Order No. 15 dt. 27/08/2019
The case of the complainant in brief is that the complainant enjoyed a policy issued by Apollo Munich Health Insurance Co. Ltd. At first o.p. nos.2 and 3 after making contanct with the complainant enquired about the said existing policy of the complainant. Thereafter, both o.p. nos.2 and 3 represented before the complainant that their company would give much more facilities by obtaining a little more premium and their companmy would give coverage upto Rs.25 lakhs. On query of the complainant he was infomred that since the complainant has already paid 3 premiums to Apollo Munich Health Insurance Co. Ltd. therefore by adopting portable system it could easily done to shift the policy and 3 years waiving peiod would be waived off. Relying upon the representations of o.p. nos.2 and 3 the complaiannt shifted his existing health insurance policy from Apollo Munich Health Insurance Co. Ltd. to o.p. no.1 by availing the portable system and gave his consent to that effect. The complainant being convinced with the assurance of o.p. nos.2 and 3 paid the premium of Rs.31,157/- for 2 years and the complainant received the policy document and the waiving period for 36 months was waived off. In the last week of may, 2018 the complainant was asked to go for medical checkup in any of the listed hospital / medical centre of o.p. no.1. The complainant went to Iris Hospital, Kolkata on 6.6.18 and medical checkup was held. The doctor examined the complainant and asked him as to whether the complainant had any record of hypertension to which the complainant disclosed that on 23.5.18 he was traumatised due to some pathetic incident on road and consulted with the doctor on 24.5.18 and he prescribed him Stamlo D one a day for 4 weeks. The prescription of Dr. Debasish Dey was there and the complainant was asked to leave the hospital and acordingly he left the hospital.
The complainant all on a sudden received a letter on 13.7.18 along with health assessment report of Iris Hospital dt.6.6.18 from o.p. no.1 intimating the termination of the health insruance policy of the complainant with mentioning of clause 5 of the policy document and due to non-disclosure of hypertension since 4 months the policy was terminated. The complainant, thereafter, made contact with o.ps. but no fruitful result was achieved, for which the complainant filed this case praying for direction upon the o.ps. to pass an order of award of Rs.21 lakhs in favour of the complainant.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the policy no.13-17-0011836-00, being ‘Active Assure – Diamond’ was issued to the complainant after filling of the proposal form which commenced on 10.3.18 and would expire on 9.3.20. The said policy came into force after the complainant shifted his existing health insurance policy from Apollo Munich Health Insurance Co. Ltd. to opt. no.1 with the intention of enjoying additional benefits. The complainant paid the premium of Rs.31,157/- for a period of 2 years and the sum assured was of Rs.25 lakhs. As per clause 5 of the said proposal form states:- “ Duty of disclosure and fraudulent claim – The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect or incomplete statements, misrepresentation or non-disclosure of any material particulars in the proposal form, personal statement, declaration, claim form declaration, medical history on the claim form and connected documents, or any material information having been withheld by you or anyone acting on your behalf, under this policy. You further understand and agree that we may at our sole discretion cancel the policy and the premium paid shall be forfeited to us”. Since the complainant suppressed the material fact and reluctant to disclose under the aforesaid clause 5 of the proposal form that he was a patient of hypertension and was suffering for a period of 4 months, non disclosure of the said disease prior to commencement of the policy and on the basis of the said clause insurance company rightly repudiated the claim of the complainant. On the basis of the said fact o.ps. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant availed the policy issued by o.p. no.1?
- Whether he suppressed the material fact at the time of obtaining the policy?
- Whether the cancellation of the policy was justified on the part of insurance company?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant enjoyed a policy issued by Apollo Munich Health Insurance Co. Ltd. At first o.p. nos.2 and 3 after making contanct with the complainant enquired about the said existing policy of the complainant. Thereafter, both o.p. nos.2 and 3 represented before the complainant that their company would give much more facilities by obtaining a little more premium and their companmy would give coverage upto Rs.25 lakhs. On query of the complainant he was infomred that since the complainant has already paid 3 premiums to Apollo Munich Health Insurance Co. Ltd. therefore by adopting portable system it could easily done to shift the policy and 3 years waiving peiod would be waived off. Relying upon the representations of o.p. nos.2 and 3 the complaiannt shifted his existing health insurance policy from Apollo Munich Health Insurance Co. Ltd. to o.p. no.1 by availing the portable system and gave his consent to that effect. The complainant being convinced with the assurance of o.p. nos.2 and 3 paid the premium of Rs.31,157/- for 2 years and the complainant received the policy document and the waiving period for 36 months was waived off. In the last week of may, 2018 the complainant was asked to go for medical checkup in any of the listed hospital / medical centre of o.p. no.1. The complainant went to Iris Hospital, Kolkata on 6.6.18 and medical checkup was held. The doctor examined the complainant and asked him as to whether the complainant had any record of hypertension to which the complainant disclosed that on 23.5.18 he was traumatised due to some pathetic incident on road and consulted with the doctor on 24.5.18 and he prescribed him Stamlo D one a day for 4 weeks. The prescription of Dr. Debasish Dey was there and the complainant was asked to leave the hospital and acordingly he left the hospital. The complainant all on a sudden received a letter on 13.7.18 along with health assessment report of Iris Hospital dt.6.6.18 from o.p. no.1 intimating the termination of the health insruance policy of the complainant with mentioning of clause 5 of the policy document and due to non-disclosure ooof hypertension since 4 months the policy was terminated. The complainant, thereafter, made contact with o.ps. but no fruitful result was achieved, for which the complainant filed this case praying for direction upon the o.ps. to pass an order of award of Rs.21 lakhs in favour of the complainant.
It is contention of the o.ps. that the policy no.13-17-0011836-00, being ‘Active Assure – Diamond’ was issued to the complainant after filling of the proposal form which commenced on 10.3.18 and would expire on 9.3.20. The said policy came into force after the complainant shifted his existing health insurance policy from Apollo Munich Health Insurance Co. Ltd. to o.p. no.1 with the intention of enjoying additional benefits. The complainant paid the premium of Rs.31,157/- for a period of 2 years and the sum assured was of Rs.25 lakhs. As per clause 5 of the said proposal form states:- “ Duty of disclosure and fraudulent claim – The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect or incomplete statements, misrepresentation or non-disclosure of any material particulars in the proposal form, personal statement, declaration, claim form declaration, medical history on the claim form and connected documents, or any material information having been withheld by you or anyone acting on your behalf, under this policy. You further understand and agree that we may at our sole discretion cancel the policy and the premium paid shall be forfeited to us”. Since the complainant suppressed the material fact and reluctant to disclose under the aforesaid clause 5 of the proposal form that he was a patient of hypertension and was suffering for a period of 4 months, non disclosure of the said disease prior to commencement of the policy and on the basis of the said clause insurance company rightly repudiated the claim of the complainant. On the basis of the said fact o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant earlier enjoyed the policy issued by Apollo Munich Health Insurance Co. Ltd. After enjoyment of the policy the complainant has alleged that he was assured by o.p. nos.2 and 3 that if the policy shifted to o.p. no.1 then the period of 3 years will be waived off and the coverage will be much more than that of the coverage provided by Apollo Munich Health Insurance Co. Ltd. The complainant filled in the proposal form and in the proposal form he did not disclose any ailment, but while the complainant was asked to appear before Iris Hospital for medical checkup he disclosed that he was suffering from hypertension. The complainant was, thereafter, informed by o.p. no.1 that as per clause 5 of the terms and conditions of the policy since there was suppression of material fact and the complainant made misrepresentation and did not disclose any illness in the proposal form and on the basis of the said proposal form the policy was issued and subsequently with the medical examination the existence of the illness was disclosed by the complainant which was noted by insurance company and the doctor who examined the complainant opined that the complainant is suffering from hypertension and that suffering continued prior to obtaining the policy by the complainant. In this respect we can rely on a judgment as reported in III (2019) CPJ (SC) wherein it was held that exclusion clause suppression of pre existing disease claim repudiated it was alleged deficiency in service, but the treatment record indicates that the insured was suffering from illness which was suppressed by the complainant and on that ground repudiation was made in terms of exclusion contained in the policy. Failure of insured to disclose past history of disease was a valid ground for repudiation. In the said judgment Hon’ble Supreme Court also held that a contract of insurance involves utmost good faith. In Satwant Kaur Sandhu vs. New India Assurance Co. Ltd. (2009) 8 SCC 316 Hon’ble Supreme Court held that :- “ …Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment”.
In the said judgment as reported in III (2019) CPJ 31 9SC) Hon’ble Supreme Court held that the Consumer Fora have made a fundamental error in allowing the claim for reimbursement of medical expenses in the face of the uncontroverted material on record. The documentary material indicates that there was a clear failure on the part of the respondent to disclose that he had suffered from illness. The ground for repudiation was in terms of the exclusions contained in the policy. Accordingly, the appeal was allowed and the judgment passed by the NCDRC dt.10.12.18 was reversed and the petition of complaint filed by the respondent was dismissed and no cost was allowed. In view of the facts and circumstances as stated above, since in this case also there is suppression of materials fact and the complainant deliberately did not disclose that he was suffering from hypertension before opening of the policy issued by o.p. no.1 and thereby after detection of the pre-existing disease of the complainant the insurance company rightly cancelled the policy of the complainant as per clause 5 of the policy conditions. Accordingly, we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.247/2018 is dismissed on contest without cost against the o.ps.
