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Judgment
Dr. Inder Jit Singh, Presiding Member
The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under Section 21(b) of Consumer Protection Act 1986, against the order dated 20.03.2017 of the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 178 of 2017 in which order dated 12.01.2017 of District Consumer Disputes Redressal Forum, Ferozepur (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 38/2016 was challenged, inter alia praying for setting aside the order dated 20.03.2017 passed by the State Commission in Appeal No. FA/178/2017.
While the Revision Petitioner (hereinafter also referred to as OP) was Appellant and the Respondents (hereinafter also referred to as Complainants) were Respondents in the said FA/178/2017 before the State Commission, the Revision Petitioner was OP and Respondents were complainants before the District Forum in the CC No. 38 of 2016. Notice was issued to the Respondents on 04.10.2017. Parties filed Written Arguments/Synopsis on 18.10.2021 (Petitioner) and 24.05.2023 (Respondents) respectively.
Brief facts of the case, as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that: -
(i) The insured/deceased (husband of Respondent No.1) obtained PNB Oriental Royal Mediclaim Policy by filling/signing a proposal form dated 21.10.2013. The signature of the insured in the proposal form confirmed that the insured have noted the contents of the prospectus. In view of the proposal, a PNB Oriental Royal Mediclaim Policy for an amount of Rs.5 Lacs was issued w.e.f. 31.10.2013 to 30.10.214 subject to conditions, clauses, warranties, endorsements. On 18.08.2014, the insured was admitted in Dayanand Medical College, Ludhiana with the problem of acute necrotizing pancreatitis with infected abdominal collection with Liver disease and was discharged on 06.09.2014 the hospital prepared a discharge summary stating the diagnosis as Peri-pancreatic Fluid Collection Cause Alcohol, ALD with Cirrhosis with Grade-1 along with mentioned history as Chronic Alcoholic x 20 years. On 09.11.2014, the third party administrator TPA Medi-Assist based upon the medical documents prepared its report with regard to the admissibility of the claim amount of Rs.3,01,439/- and stated that the insured was admitted at DMC hospital for treatment of AC Edematous Pancreatitis, DM, Peri-pancreatic Fluid Collection Cause alcohol, ALD with Cirrhosis Grade-I CTP on 18.08.2014 and charged on 06.09.2014. As per the documents submitted it is evident that the claimant is suffering from Alcoholic liver disease and therefore, the claim does not fall under the preview of the policy. The claim is being repudiated under exclusion-4.7 of the policy. The insured died on 22.11.2014. The Respondents being legal heirs of insured/deceased lodged the claim with the Petitioner for payment of the amount spent on his treatment. The Respondents filed complaint before the District Forum on 03.02.2016.
Vide Order dated 12.01.2017, in the CC No. 38 of 2016 the District Forum allowed the complaint with Rs.2,000/- as consolidated compensation for mental agony, pain and harassment. The OP was directed to pay Rs.3,01,439/- to the complainants as medi-claim as lodged by them with the OPs alongwith interest @9% per annum from the date of repudiation of claim i.e. 09.11.2014 till realization. The OP was also directed to pay Rs.3,000/- as litigation expenses. It was directed to comply with the order within a period of 30 days from the date of receipt copy of this order, failing which complainant shall be at liberty to get the order executed.
Aggrieved by the said Order dated 12.01.2017 of District Forum, Petitioner appealed in State Commission and the State Commission vide order dated 20.03.2017 in FA No.178 of 2017 has dismissed the appeal.
Petitioner has challenged the said Order dated 20.03.2017 of the State Commission mainly on following grounds:
i. Because the State Commission has duly noted that treating doctor has clearly stated in its discharge summary dated 06.09.2014 that the Peripancreatic Fluid Collection Cause is alcohol and the personal history of the insured was Chronic Alcoholic for the last 20 years. The State Commission has not examined the doctrine of proximate cause while rejecting the appeal.
ii. It is submitted that though the copy of the proposal form was not placed on record but the State Commission has failed to consider that the copy of prospectus was duly placed on record which clearly indicates and specifies the exclusion clause under the policy. The copy of the proposal form is now filed with the Revision Petition along with application, which duly specifies the signature of the proposer, and the same was duly singed by PNB Branch Manager at Ferozpur. The proposal form ;duly contains the authorization to PNB to debit the premium payable under the policy from the bank account of the insured with its PNB Branch Ferozpur. In view of the above facts, the District Forum has wrongly relied upon the submissions that the insured never filled the proposal form rather the agent just got signature of the blank proforma. It is submitted in case of PNB Oriental Roya Mediclaim Policy, which is only meant for the account holders/employees of Punjab National Bank, no agent is required for the same as the account holder himself proposed to the bank for obtaining the policy.
Heard counsels of both sides. Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below.
7.1 It is contended by the Petitioner that the State Commission has not considered the submission made by the Respondents that the policy terms and conditions were not supplied, therefore, these terms and conditions are not binding on the complainant as there is no evidence on the file to the effect that the conditions were ever supplied or brought into the knowledge of the insured at the time of insurance. The insured filed the proposal form dated 21.10.2013 and prospectus, which contains the relevant Terms and Conditions, therefore, the stand of the insured is not correct and not properly analyzed by the State Commission and District Forum.
7.2 In support of its contentions, the Petitioner has relied upon the judgment passed by the Hon’ble Supreme Court in Life Insurance Corporation of India Vs. Manish Gupta , Civil Appeal No. 3944 of 2019 decided on 15.04.2019, has dealt with the similar situation and held as under:-
“The District Forum held in favour of the Respondent. The NCDRC, while affirming the SCDRC, held that though the treating doctor had recorded, under the column of 'past history', that this was a known case of rheumatic heart disease since childhood, the doctor had not been examined in order to prove how the information had been recorded in his report. According to the NCDRC, the notes of the doctor did not indicate that it had been recorded on the basis of the information furnished by the patient. In this view of the matter, the decision of the District Forum, as affirmed by the SCDRC, has not been interfered with. …..”
“….The consumer fora have made a fundamental error in allowing the claim for reimbursement of medical expenses in the face of the uncontroverted material on record.
The documentary material indicates that there was a clear failure on the part of the respondent to disclose that he had suffered from rheumatic heart disease since childhood. The ground for repudiation was in terms of the exclusions contained in the policy…..”
7.3. The Petitioner further contended that the scope of cover, terms and conditions of the policy applicable to the present case are admissible and could be relied upon and interpreted in view of the judgment pronounced by the constitutional bench of the Hon’ble Supreme Court in case of General Assurance Society Ltd. Vs. Chandumull Jain and Anr. 1966 AIR 1644, 1966 SCR (3) 500 decided on 7 February, 1966, it was held that :
“Looking at the proposal, the letter of acceptance and the cover notes it was clear that a contract of insurance under the standard policy of fire and extended to cover flood, cyclone, etc., had come into being The fact that the policy was not actually delivered made no difference because when a contract of insurance is complete, it is immaterial whether the policy is actually delivered after the loss, and for the same reason the rights of the parties are governed by the policy to be, between acceptance and delivery of the policy. Even if no terms are specified the terms contained in a policy customarily issued in such a case, apply. In the present case the cover notes clearly said that the usual terms of the society's policies would apply. Condition (10) was a usual condition of such policies and therefore it could be invoked by the Society.”
7.4. It is also contended by the Petitioner that the State Commission failed to directly co-relate the admission of the patient before his Doctor, who had prepared the discharge summary based on the revelation made by the insured with regard to history of consumption of alcohol. There was also no other reasons specified by the treating doctor with regard to the cause of Liver Cirrhosis except the consumption of alcohol in its discharge summary. The finding of the State Commission that a discharge summary cannot be relied upon unless the doctor who recorded it, has been examined or his affidavit is tendered on record is not based upon the correct proposition of Law. The Respondent has itself submitted the discharge summary dated 06.09.2014 for processing of the Medi-claim. There was no such allegation made by the Respondents or any contrary evidence produced that the discharge summary prepared by the treating doctor of the hospital was not correct it its totality or with regard to recording of medical facts of the deceased, hence, same cannot be brushed aside. The insured entrusted his medical examination and treatment to the doctors of DMC hospital. The word ‘entrust’ would imply giving responsibility to a person upon whom the other has confidence. It envisages establishment of a relationship and discharge of such trust. Therefore, the finding arrived by such treating doctor with regard to the fact that the proximate cause was consumption of alcohol which has led to Liver Cirrhosis is caused due to the pre-existing condition and it is clearly an exclusion No. 4.7 under the policy that ‘diseases due to and/or use, misuse or abuse of alcohol or use of intoxicating substances or such abuse or addiction etc. is not covered under the policy’. It is also contended that the above Exclusion Clause is the Standard Clause enumerated in every similar Mediclaim Policy issued by the petitioner and in the present case, it is duly stated in the policy schedule that the terms and conditions of the policy are available on the Website of the Petitioner or Punjab National Bank.
7.5. On the other hand, it is contended by the Respondents that the findings of both the Fora are just, fair and passed in an equitable manner and hence should not be set aside. The Petitioner was unable to prove that the liver cirrhosis was caused due to use of alcohol. Moreover, there can be number or reasons of liver cirrhosis to which the petitioner could not deny. The terms and conditions of the policy were not brought into the knowledge of the deceased , hence they are not binding upon the respondents, so the petitioner cannot withhold the claim unless proved by the petitioner. The genuine claim of the respondents had been repudiated by the petitioner without any reasonable ground.
7.6. In support of their contentions, the Respondents have relied upon the judgment passed by the Hon’ble Apex Court in M/s Modern Insulators Ltd. Vs. The Oriental Insurance Company Ltd. 2000 (1) CPR 93 SC 242, wherein it was held that the clauses which are not explained to the complainants are not binding upon the insured and are required to be ignored. The Respondents also relied on the judgment passed by the Hon’ble Punjab & Haryana High Court in New India Assurance Company Ltd. Vs. Smt. Usha Yadav & Ors., 2008 (3) RCR (Civil) Page 111, it was held that it seems that insurance companies are only interested in earning premiums and find ways and means to decline the claims. The conditions, which are hidden need to be simplified so that these are easily understood by a person at the time of buying the policy. The insurance companies in such cases, rely upon the clauses of agreement which a person is generally made to sign on dotted lines at the time of obtaining a policy.
In this case OP/Insurance Company has repudiated the claim of Respondents on the ground that Deceased Life Assured (DLA) was suffering from Alcoholic Liver Disease and hence his claim fell under the exclusion clause 4.7. District Forum in its order observed that clause 4.7 of policy which was not explained to the insured is not binding upon the complainant. The motive of the insurance company is to repudiate the claim on every frivolous grounds. Clause 4.7 of the policy is reproduced below:-
"Convalesence, General debility, "run down" condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, and fertility sub fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases /accident due to and or use, misuse of abuse of drugs/alcohol or use of intoxicating substances or such abuse or addictions etc."
State Commission in its order has observed “………counsel for the appellant could not convince that Liver problem was on account of the insured being alcoholic. It was put to him that there can be number of reasons of liver cirrhosis, to which he could not deny. He could not produce any medical literature to prove that liver cirrhosis was only instinctive with the use of Alcohol.…….”. The State Commission further observed that:
“……The proposal form, which is basis for issuance of the policy, has not been placed on record to explain that the policy's terms and conditions were explained to the insured. In case the policy's terms and conditions have not been explained then these are not binding upon the complainant as held by Hon'ble Supreme Court of India in case, 2000 (1) CPR 93 (Supreme Court) 242 titled as "M/s Modern Insulators Ltd. Vs. The Oriental Insurance Company Ltd.", that Clause which was not explained to the insured is not binding upon the insured. Further the policy is for the period of 31.10.2013 to 30.10.2014 and the treatment period is 18.8.2014 to 6.9.2014, in case as per the observation made by the Hospital in his discharge summary that insured was a known case of DM and was medication from 15 years and OP failed to place on record any documents to show that he was taking medicines for the last 15 years from the DMC, Ludhiana as alleged by them……… There is no evidence that policy's terms and conditions were explained to the insured at the time of taking the policy because proposal form has not been placed on record and no evidence that policy's terms and conditions alongwith proposal form were dispatched to the complainant. In these circumstances, the observations of the District Forum are correct that the insurance companies take shelter of their exclusion clauses and normally go for repudiation of the claim of frivolous grounds.”
The Petitioner/Insurance Company has admitted that proposal form was not placed on record before the District Forum/State Commission, which has now been filed with the Revision Petition. Even if we accept the contention of the Petitioner that State Commission’s observations that discharge summary cannot be relied upon unless the doctor who recorded it has been examined or his affidavit is tendered on record are not correct, we are of the view that State Commission has given valid reasons for not accepting the contentions that liver problem was on account of the insured being alcoholic as there could be number of reasons of liver cirrhosis.
We have carefully gone through the orders of the State Commission, District Forum, other relevant records, case laws relied upon and rival contentions of the parties. The judgment of Hon’ble Supreme Court in Branch Manager, Bajaj Allianz Life Insurance Co. Ltd. and Ors. vs. Dalbir Kaur, Appeal No 3397 of 2020 decided on 09.10.2020, relied upon by the Petitioner is distinguishable on facts. In this case there was a material suppression of facts about the pre-existing ailments, which was established by medical records obtained during the course of investigation. In fact, the deceased was hospitalised to undergo treatment for such a condition in proximity to the date of his death, which was also not disclosed in spite of specific queries relating to ailments, hospitalisation or treatment undergone by the proposer in the policy proposal form. Similarly, in the other case laws relied upon by the Petitioner, which are also referred to in the Dalbir Kaur (Supra), Life Insurance Corporation of India Vs. Asha Goel (2001) 2 SCC 160, Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. (2009) 8 SCC 316, the issues pertained to suppression of material facts in the proposal form. In the present case, claim has been repudiated on account of it falling in the exclusion clause 4.7 of the policy. State Commission has appropriately addressed this issue in its order, we tend to agree with the State Commission in this regard and find no reason to interfere with the finding of State Commission in this regard. Both the fora below have given concurrent findings about the admissibility of the claim. As was held by Hon’ble Supreme Court in Rubi Chandra Dutta Vs. United India Insurance Co. Ltd. [(2011) 11 SCC 269], the scope in a Revision Petition is limited. Such powers can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order. In Sunil Kumar Maity Vs. State Bank of India & Ors. [AIR (2022) SC 577] held that “the revisional jurisdiction of the National Commission under Section 21(b) of the said Act is extremely limited. It should be exercised only in case as contemplated within the parameters specified in the said provision, namely when it appears to the National Commission that the State Commission had exercised a jurisdiction not vested in it by law, or had failed to exercise jurisdiction so vested, or had acted in the exercise of its jurisdiction illegally or with material irregularity.” We find no illegality or material irregularity or jurisdictional error in the order of the State Commission. Hence, the same is upheld. Accordingly, the Revision Petition is dismissed.
The pending IAs in the case, if any, also stand disposed off.