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New India Assurance Co. Ltd. v. Murari Lal Bhusri
Concise Structured Summary of the Opinion (V.B. Gupta, Presiding Member)
Factual and Procedural Background
This revision challenges the order dated 10 October 2006 passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (the "State Commission"), which dismissed an appeal filed by the petitioner challenging the order dated 15 November 2000 passed by the District Consumer Disputes Redressal Forum, Ferozepur (the "District Forum").
The respondent had taken a series of medi-claim policies from 28.6.1993 onward (policies listed up to the 5th policy covering 06.8.97 to 05.8.98). The respondent underwent coronary artery bypass grafting (CABG) on 14 February 1998 at Escorts Heart Institute & Research Centre, New Delhi, and submitted a claim of Rs. 1,71,350/- for treatment expenses.
The petitioner (insurance company) repudiated the claim on the ground that the disease was pre-existing at the time the policy (or earlier policies) were taken. The District Forum allowed the complaint on 15 November 2000, directing the petitioner to pay Rs. 1,71,350/- with interest at 18% per annum from the filing of the complaint (30 November 1999) until realization, and Rs. 500 as litigation cost. The State Commission affirmed the District Forum's findings; the present revisional petition followed.
Legal Issues Presented
- Whether the insurer was justified in repudiating the claim on the ground of a pre-existing disease.
- Whether the policies constituted a continuous series (in particular whether the 5th policy of 6 August 1997 should be treated as continuous with the 4th policy that ended 31 July 1997), and the legal consequence of any alleged break in continuity.
- Whether there was suppression of material facts by the insured that would disentitle him to the claim.
Arguments of the Parties
Petitioner's (Insurer's) Arguments
- The insurance policy excludes liability for expenses arising from pre-existing diseases; therefore the claim must be repudiated.
- The discharge summary indicates the respondent had coronary heart disease for the last six years and had undergone CART (angiography) five years prior, revealing double-vessel disease; on this basis the disease pre-existed the relevant policy period and the claim should be denied.
- There was an admitted gap of 35 days in issuance of the policy for the fourth year; that gap amounts to treatment of subsequent policy as a fresh policy, which would defeat the claim.
Respondent's Arguments
- The impugned order of the State Commission contains no illegality; the District Forum's findings are valid.
- Evidence produced by the petitioner included testimony of Dr. Dinesh Dhir, who admitted on cross-examination that he never examined the respondent and that his opinion was based on experience and the case history from Escorts Hospital; this undermines the petitioner's proof that the condition was pre-existing.
Table of Precedents Cited
| Precedent | Rule or Principle Cited For | Application by the Court |
|---|---|---|
| Narsingh Singh through LRs v. Shanti Devi through Lrs, 2010 (115) DRJ 601 (Delhi High Court) | Under Article 227, concurrent findings of fact by two courts below should not be disturbed except in exceptional cases (where below courts did not exercise jurisdiction, acted beyond jurisdiction, or ignored well-settled law). | The Court relied on this principle to justify non-interference with the concurrent findings of the District Forum and the State Commission absent any jurisdictional error or disregard of law. |
| Mudigonda Chandra Mouli Sastry v. Bhimanepalli Bikshalu, (1999) 7 SCC 66 : AIR 1999 (SC) 3095 | The High Court exercising revisional jurisdiction must not reassess evidence and interfere with findings of facts recorded by two courts below. | Reiterated the Court's approach of not reappraising evidence and supporting the principle that revisional jurisdiction is limited and should not be used to re-evaluate factual findings. |
| Rubi (Chandra) Dutta v. United India Insurance Co., 2011 (3) Scale 654 | The revisional powers of the National Commission (under Section 21(b) of the Act) can be exercised only where a prima facie jurisdictional error appears in the impugned order. | The Court invoked this precedent to observe that there was no jurisdictional error or miscarriage of justice warranting interference with the concurrent findings of the two fora below. |
Court's Reasoning and Analysis
The Court followed a stepwise analysis that adhered closely to the record and to principles limiting revisional interference:
- Policy continuity: The Court noted that treatment occurred during the subsistence of the fifth policy (6 August 1997 to 5 August 1998) which, by the insurer's own rules and admission of counsel, would be treated as continuous with the fourth policy that ended on 31 July 1997. The fifth policy was obtained within one week of expiry of the fourth policy.
- Burden to show pre-existence prior to relevant date: The Court observed that even if a break in continuity were assumed, the insurer could prevail only by proving that the disease existed prior to 1 August 1996 (i.e., prior to the relevant continuous policy period).
- Examination of medical evidence: The Court examined the discharge summary(s). The discharge summary referred to CART five years earlier revealing double-vessel disease and referred to the patient having angina on exertion for the last one month (in one version) and, elsewhere, angina on exertion for the last six years. However, the Court emphasised that there was nothing on record to show that the disease for which treatment (CABG on 14-02-1998) was taken was the same disease demonstrably existing prior to taking the policy.
- Legal distinction and evidentiary sufficiency: The Court used an illustrative analogy (a prior eye disease and a later cataract operation) to explain that not all prior ailments automatically bar a later, distinct insured claim; to repudiate a claim, the insurer must show the specific disease treated was pre-existing and known at the time of taking the policy. The Court concluded that even if angina in common parlance might be regarded as a heart disease, that would not necessarily equate to the triple-vessel disease for which the respondent underwent surgery.
- Credibility of insurer's medical evidence: The Court relied on the fact that the petitioner's medical witness admitted he had not examined the respondent and gave an opinion based on case history, weakening the insurer's case that there was knowledge or suppression by the insured.
- Concurrent findings and revisional limits: The Court applied the cited precedents (Narsingh Singh; Mudigonda; Rubi Dutta) to hold that two fora below had given detailed, reasoned, concurrent findings which did not demonstrate jurisdictional error or such infirmity as to justify revisional interference. The Court therefore deferred to those findings.
Holding and Implications
Holding: The revisional petition is dismissed.
Implications:
- Direct effect on the parties: The Court affirmed the concurrent findings of the District Forum and the State Commission. The District Forum's order directing the insurer to pay Rs. 1,71,350/- with interest @ 18% p.a. from 30 November 1999 till realization and Rs. 500 as litigation cost stands as affirmed by the fora below. The Court ordered that parties shall bear their own costs.
- On precedent and broader law: The Court expressly relied on established principles limiting revisional jurisdiction and did not lay down any new legal principle. The decision is an affirmation of non-interference with concurrent factual findings in absence of jurisdictional error.
This summary is based exclusively on the content of the provided opinion and does not add, infer, or extrapolate facts beyond the opinion's text.
V.B Gupta, Presiding Member:— In this revision there is a challenge to the order dated 10 October, 2006 passed by the State Consumer Disputes Redressal Commission, Punjab, Chandigarh (For short ‘State Commission’). State Commission vide impugned order, dismissed the appeal filed by the petitioner challenging order dated 15 November, 2006 passed by District Consumer Disputes Redressal Forum, Ferozepur (for short “District Forum”).
2. Brief facts are that respondent had been taking medi-claim policies right from the year 1993, details of which are as under:—
Sr. No. Policy No. Risk Period Insurers 1. 48/01738 28.6.93 to 26.6.94 B.O Fazilka 2. 48/02005 25.6.94 to 24.6.95 -do- 3. 48/02296 27.6.95 to 26.6.96 -do- 4. 48/02671 01.8.96 to 31.7.97 -do- 5. 48/03025 06.8.97 to 05.8.98 -do-
3. Respondent underwent bye-pass surgery in Escorts Heart Institute & Research Centre, New Delhi on 14 of February, 1998. In the discharge summary issued by Escorts Hospital, it was mentioned that CART was done on 31-01-1998 and it was found that there was a triple vessel disease EF 50%. Ultimately, bye-pass surgery was done and respondent submitted a claim for the sum of Rs. 1,71,350/- as amount spent on his treatment.
4. This was repudiated by the petitioner, on the ground that the disease for which the treatment was done was pre-existing at the time the insurance policy was taken.
5. District Forum vide order dated 15 November, 2000, allowed the complaint with cost directing the petitioner to pay Rs. 1,71,350/- with interest @ 18% p.a from filing of the present complaint i.e 30 November, 1999 till realization and also to pay Rs. 500 as cost of litigation to the respondent within one month from the date of receipt of the copy of the order.
6. It is argued by learned counsel for the petitioner that as per the insurance policy, the company is not liable to make any payment under this policy in respect of any expenses incurred by the insurer for those diseases which are pre existing.
7. The other contention is that in the discharge summary of Escorts Hospital, it is clearly mentioned that respondent was suffering from coronary heart disease for the last six years and has undergone CART (Angiography) five years back which revealed DVD (Double Vessel Disease) and as such the impugned order is liable to be set aside.
8. It is also contended that admittedly there was a gap of 35 days in issuance of the policy for the fourth year, which has been treated as a fresh policy. As such petitioner is not entitled to any claim and impugned order is liable to be set aside.
9. On the other hand, it is contended by learned counsel for the respondent that there is no illegality in the impugned order passed by the State Commission. Petitioner, has examined Dr. Dinesh Dhir as their witness who in his cross examination has stated that he never examined the respondent/complainant till date and he never asked the petitioner to produce the patient/complainant for examination before submission of the report. Further, as per statement of this doctor, he has given opinion only on the basis of his experience as well as case history of Escort Hospital.
10. District Forum in its order, observed:—
“It is admitted case of the opposite party that the complainant got insured himself with the opposite party since 28-06-93. If the complainant was suffering from heart disease then why the opposite party issued mediclaim policies to the complainant. In our view if a person has knowledge that he is suffering from heart disease, he cannot take risk of his life for a long period for taking benefit of insurance policy. In the circumstances of the case it is clear that the complainant was not suffering from any heart disease prior to taking the mediclaim policy in question and he has not concealed any fact from the opposite party regarding his heart problem. As such he is entitled to the amount which was incurred by him for his treatment. No receipt/bill/ticket has been produced by the complainant to prove that he spent Rs. 4000/- as traveling expenses from Fazilka to New Delhi for his treatment. As such the complainant is not entitled to claim the same from the opposite party. The opposite party has illegally repudiated the claim of the complainant and deprived the complainant from the use of the amount of claim for which the opposite party is liable to pay interest on the delayed payment. The complainant has to file the present complaint in order to get the amount of claim from the opposite party. As such he is also entitled to costs of litigation.”
11. State Commission concurred with the findings of District Forum and observed:—
“However, the facts reveal, which have been enumerated above, that the medical treatment was taken during the subsistence of the fifth policy, which was taken on 6th of August, 1997 and was a continuous policy after the fourth policy had come to an end on 31st of July, 1997. The 5th policy was taken within one week of the expiry of the 4th policy. This is not being disputed by the learned counsel for the appellant that the 5th policy under the rules and regulations of the Insurance co. would be taken a continuous policy of the 4th policy.
Even if we assume that there is a break in the policy i.e 3rd and 4th then the appellant might succeed if he can show that the disease for which the treatment was taken existed prior to 1-8-1996.
Let us examine the evidence on the record which, according to the learned counsel for the appellant, is a pointer that the complainant had the disease prior to 1-08-1996 for which he took treatment after getting admitted on 31-01-1998 (the operation was done on 14-02-1998). Learned counsel for the appellant referred to the discharge summary of the Escorts Hospital in the resume of history. It was mentioned as under:—
RESUME OF HISTORY”
Mr. Murari Lal Bhusri is a 62 years old pleasant gentleman who is hypertensive, diabetic, nonsmoker and has no family history of ischaemic heart disease. He underwent CART 5 years ago, which revealed DVD with normal LV function. Now for the last one month he has been having retrosternal burning sensation upon exertion, relieved by taking rest. No h/o CVA/TIA/Allergy in the past. He was admitted to this hospital for coronary angiography
This resume, according to the learned counsel for the appellant, shows that 5 years ago the complainant had undergone CART, which revealed DVD with normal LV function. Therefore, the counsel argued that the complainant had the disease for which he took the treatment on 14th of February, 1998. It's further mentioned that the complainant had been having angina on exertion for the one moth. There is no history of myocardial action in the past. This was written after discharge on 20-02-1998.
The question that arises for our consideration is: are the diseases, which have been mentioned above are the same for which the treatment was taken? Take for instance a person is having a particular disease in the eye prior to taking of the policy. After taking the policy he undergoes a cataract operation, can the claim be repudiated on the ground that the complainant had some eye disease prior to the taking of the policy and therefore, nothing is reimbursable so far as cataract operation is concerned. According to us, if it can be proved that the cataract was prior to the taking of the policy, perhaps, the claim can be repudiated. There is nothing on the record to show us that the disease for which the treatment was taken on 14-02-1998 the complainant was suffering from the same disease prior to the taking of the policy. Though in common parlance one may say that angina is not a disease but even if it is to be taken a disease of heart, it cannot certainly be said to be triple vessel disease for which treatment was undertaken by the complainant. In these circumstances, leaning towards the consumer, we will hold that the Insurance Co. was not legally right in repudiating the claim of the complainant. We agree with the approach of the District Forum when it allowed the complaint as aforesaid.”
12. As per record, Coronary artery bypass grafting of the respondent was done on 14 February, 1998. Relevant portion of discharge summary dated 20 February, 1998 of Escorts Heart Institute reads as under:—
“Mr. Bhusri is a 62 year old gentleman who is known hypertensive, known diabetic, case of coronary artery disease with pleasing personality. He had been having angina on exertion for the last 6 years. There is no history of myocardial infarction in the past. He was advised further investigation.”
13. As apparent from the above discharge summary, there is no history of myocardial infarction in the past and respondent was advised further investigation. Thus, there is no evidence on record to show that respondent was aware of any pre-existing disease at the time when the insurance policy was taken and accordingly there is no suppression of material facts.
14. In Narsingh Singh through LRs v. Shanti Devi through Lrs, 2010 (115) DRJ 601. Delhi High Court observed;
“It is well settled that where two Courts below have given a concurrent findings of facts, this Court under Article 227 of the Constitution of India shall not disturb the findings even if there is some mistake committed in appreciation of some part of evidence. Under Article 227, this Court does not correct the mistakes of law or mistakes of facts. The intervention of the this Court under Article 227 has to be only in those exceptional cases where the fora below had either not exercised their jurisdiction or had acted beyond jurisdiction or had ignored the well-settled legal proposition and acted contrary to law.”
15. Supreme Court in Mudigonda Chandra Mouli Sastry v. Bhimanepalli Bikshalu, ((1999) 7 SCC 66 : AIR 1999 (SC) 3095) observed;
“It was also not open to the High Court in exercise of its revisional jurisdiction to have indulged in a reassessment of evidence and thereby interfered with the finding of the facts recorded by the two Courts below.”
16. Recently, Supreme Court in Rubi (Chandra) Dutta v. United India Insurance Co., 2011 (3) Scale 654 observed that;
“Also, it is to be noted that the revisional powers of the National Commission are derived from Section 21(b) of the Act, under which the said power can be exercised only if there is some prima facie jurisdictional error appearing in the impugned order, and only then, may the same be set aside. In our considered opinion there was no jurisdictional error or miscarriage of justice, which could have warranted the National Commission to have taken a different view that what was taken by the two Forums. The decision of the National Commission rests not on the basis of some legal principle that was ignored by the Courts below, but on a different (and in our opinion, an erroneous) interpretation of the same set of facts. This is not the manner in which revisional powers should be invoked. IN this view of the matter, we are of the considered opinion that the jurisdiction conferred on the National Commission under Section 21(b) of the Act has been transgressed. It was not a case where such a view could have been taken, by setting aside the concurrent finding of two fora.”
17. Since two Fora below have given detailed and reasoned orders which does not call for any interference nor they suffer from any infirmity or erroneous exercise of jurisdiction, present petition being without any legal merits, is hereby dismissed.
18. Parties shall bear their own costs.
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