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A/466/2018

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Case Summary: United India Insurance Company Limited & Anr. v. Reetu Goel & Another (Appeal No.466 of 2018)

Factual and Procedural Background

This appeal arises from an order dated 06.11.2017 of the District Consumer Disputes Redressal Forum, Gurgaon. The District Forum had allowed a complaint filed by Smt. Reetu Goel and directed the opposite parties (the appellants in this appeal, United India Insurance Company Limited and its branch) to reimburse a total amount of Rs.3,30,023/- (consisting of Rs.53,882/- for treatment from 14.03.2013 to 16.03.2013 and Rs.2,76,141/- for admission from 16.03.2013 to 26.03.2013) along with interest @ 9% per annum from the date of filing of the complaint till realization, and to pay Rs.20,000/- as compensation for mental agony, harassment and litigation expenses.

The appellants filed the present appeal under Section 15 of the Consumer Protection Act, 1986 seeking to set aside the District Forum's order. A miscellaneous application for condonation of delay in filing the appeal was also filed; the Commission allowed that application and condoned the delay.

Factual matrix relied upon in the complaint: the complainant held mediclaim policies covering 18.05.2010–17.05.2011, 18.05.2011–17.05.2012 and 18.05.2012–17.05.2013. She was admitted to Fortis Hospital, Vasant Kunj on 14.03.2013 (treated to 16.03.2013; expenses Rs.53,882/-) and again admitted for further treatment culminating in surgery on 19.03.2013 and discharge on 26.03.2013 (expenses Rs.2,76,141/-). Her claim was repudiated by the insurer (letters and dates include repudiation communicated on 11.06.2013 and 22.08.2013), the insurers alleging concealment of pre-existing diabetes (claimed to be of several years' duration in some hospital letters).

Legal Issues Presented

Whether the repudiation of the complainant's mediclaim by the insurers amounted to a justified denial based on concealment of pre-existing disease (diabetes), or whether the repudiation constituted deficiency in service warranting reimbursement and compensation.
Whether the District Consumer Forum's order directing reimbursement of Rs.3,30,023/-, interest and compensation of Rs.20,000/- should be set aside on the facts and evidence presented before the State Commission.

Arguments of the Parties

Appellants' (United India Insurance Company Limited & Anr.) Arguments

The appellants maintained that they were bound by the terms of the insurance contract and that no deficiency in service had occurred in the processing of the complainant's claim.
They contended that the discharge summary and other documents revealed inconsistencies/variations: some records indicated diabetes of 3–4 years' duration while other records suggested recent detection; the insurers' investigation concluded there appeared to be concealment of material facts.
The appellants relied on prior judicial decisions (cited in the opinion) to argue that claims can be repudiated where policyholders have misrepresented or concealed material pre-existing conditions, and used one cited decision to argue that it would be too coincidental for a serious event to occur immediately after inception of cover in certain factual contexts (as summarized in the opinion).
The insurers noted procedural/documentary matters such as a letter sent by the complainant's husband on 16.03.2013 being received in the TPA office only on 05.04.2013, as part of justification for the processing/denial timeline and the inquiry into variations.

Respondent/Complainant (Reetu Goel) Arguments

The complainant asserted that the diabetes was recently detected (not a longstanding pre-existing condition), and that repudiation of the claim by the insurers was arbitrary and illegal.
She sought reimbursement of the amounts expended during the two periods of hospitalization (total Rs.3,30,023/-), interest, and compensation for mental agony, harassment and litigation expenses (Rs.20,000/-).
Evidence relied upon by the complainant included discharge summaries and certificates (Exhibits C-7, C-8, C-10, C-11 and related documents) from treating doctors stating diabetes was recently detected and that diabetes had no relation to the rheumatic heart disease for which she was treated.

Table of Precedents Cited

Precedent	Rule or Principle Cited For	Application by the Court
Oriental Insurance Company Limited v. Mahendra Construction, Civil Appeal No.3359 of 2019 (decided 01.04.2019)	Relied upon by counsel for the appellant as authority discussing repudiation where a complainant had a heart attack and history of diabetes mellitus and hypertension; used in argument to suggest improbability/coincidence issues in temporal occurrence of events relative to policy.	The Commission observed that the judgment was on its own facts and was distinguishable. It did not accept the precedent as grounds to overturn the District Forum's factual findings in the present case.
United India Insurance Company Limited & Another v. Subhash Chandra, Revision Petition No.469 of 2006 (NCDRC, decided 19.05.2010)	Relied upon by counsel for the appellant as relevant authority (as cited in the appeal) in support of arguments related to repudiation where pre-existing conditions and factual coincidences were in issue.	The Commission treated this authority as fact-specific and, like the other cited decision, found it distinguishable on the facts. The Commission did not apply it to reverse the District Forum's order.

Court's Reasoning and Analysis

The State Commission proceeded by reviewing the record, including discharge summaries and certificates produced by the complainant from the treating hospitals and treating physicians (referenced in the opinion as Exhibits C-7, C-8, C-10, C-11 and related certificates). The Commission's reasoning can be summarized in the following steps, staying strictly within the content of the opinion:

The miscellaneous application to condone delay in filing the appeal was allowed; the appeal was admitted for hearing.
The Commission examined the District Forum's factual conclusion that the insurers' repudiation of the claim amounted to deficiency in service and warranted reimbursement and compensation.
On the evidentiary record, the Commission noted multiple certificates/discharge summaries prepared by treating doctors which explicitly stated that the complainant's diabetes mellitus was recently detected (the opinion records phrases such as "recently detected" and "3/4 weeks" in the treating doctors' certificates and discharge summaries).
Specific medical certificates (including one by Dr. Sandeep Attawar and another by Dr. Tapan Ghose) were considered: these documents stated that the complainant had rheumatic heart disease and that diabetes was recently detected and had no relation to the rheumatic heart disease for which she was treated; one certificate clarified that an earlier notation of diabetes duration ("3–4 yrs") was made before a detailed history was taken and before all documents/records were available.
The Commission acknowledged the insurers' position that there were variations in the documents and that the investigation team was of the view that the case "seemed to be of concealing facts," which formed the basis for repudiation; the Commission also noted documentary/timing matters such as the husband's letter dated 16.03.2013 being received in the TPA office on 05.04.2013.
After evaluating the medical evidence, the Commission concluded that the complainant had successfully established that diabetes had been recently detected (the opinion states "she was not suffering from diabetes mellitus for the last 4/5 years rather it was for the 3/4 months" and elsewhere records doctors' statements to the effect of "recently detected"/"3/4 weeks"); additionally, the medical evidence indicated diabetes bore no relation to the rheumatic heart disease that required treatment and surgery.
The Commission considered the precedents relied upon by the appellants but treated them as fact-specific and distinguishable from the present facts; it therefore did not regard them as compelling authorities to overturn the District Forum's factual findings.
Given the foregoing, the Commission found no fault with the impugned order of the District Consumer Forum and concluded that the appeal lacked merit.

Holding and Implications

Holding: The appeal is DISMISSED.

Direct consequences stated in the opinion:

The impugned order of the District Forum directing reimbursement of Rs.3,30,023/- and payment of Rs.20,000/- as compensation is upheld.
The statutory amount of Rs.25,000/- deposited by the appellants at the time of filing the appeal is ordered to be disbursed in favour of the complainant, Reetu Goel, against proper receipt and identification in accordance with rules, subject to any further appeal/revision.
Pending applications, if any, were disposed of in terms of the Commission's order; a copy of the order is to be provided to the parties free of cost and uploaded on the Commission's website; the file is to be consigned to the record room with a copy of the order.

Broader implications: The opinion treats the cited precedents as fact-specific and distinguishable and does not purport to lay down a new legal principle. The decision's immediate effect is confined to upholding the District Forum's award in favour of the complainant; the Commission did not state any new precedent-forming rule beyond its fact-bound conclusion.

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UNITED INDIA INSURANCE CO. v. REETU GOEL AND ANOTHER

APPEAL NO.466 OF 2018 18.01.2023

United India Insurance Company Limited & Anr. VS. Reetu Goel & Another DISMISSED Page 1 of 9

STATE CONSUMER DISPUTES REDRESSAL COMMISSION

HARYANA, PANCHKULA

Date of Institution: 17.04.2018 Date of final hearing: 18.01.2023 Date of Pronouncement: 18.01.2023

APPEAL NO.466 OF 2018

IN THE MATTER OF

1. United India Insurance Company Limited, Registered Head Office, 24, Whites Road, Chennai-600 019.

2. United India Insurance Company Limited, SCO No.17-18, 1^st Floor, HUDA Shopping Complex, Sector 7, Gurgaon through its Branch Manager,

Both the appellants are now represented through the duly authorized signatory of Regional Office at SCO No.123-124, Sector 17-B, Chandigarh.

….Appellants/Opposite Parties No.1 & 2

Versus

1. Reetu Goel wife of Dinesh Goyal, resident of H-127, Sarita Vihar, New Delhi now at Royal Court Society, Flat No.D-8, Sector 39, Gurgaon.

….Respondent No.1/Complainant

2. E-Meditek Private Limited, Corporate Office Plot No.577, Udyog Vihar, Phase V, Gurgaon-122016 through its Authorized Person signatory.

…….Respondent No.2/Opposite Party No.3

CORAM: HON'BLE MR. JUSTICE T.P.S. MANN, PRESIDENT

MRS. MANJULA, MEMBER

Present: Shri Sudhir Gupta, proxy counsel for Shri Nitin Gupta, counsel for the appellants.

Ms. Garima Upadhyay, counsel for respondent No.1 Presence of respondent No.2 already dispensed with

PER: T.P.S. MANN, J.

ORDER

1. For the reasons stated therein, the miscellaneous application is allowed and the delay in filing of the appeal is condoned.

2. The appellant, who stood arrayed as opposite parties No.1 and 2 in the complaint have filed the present appeal under Section 15 of the Consumer Protection Act, 1986 seeking setting aside of the order dated 06.11.2017 passed by the District Consumer Disputes Redressal Forum, Gurgaon whereby complaint preferred by Smt. Reetu Goel was disposed of by holding that the rejection of the claim of the complainant, who was having mediclaim policies since 2010 tantamount to deficiency in service on the part of the opposite parties and accordingly, the opposite parties were directed to reimburse total amount of Rs.3,30,023/- to the complainant i.e. Rs.53,882/- incurred during her treatment w.e.f. 14.03.2013 to 16.03.2013 and Rs.2,76,141/- on account of her admission from 16.03.2013 to 26.03.2013, total amount being Rs.3,30,023/- alongwith interest @ 9% per annum from the date of filing of the complaint till its realization. The opposite parties

were also directed to pay a sum of Rs.20,000/- as compensation for mental agony, harassment as well as litigation expenses.

3. While filing the complaint, the complainant pleaded that she had purchased mediclaim policy No.221403/48/10/97/00000159 valid from 18.05.2010 to 17.05.2011 and the same continued from 18.05.2011 to 17.05.2012 and thereafter from 18.05.2012 to 17.05.2013. On 14.03.2013, the complainant fell ill and was admitted in Fortis Hospital, Vasant Kunj, New Delhi where she was medically checked up by Dr. Tapan Ghose. The complainant remained under treatment from 14.03.2013 to 16.03.2013 in that hospital and the complainant incurred an expenditure of Rs.53,882/-. The complainant moved an application through her husband Dinesh Goel on 16.03.2013 to opposite party No.2 wherein it was stated that the complainant applied for cashless claim but till date, it was not approved. The complainant was again admitted in Fortis Hospital for further treatment and she was checked up by Dr. Sandeep Attawar at that time and she was feeling difficulty in breathing. On 19.03.2013 she was operated upon and lateron, she was discharged on 26.03.2013. The complainant spent a total sum of Rs.2,76,141/-. The complainant submitted her claim with the opposite parties but the opposite parties repudiated the claim on 11.06.2013 on the ground that the patient was having diabetes since four years whereas the history was wrongly mentioned. In fact diabetes was recently detected. The complainant again

requested the opposite parties to settle the claim vide application dated 17.06.2013 but the opposite parties acted arbitrarily and issued letter dated 22.08.2013 vide which the claim of the complainant was repudiated, which was illegal and against the law and facts. She accordingly prayed for directing the opposite parties to make the payment of claim amount of Rs.53,882/- plus Rs.2,76,141/- alongwith interest and also to pay compensation for mental agony, harassment as well as litigation expenses.

4. Upon notice, opposite parties No.1 and 2 appeared and filed joint written statement. However, opposite party No.3 failed to appear despite service and accordingly, it was proceeded ex parte.

5. Opposite parties No.1 and 2 in their written statement alleged that both the parties were bound by the contract of insurance. The complaint was misconceived as there was no deficiency in service on their part in rendering services to the complainant. It was also alleged that the complainant was admitted in Fortis Hospital on 14.03.2013 and discharged on 16.03.2013. At the time of discharge, a certificate was also issued by the hospital as per which the complainant was a known case of diabetes mellitus since last 3-4 years. After discharge from the Fortis Hospital, Delhi, the husband of the complainant informed the opposite parties that he wanted to have second opinion from Fortis Hospital. Thereafter, the complainant was admitted and treated in Fortis Hospital from 16.03.2013 and was operated on 19.03.2013 and discharged on 26.03.2013. After receiving the

discharge summary from the complainant, the opposite parties processed the claim of the complainant and certain clarifications were sought as the husband of the complainant sent email to the office of TPA and attached procured undated letter from the Fortis Hospital, Gurgaon besides letter dated 14.05.2013. The opposite parties processed the claim of the complainant and found the variations. As per discharge summary diabetes was recently detected and as per doctor's prescription diabetes was since four years and policy since 2010. The investigation team remarked that the case seemed to be of concealing facts and accordingly they had no other option but to repudiate the claim of the complainant. It was admitted that the husband of the complainant sent a letter dated 16.03.2013, which was received in the office of opposite party No.3 on 05.04.2013. As such, there was no deficiency in service on the part of answering opposite parties and prayer accordingly made for dismissal of the complaint.

6. After hearing counsel for the parties and perusing the record available on the file, the District Consumer Forum disposed of the complaint by directing the opposite parties to reimburse the total amount of Rs.3,30,023/- besides Rs.20,000/- as compensation for mental agony, harassment as well as litigation expenses.

7. After hearing counsel for the parties and going through the record which stands requisitioned, the State Commission finds that in discharge summary, it was mentioned that diabetes had been

recently detected. The certificate was issued by the doctor, who treated the patient that diabetes mellitus was detected for the last 3/4 weeks. In the certificate Ex.C-7 and C-8, it was mentioned that there was no prior history of rheumatic heart disease and after admission, she was diagnosed as case of severe MS, probably of rheumatic origin. As such, the diabetic condition of the patient was recently detected i.e. 3/4 weeks and not 3/4 years, which had been made the base for rejection of the claim by the opposite parties.

8. There is another certificate Ex.C-10 issued by Fortis Hospital wherein it was mentioned that diabetes had no relation with the rheumatic heard disease. Therefore, the complainant was not suffering from diabetes for the last 3/4 years. Resultantly, the patient was suffering from diabetes from 3/4 weeks and the diabetes had no concern with the disease, for which the complainant was treated.

9. During the recording of evidence, the complainant had placed on record certificate Ex.C-10 (colly) issued by Dr. Sandeep Attawar, Director CTVS of Fortis Memorial Research Institute, Gurgaon wherein it is stated that the complainant was diagnosed to be suffering from rheumatic heart disease, severe MS, PAH, SR with intermittent AF, normal coronaries had undergone mitral valve replacement on 19.03.2013 and diabetes has no relation with the above rheumatic heard disease.

10. To the same effect was the certificate Exhibit C-10 (colly) issued by Dr. Tapan Ghose wherein it was mentioned as under:

Mrs. Reetu Goel, 46 years lady, was admitted to this hospital on 14.03.2013 and was diagnosed to be having severe MS with severe TR and LA mass. on detailed history with evaluation, she was found to having diabetes mellitus since last 3-4 weeks (recently detected) which is mentioned in her discharge summary already. The

duration of diabetes written in the first letter (3-4 yrs) was before detailed history was taken and before all the documents and records were made available.

11. Similarly, there is discharge summary Exhibit C-11 (colly) issued by Department of Cardiology of Fortis Flt. Lt. Rajan Dhall Hospital wherein it was mentioned that though the complainant was diabetic but it was recently detected. Relevant portion of the discharge summary is as follows:

DIAGNOSIS

Diabetes mellitus type 2 Rheumatic heart disease Severe mitral stenosis Severe PVH

Severe PAH

Congestive heart failure LA mass (?? LA myoxoma)

PRESENT ILLNESS

Mrs. Reetu Goel, 46 years old female is normotensive, diabetic (recently detected), nonsmoker with having no family history of coronary artery disease. She presented with complaints of off & or breathlessness since 1½-2

years which increased since last 7 days. She was admitted for further evaluation and management.

12. Counsel for the appellant has relied upon the judgment of the Hon'ble Supreme Court in Oriental Insurance Company Limited Vs. Mahendra Construction, Civil Appeal No.3359 of 2019 decided on 01.04.2019 and also on the order of the Hon'ble National Consumer Disputes Redressal Commission, New Delhi in United India Insurance Company Limited & Another Vs. Subhash Chandra, Revision Petition No.469 of 2006 decided on 19.05.2010 to contend that the complainant therein suffered a heart attack and had a history of diabetes mellitus and hypertension. However, it would be too much of a co-incidence to argue that within a week of the complainant taking the policy, he had a sudden heart attack.

13. Both the judgments cited by counsel for the appellant are on their own facts. In the present case before us, the complainant has been successful to establish that she was not suffering from diabetes mellitus for the last 4/5 years rather it was for the 3/4 months. Even if it is taken that the complainant was suffering from diabetes mellitus for the last 3/4 years but the same had no relation with the rheumatic heart disease.

14. In view of the above, no fault can be found with the impugned order passed by the District Consumer Forum. The appeal is devoid of any merit and, accordingly, dismissed.

15. Application(s) pending, if any, stand disposed of in terms of the aforesaid order.

14. The statutory amount of Rs.25,000/- deposited by the appellants while filing the appeal be disbursed in favour of complainant- Reetu Goel against proper receipt and identification in accordance with rules, subject to appeal/revision, if any.

15. A copy of this order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 2019. The order be uploaded forthwith on the website of the Commission for the perusal of the parties.

16. File be consigned to record room along with a copy of this order.

(T.P.S. MANN)

PRESIDENT

(MANJULA)

MEMBER

Pronounced On: 18.01.2023

UNITED INDIA INSURANCE CO. v. REETU GOEL AND ANOTHER

Case Summary: United India Insurance Company Limited & Anr. v. Reetu Goel & Another (Appeal No.466 of 2018)

Factual and Procedural Background

Legal Issues Presented

Arguments of the Parties

Appellants' (United India Insurance Company Limited & Anr.) Arguments

Respondent/Complainant (Reetu Goel) Arguments

Table of Precedents Cited

Court's Reasoning and Analysis

Holding and Implications

UNITED INDIA INSURANCE CO. v. REETU GOEL AND ANOTHER

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