This appeal is directed against the final order dated 13/12/2018 delivered by Ld. DCDRF Uttar Dinajpur in CC No 13/2018. The factual  matrix of the case is that one. Amaresh Basak has purchased health insurance policy for his wife Sithi Basak, son Arkaprabha and for himself bearing policy number 0314832815P109544160 for the period between 19/11/2015 and 18/11/2016 from United India Insurance Company Limited of Raiganj Branch, by making payment of premium amount. The said Amaresh Basak actually has entered into the health policy since 2011 and he was continuing the policy by renewal after paying the annual premium regularly. Suddenly on 21/09/2016 his wife Sithi Basak was attacked with cardial arrest and was admitted at Raiganj District Hospital and she was treated there till 25/09/2016. But her health condition could not be improved. So the complainant went to R N Tagore hospital, Kolkata for treatment his wife Sithi on 30/09/2016 and asper advice of the doctor of R N Tagore Hospital he admitted his wife Sithi at peerless Hospital and research center at Kolkata on 1/10/2016 for medical test and for the treatment and thereafter due to serious condition of his wife he took his wife Sithi to Chennai at Ramchandra Medical Centre and after a long treatment there she could be recovered from the heart ailment. The complainant thereafter for reimbursement of medical expenses, submitted a claim before the Insurance Company by furnishing claim application which was repudiated  by the insurance company vide letter dated 20/02/2017 on the ground that the patient Sithi was suffering from type II DM for the last 12 years which was not disclosed in the proposal of the policy and thus violated the provisions and the terms and condition in the policy mentioned in clause no 5.8. So the complainant was compelled to register consumer complaint before the Ld. consumer forum for medical reimbursement of rupees 1 lakh along with interest, rupees 50,000 for harassment and rupees 5000 for litigation cost. The United India Insurance Company has contested the case by filing the WV and contended that the Insurance Company was not liable to make any payment of medical reimbursement as because the insured has suppressed her illness of 12 years at the time of furnishing the insurance proposal and also as per provisions of the policy no reimbursement could be provided up to 45 months since the date of inception of the policy.. The complainant Amaresh Basak has been examined as PW-1 and he was cross-examined by the OP Insurance Company. Dr. Suman Basak and one administrative officer of Insurance Company Sri BS Raja Gopal were examined as OP no. 1 and OP no. 2 and they are also cross examined by the complainant side.

Thereafter the Ld. DCDRF, Raiganj had delivered the impugned judgment after consulting the evidences on record and on perusal of the documentary evidences. Ld. Forum came to a conclusion, that the insurance company has wrongly repudiated the insurance claim of the complainant and for that treason, the consumer complainant under section 12 of CP Act, was allowed as per provisions of Section 13 of CP Act, and the insurance company was directed to pay rupees 90,000 for the cost of treatment, rupees 10,000 as harassment and rupees 5000 as litigation cost and also asked to pay the same money within one month failing which 5 per cent interest per annum over the awarded money could have to be imposed.

Being aggrieved with the order, this appeal follows on the ground that the order of Ld. DCDRF, Raiganj was bad in law which is liable to be set aside. The appeal was admitted in due Course and the notice upon the respondents was sent to his address which was duly acknowledged and the respondent Amaresh Basak Has contested the case through his Ld. Advocate.  Accordingly, the appeal was heard in presence of Ld. Advocate of both sides.

Decisions with reasons,

Admitted position is that, the complainant A Basak has got into an agreement of health insurance on behalf of himself and his wife and son with New India Insurance company limited, since 2011 with paying the annual premiums in due course and there was no lapse of insurance policy on account of any non-payment of premiums. Now the question is whether the insurance Company has any opportunity to repudiate the claim of a bona fide insured person. During the course of argument, the Ld. Advocate of the Insurance Company submits that as per clause 5.8 of insurance policy, there is a condition that if the insured at the time of entering into the insurance agreement suppressed any material fact and then the policy shall be void and all premium paid hereon shall be forfeited to the company in the event of misrepresentation, misdescription or non-discloser of any material fact. He mentioned that Dr. Suman Basak has made treatment of the patient Sithi Basak on 21/09/2016 when the patient was attacked with stroke and on that day in the prescription sheet, in the history of illness heading he mentioned that the patient was suffering in type ii DM for last 12 years and S Basak has proved the said prescription on dock as witness and for that reason, the insurance company has right cause to repudiate the claim of the insured. Ld. Advocate of the respondent mentioned in his argument that Dr. Suman Basak has mentioned in his perception about the disease of the patient for the last 12 years suffering in Type ii DM only on the basis of the statement of patient whereas no medical documents was there to prove that the patient was suffering in diabetic for the last 12 years. After going through the entire case record very carefully, particularly with a careful watch of all the necessary medical papers, the Commission find that at the time of submitting the proposal form Sithi Sarkar was 39 years old. She was hale and hearty at that point of time and the said agreement of insurance was entered in the year 2011. She had no serious medical ailment till 21/09/2016 when she was attacked with stroke. No medical reimbursement claim was there between 2011 and 2016. The insurance company also at the time of accepting the insurance proposal has verified all the necessary documents and physical condition of the insured person and when they became satisfied over the statements furnished in the insurance proposal then they became agreed to enter into the said insurance agreement. So, there is no opportunity to hold that the insured party has suppressed materials facts before the insurance company at the time of going into the insurance proposal. On the other hand, Diabetic Disorder is very common in our country where most of the people are now suffering in excitements and tensions. It is the day to day affair of every common people of our country to suffer in anxiety problems and we know very well that most of the diabetic disorders comes from excitements. Rather no documentary evidence was there on the part of the insurance company to prove that the patient Sithi was suffering in type ii Dm for the last 12 years. If we consider the case of the insured by applying humane approach then we must say that the insured is well entitled to be reimbursed for the medical expenses she has incurred for her ill-health.

Therefore, the order of Ld. forum appears to be convincing and justified one in accordance with the provisions of the consumer protection Act, 1986.

So, the appeal devoids of any merit.

Hence, it is,

Ordered,

That the appeal be and same is dismissed on contest without cost. The final order of Ld. DCDRF, Uttar Dinajpur dated 13/12/2018 is hereby confirmed but the effect of order of the Ld. Forum to be enforced form the day of receiving the copy of order of this appeal by the appellants. The appellants are asked to pay the decretal amount which awarded by the Ld. DCDRF, Uttar Dinajpur dated 13/12/2018 in connection with CC no. 13 pf 2018 within 30 days from the date of receiving copy of the order of this Commission failing which it will carry interest at the rate of 5 per cent per annum over the awarded money.

Let a copy of this order be sent to the concern forum and also to be supplied to the parries free of cost.