest is not awardable under the provision of Consumer Protection Act, 1986. IN terms of Section 14 of the Consumer Protection Act, 1986 a consumer is entitled to amount of compensation as to the loss or injury suffered by him due to negligence on the part of the O.P. The appeal is disposed of in above terms. Bank Guarantee/FDR, if any, furnished by the appellant be returned forthwith. A copy of this order as per the statutory requirements be forwarded to the parties free of charge and also to the concerned District Forum and thereafter the file be consigned to Record Room. Appeal disposed of.