1. In this case Shri Raj Narain had obtained a medi-claim policy from the National Insurance Company for one year from 7th June, 1999. While he was in Bareilly, Uttar Pradesh, after three days of taking the policy he fell sick and he consulted Dr. O.P. Aggarwal and on his advice he under went comprehensive medical checkup. In the third week of June, 1999 he consulted Dr. Vijay Kumar Kohli who referred him to Malhotra Heart Institute wherein he was admitted on 22nd June, 1999 and underwent a heart surgery on 24th June, 1999. He was discharged on 5th July, 1999. He submitted a claim form, claiming Rs. 1,61,612 through his letter dated 22nd July, 1999. The Insurance Company rejected the claim of the petitioner by taking a plea that it was a pre-existing disease. They had appointed Dr. A.K. Batra for investigation into the case. Dr. Batra opined that the petitioner had a pre-existing disease which was not revealed by him while taking the insurance policy. As the Insurance Company had repudiated the claim he filed a complaint before the District Forum claiming Rs. 1,82,968 along with interest @ 24% per annum and compensation of Rs. 5,000.
2. The District Forum after hearing the parties and going through the records of the case held that the complainant was neither aware of any exclusion clause nor he was supplied with the terms and conditions of the policy at the time of issuing cover note. Secondly, the Insurance Company had failed to establish that the complainant was having a heart disease prior to taking the policy. Lastly, the Insurance Company was deficient in service for not settling the claim of the complainant. Accordingly, the Insurance Company was directed to settle the medi-claim of the complainant within 60 days from the receipt of the order and pay interest at the rate of 10% per annum on the claimed amount with effect from 90 days after filing of the complaint till its realization.
3. Dissatisfied by the order of the District Forum, the Insurance Company had filed an appeal before the State Commission. The State Commission after hearing the Counsel for the parties dismissed the appeal.
4. Aggrieved by the order of the State Commission, the Insurance Company has filed this revision petition. Learned Counsel for the petitioner submitted that within three days of taking the policy, the complainant felt pain in his chest and went for a check-up and three weeks later he underwent a heart surgery and hence, it is a clear case of concealing the preexisting disease. The terms of the policy clearly stipulate that if the insured person undergoes treatment including hospitalization and surgical treatment for a pre-existing disease, the Insurance Company is not liable to pay compensation according to the learned Counsel. The Investigator Dr. A.K. Batra has given a clear report in support of his contention that it was a pre-existing disease. On the other hand, the learned Counsel who is appearing for the Caveator has submitted that there was a delay of 75 days in filing this revision petition for which no convincing reasons had been given. He also submitted that the insured was neither aware of the medical problem when the policy was taken nor was he aware of the terms and conditions of the policy.
5. Though Dr. Batra has given his report as an investigator he has not filed any affidavit. Further no affidavit of Dr. O.P. Aggarwal who has initially treated the insured prior to the hospitalization has been filed before us. It is also not disputed that the policy document which includes the terms and conditions of the policy was not given to the insured prior to the surgery. That there is a delay of 75 days is not disputed. Condonation application indicates that the order of the State Commission was passed on 29th March, 2007 and the certified copy of order, was receivedby them only on 8th May, 2007. Para 22 of the State Commission's order reads as follows:
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.
Announced on the 29th March, 2007.
6. The judgment was pronounced on 29th March, 2007 and the copy of the order was despatched free of cost to the parties and the Insurance Company has an office at Delhi. We do not know why the Insurance Company has not obtained a certified copy of the order earlier. Secondly, a certified copy of the State Commission's order was received by the Regional Office of the Insurance Company only on 8th May, 2007 and after a month the file was sent to their panel's advocate for receiving opinion. It is also stated in the application for condonation of delay that the certified copy of the order was misplaced and despite best efforts the same could not be traced and the same was traced only on 23rd August, 2007. Thereafter, they drafted the revision petition and they have requested for condonation of 120 days of delay in filing this revision petition. The reasons given by the Insurance Company are not convincing.
Insurance Company has not filed any documents of the hospital/clinic showing that the patient was having any pre-existing disease.
7. In Revision Petition No. 1696 of 2005, Praveen Datnani v. Oriental Insurance Co. Ltd. IV (2006) CPJ 189 (NC), this Commission has held that:
The District Forum also relied on Clause 4.1 of the policy which states that it is not material whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the Insurance Company to disown the liability.
If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bona fide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc., prior to 11th August, 2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the complainant that he was thoroughly checked up by the Doctors who were nominated by the Insurance Company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.
In view of the above discussion and from the records available before us, in our opinion, the complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed.
8. Ratio of this case is applicable to a great extent to this case on hand. Accordingly, we do not see any reasons to interfere with the concurrent decisions of the lower Fora. Therefore the Revision Petition is dismissed. There shall be no order as to costs.