National Consumer Disputes Redressal Commission (NCDRC): Justice Ram Surat Ram Maurya (Presiding Member) upheld the decision of State Commission with regard to Mediclaim insurance policy being denied.
Present appeal was filed against the State Consumer Disputes Redressal Commission’s decision whereby the complaint was allowed, and appellant was directed to reimburse the medical claim of complainant with interest @6% per annum from the date of repudiation till the date of payment.
The deceased insured had obtained a Mediclaim insurance policy from Apollo Munich Health Insurance and further ported Mediclaim Insurance Policy to Star Health & Allied Insurance Company Ltd., which was valid till midnight of 26-2-2018. The policy was renewed the next day itself.
One morning, the deceased fell unconscious and was diagnosed with “Neuroleptic Malignant Syndrome due to Anti Psychotic Drug Sepsis”. Later he was diagnosed with “Neuroleptic Malignant Syndrome due to Anti Psychotic Drug Rhabdomyolysis Aki Ventilator Associated Trachetis”
On not being satisfied with the treatment, he asked the doctor for discharge and was admitted to another hospital on the same day. Due to no improvement in his condition, he was brought back home as the family was not in a condition to bear his medical expenses.
In the discharge papers of the initial hospital, the deceased was diagnosed to be suffering from “known case of Schizophrenia” to which the complainant protested but the doctor stated that it is the medical term for depression.
The insurance company repudiated the medical claim stating that the deceased while porting the policy did not disclose his disease as he was suffering from “Schizophrenia” for last 20 years, which was proved from Indoor case record submitted along with medical claim.
Complainant submitted that the deceased developed depression, after death of his mother on 02.11.2017. Prior to it, he was not suffering from any disease as such there was no concealment of the disease at the time of obtaining the policy. Repudiation of the claim was illegal.
State Commission stated that it was not noted that in the discharge papers of the Columbia Asia Hospital that “the patient was on mild medication for last 20 years” Further, it added that,
The disease Schizophrenia was developed after, obtaining Insurance Policy. In any case, this was a ported policy, in continuation of earlier policy which was obtained in 2013. As the claim was made of the treatment in September, 2019 as such exclusion clause of the policy was not applicable as 4 years had expired. On these findings, State Commission allowed the complaint.
Analysis, Law and Decision
Commission observed that the contract of Insurance is a contract of uberrima fides and non-disclosure of any material fact vitiates the policy.
Coram noted that the policies were obtained prior to the death of deceased’s mother and at that time he was not suffering from any disease. Apart from the handwritten letter of Dr Manjeet Nath Das, there was no evidence on record to prove that Vivek Khanna was suffering from any disease at the time of obtaining policy.
Indian Medical Council (Professional Conduct Etiquette and Ethics) Regulation, 2002, provides mandatory provision for the hospitals/ doctors to record/maintain Case Summary and Discharge Summary. Neither in Case Summary nor in Discharge Summary of Columbia Asia Hospital or of Sir Ganga Ram Hospital, this fact was noted that the patient was on mild medication, for last 20 years. This handwritten letter dated 17.09.2019 was contrary to the hospital record.
No person affidavit from the doctor concerned was placed hence no reliance on his letter was placed.
Section 45 of Insurance Act, 1938 provided two year limitation for questioning the policy on the ground of suppression/non-disclosure/misrepresentation of the fact at the time of obtaining policy. But the two years period was expired and for the first time on 4-11-2019 the same was questioned.
In view of the above, appeal was dismissed. [Star Health & Allied Insurance Co. Ltd. v. Vineet Khanna, First Appeal No. 383 of 2021, decided om 17-09-2021]
Advocates before the Commission:
For the Appellant: Mr S.M. Tripathi, Advocate
For Respondent-1: Mr Nikhlesh Jain, Authorised Representative
