M. OBAIDUR RAHMAN Vs. NATIONAL INSURANCE CO. LTD.

JUDGEMENT

(1.) This Revision Petition, under Section 21(b) of the Consumer Protection Act, 1986, (for short, the "Act") has been filed by the Complainant challenging the order, dated 20.10.2009, passed by the Tamil Nadu State Consumer Disputes Redressal Commission at Chennai (for short "the State Commission") in A.P. No. 221 of 2004. By the impugned order, the State Commission, while accepting the plea of the Respondent Insurance Company to the effect that at the time of submitting proposal for Mediclaim Policy, the Complainant had suppressed the facts relating to a pre-existing disease and its treatment and there was no deficiency in service on the part of the Insurance Company in repudiating the claim preferred under the Policy, has overturned the order, dated 05.12.2003, passed by the District Consumer Disputes Redressal Forum, Chennai North (for short "the District Forum") in Complaint No.83 of 2002 and dismissed the Complaint. In turn, the District Forum, while allowing the Complaint, had directed the Insurance Company to pay to the Complainant a sum of Rs. 2,07,461/- towards reimbursement of the medical bills along with Rs. 10,000/- as compensation for mental and financial strain and Rs. 1000/- as litigation expenses.

(2.) The material facts giving rise to the present Revision Petition, as culled out from the Complaint, are: that the Complainant took a Mediclaim Insurance Policy by paying a sum of Rs. 12,432/- as premium. The policy was valid from 07.09.2000 to 06.09.2001 and covered the Complainant, his wife and four children. While the insured amount in respect of the Complainant and his wife was Rs. 3,00,000/- each, in respect of his four children, it was Rs. 1,50,000/- each. During the validity period of the policy, the Complainant was admitted in the Apollo Hospital, Chennai on 22.06.2001 and was discharged on 25.06.2001 with the diagnosis: Coronary Artery disease (two vessel disease); old Inferior Wall Myocardial Infarction (IWMI), Angina Pectoris, systemic hypertension etc. He was again admitted in Apollo Hospital on 29.06.2001 and underwent cardiopulmonary Bypass on 02.07.2001 and was discharged on 10.07.2001. For the said treatments, he incurred medical expenses amounting to Rs. 30,316.44 and Rs. 1,77,414.75. On 26.06.2001 and 19.07.2001, the Complainant lodged two claims with the Insurance Company for reimbursement of the afore-stated sums. However, the Insurance Company, vide its letters dated 13.07.2001 and 23.08.2001 intimated the Complainant that the claims were not payable since the disease mentioned in the Discharge Summary was pre-existing one. According to the Insurance Company, from the hospital record, primarily, the Discharge Summary furnished by the Complainant in support of his claims, it was evident that the claims were related to the treatment of "pre-existing disease/ailment", but this fact was not disclosed by the Complainant at the time of taking the policy in question and therefore, the claims, being excluded under the policy in question, were not payable.

(3.) Being aggrieved, the Complainant filed complaint in the District Forum. Contesting the allegation of suppression of pre-existing disease, it was pleaded that he had taken the policy in question in September, 2000 and as per the Discharge Summary, issued by the Apollo Hospital, dated 25.06.2001, Coronary Artery Disease and old Inferior Wall Myocardial Infarction (IWMI), for which he was advised to undergo CABG surgery on 02.07.2001, was detected much after his obtaining the policy. Inter-alia, contending that the Insurance Company has rejected the claims, without application of mind, he prayed for a direction to the Insurance Company to pay: (i) Rs. 2,07,461/- towards medical expenses; (ii) Rs. 1,00,000/- as compensation for deficiency in service; (iii) Rs. 1,00,000/- as damages for the resultant mental agony and pain; and (iv) costs of the Complaint.