ORDER
(Passed this on 1st April, 2017)
Shri Shekhar P. Muley, President.
01. This complaint is against an Insurance Company for not settling the claim of the complainant.
02. The Opposite Parties are Head office and Local office of Cholamandalam Insurance Company. The complainant has taken Health Gold Plan Policy of the OP. The period of the policy was from 12/3/2012 to 11/3/2013 and health risk up to Rs.4 lakh was covered for himself and his wife. Under the policy heart related diseases are covered. On 24/3/2012 the complainant had heart problem and he was admitted in the hospital of Dr. Deshpande. He was hospitalised till 1/4/2012 for treatment for which he incurred expenses of Rs.1,94,350/-. After discharge, he made claim with all papers, bills and documents to the O.P. But the O.P. avoided
to settle the claim. On 11/5/2012 the O.P. informed him about repudiation of the claim. Alleging that the reason for repudiation is illegal and wrong, it is prayed that the O.P. be directed to settle his claim of Rs.1,94,350/- with 12% interest with litigation cost.
03. The O.P. filed reply and admitted the policy of the complainant for aforesaid period. The sum assured was Rs.4 lakh. But it is denied that he suffered heart problem on 24/3/2012 and was admitted in the hospital till 1/4/2012 and incurred Re.1,94,350/- on treatment. It is not denied that the claim was repudiated and it is further stated that any pre existing condition benefits are not payable for any condition as defined in the policy, until 24 consecutive months of coverage for the insured person have elapsed since inception of the policy. As such there is no deficiency in service and the complaint being not tenable, it be dismissed.
04. Heard both the sides. Perused documents placed on record and notes of argument. We record our findings and reasons as under.
FINDINGS AND REASONS
05. Bare reading of the policy terms and conditions make it clear that no benefits under the policy is payable to the insured person if the claim directly or indirectly arising out of or connected to any pre existing disease, ailment or injury, until 24 consecutive months of coverage for the insured person have elapsed. Conversely it means if the insured person is having pre existing ailment at the time of inception of the policy, he may get the benefit under the policy only after lapse of 24 months continuous coverage. Thus there is a cap of two years for making claim in respect of pre existing disease. This condition is binding on the complainant.
06. Now let us find out whether the complainant had any pre existing condition when he purchased the policy. In the complaint he has not mentioned what was the reason for repudiation of his claim, except alleging that the reason was illegal. Admittedly he was admitted to a Heart Clinic for heart ailment on 24/3/2012 and was an indoor patient there
till 1/4/2012. He was operated upon for Coronary Artery Bypass Graft Surgery on 26/3/2012. He was diagnosed with Systemic Hypertension, Ischaemic Heart Disease, Severe Triple Vessel Coronary Artery Disease with + TMT and unstable Angina. He was having Systemic HTN, NIDDM since 1997. It looks obvious that his heart ailment did not occur all of sudden on 24/3/2012. Neither party produced clear evidence to ascertain since when the complainant was having this pre existing condition. It is also to be considered whether he was aware of such pre existing condition or not. Because sometimes a person, though suffering from heart ailment, is not aware of his condition because of no pain. Hence, to verify this fact, we have closely scrutinised the bills of medicines produced by the complainant. Obviously the bills are produced to prove treatment expenses he had incurred in the hospital.
07. He has placed on record total 18 bills, out of which last three bills are of the hospital and three bills are of Blood Bank. Rest of the bills are of medicines. There is no doubt about these six bills. Now what is important to note and which surprises us is that out of 12 medicines bills 8 bills are old bills; much prior to his admission in the hospital. Some bills are of the year 2011, even prior to issuance of the policy. How can he be so audacious to claim bills amount which he
had spent much before he purchased the policy. This is a blatant attempt to cheat, not only the OP but to the forum also to extract money under the policy by producing old bills. The complainant has not come with clean hands to seek relief’s, which also disentitles him from seeking relief’s.
08. Besides, these bills go to show that he was aware of his ailment related to heart since prior to taking policy. But he has not disclosed this fact to the O.P. non disclosure of pre existing condition while taking a policy amounts to breach of policy condition. The contract of policy is based on utmost trust between the contracting parties and each party is under obligation to make true and correct disclosure of all relevant facts, otherwise the contract becomes void ab initio. On the old bills there is mention of Dr. Deshpande, who had treated him for heart problem. So an inference can be drawn that he was aware of his heart problem since long. Now he cannot feign ignorance of his heart problem.
09. Considering these facts the complaint is liable to be dismissed. Hence, the following order.
ORDER
- The complaint is dismissed with no order as to cost.
- Copy of judgment and order be given to both the parties, free of cost.
