ORDER
B.K. Taimni, Member
1. Appellant was the complainant before the State Commission, where he had filed a complaint alleging deficiency in service on the part of the respondent, New India Assurance Company (hereinafter referred to as Insurance Company).
2. Undisputed facts of the case are that the appellant/complainant, was a holder of a mediclaim policy valid from 19.3.1990 to 18.3.1991. The Policy was for the benefit of Smt. Manjit Bawa as also for the appellant/ complainant Brig. J.S. Bawa (Retd.). The appellant/complainant underwent a Coronary Bypass Surgery at Escorts Heart Institute and Research Centre, New Delhi and thereafter filed a claim for reimbursement for Rs. 90,800 which was repudiated by the respondent Insurance Company on 7.2.1997 for non-disclosure of facts at the time of taking the insurance cover. It is pertinent to mention here that the appellant/ complainant had also earlier approached the Directorate of Public Grievances, Cabinet Secretariat, Government of India, New Delhi, where the claim was also disallowed in following terms:
The matter was referred to New India Assurance Company and it has been reported by them that the revised discharge summary slip does not differ with the original one and clearly indicates that you were a known case of CAD for 10 years on treatment. Hence, the Insurance Company has concluded that the disease is pre-existing and the claim was rightly repudiated by them. It has been pointed out that the contents of the Discharge Summary submitted by you are contradictory e.g. He used to have chest pain off and on for the last 10 years but TMT was negative and he was not on any antianginal treatment. He has been taking antianginal treatment for ischemia and his CART revealed severe Triple Vessel Disease. As such your case is being closed in this Directorate.
3. It is in these circumstances a complaint was filed on 11.5.1993 before the State Commission, who after hearing the parties dismissed the complaint, hence this appeal before us.
4. We heard the learned Counsel for both the parties at considerable length and also perused the material on record.
5. There is no dispute that the complainant had obtained two mediclaim policies-one from the respondent New India Assurance Co. Ltd. and the second from United India Insurance Co. It is also not in dispute that the appellant preferred a claim for the same episode with the United India Insurance Company who settled it with the appellant by paying Rs. 30,250 in full and final settlement with the appellant.
6. After perusing the material on record and hearing the Counsel for the parties, we find that there are more than one dimensions to this case. Firstly, if we see the original discharge certificate dated 10.6,1990 Issued by the Escorts Heart Institute it had stated that the appellant was having chest pain off and on for the last ten years. There is no dispute that the claim was repudiated by the respondent Insurance Company on 7.11991 based on the material available on that date as also based on the reports of the Doctors, namely, Dr. S.B. Rajpal as also Dr. Pran Nath. What we see in record is a rectification slip issued by the Escorts Heart Institute on 14.12.1992. We are not impressed with this ‘error-rectification’ issued on 14.12.1992. It is not in dispute that on the date of discharge certificate certain entries with regard to history of the patient were issued and it is not the case of the appellant that he is not illiterate. We are not inclined to place much credence on an uncorroborated rectification of error by Escorts Heart Institute which is not supported by any affidavit of the Hospital Authorities.
7. What is more galling to us is the absence of bona fide on the part of the appellant. There is no disputing the fact that the appellant had two Insurance Policies from two different insurance companies. It is also not in dispute that the United India Insurance Company had settled the claim of the appellant by paying him Rs. 30,250 on 7.2.1991 as per material on record for the same episode, against a claim made with the United India Insurance Company for Rs. 85,000. It is also not in dispute that the claim preferred with the respondent New India Assurance Co. Ltd. for Rs. 90,800. We will not like to pass any harsh judgment on this aspect but in our view the appellant has been less than fair to us, as also to himself when he preferred two separate claims for the same ailment/ episode and almost for the same amount and yet we do not see any reference in the complaint filed before the State Commission of his having received Rs. 30,250 from the United India Insurance Co. His claim before the State Commission from the respondent Insurance Company was for Rs. 1 lakh; so much for the bona fide of the appellant/complainant.
8. Learned Counsel for the appellant wishes to rely upon Clause 9 of the Policy, which reads as under:
If at the time when any claim arises under this Policy, there is in existence any other insurance (other than Cancer Insurance Policy in collaboration with Indian Cancer Society and Medical Benefit extension under Personal Accident Policy) whether it be effected by or on behalf of any insured person in respect of whom the claim may have arisen covering the same loss, liability, compensation, costs or expenses the Company shall not be liable to pay or contribute more than its rateable proportion of any loss, liability, compensation, costs or expenses. The benefits under this Policy shall however be in excess of the benefits available under Cancer Insurance Policy and Medical Benefits extension under Personal Accident Policy.
9. Learned Counsel for the appellant also wishes to rely upon the letter which he wrote to the Divisional Manager of the United India Insurance Co. Ltd., which is reproduced as under:
This is to thank you Cost sincerely for settling my claim so promptly. However, please allow me to point out that against a claim of about Rs. 85,000. I have been paid only Rs. 30,250 whereas the maximum payable under the policy is Rs. 37,500. Would you kindly elucidate the reasons for the shortfall of over Rs. 7,000 please?
10. As far as the conditions of Policies are concerned, we had no difficulty in seeing or in appreciating this condition the way learned Counsel for the appellant wishes to read it. But we have great difficulty in appreciating the appellant/complainant preferring two claims for almost the same amount before two insurance companies for the same episode without revealing as to what amount has been claimed/obtained from the other Insurance Company. The learned Counsel for the appellant argued that what the appellant claiming is the rateable proportion of loss/amount claimed from the respondent Insurance Company. For two reasons we are unable to accept this plea of the appellant-firstly, at no stage the appellant shared the factum before either of the Insurance Companies that they have the Insurance Cover from the other Insurance Company and more importantly and secondly as per material on record, the appellant had filed a complaint before the District Forum claiming the remainder amount from the United India Insurance Company, the other Insurer. We are unable to appreciate as to how and under what circumstances, the appellant could claim the same amount from two different Insurers relating to same episode except perhaps in an attempt for undue enrichment by keeping one of the Insurers in dark about his dealing with the other Insurer. It is worth noting that neither the policy issued by the United India Insurance Company nor the copy of the claim form preferred before them has been brought on record.
11. In our view, the suspicion of the State Commission is correct, that perhaps the intention/attempt was to grab the amount from both the Insurance Companies for the same episode, without telling any of them that the appellant has preferred a claim/received the claim from United India Insurance Company.
12. As permaterial on record, the appellant has also filed a complaint with the District Forum for obtaining the balance amount against United India Insurance Co. That being so, the cat comes out of the bag and our worst suspicion gets confirmation that effort is to recover amount from both the Insurance Companies for the same amount in respect of the same episode. ‘Rateability’ will have relevance, if two separate claims had been made before the Insurers clearly spelling out the amount being claimed from each of the Insurers keeping in view the terms/ conditions and limits of the Policy. This has not been done. It is too late in the day to seek shelter under Condition 9 of the Policy. This condition finds no mention in the complaint filed before the State Commission. In these circumstances, Condition 9 will not help the appellant. We refrain from passing any harsher order against the appellant who had been a senior officer in the Indian Army. There can be no doubt that consumer Fora are designed to help an honest Consumer with bona fide and not otherwise. In the aforementioned facts, the appellant has completely failed to prove his bona fide.
13. In the aforementioned circumstances, we find no merit in this Appeal, and no ground to interfere with the well reasoned order passed by the State Commission. Hence this Appeal is dismissed.
