Sri Shyamal Gupta, Member

This is the Appellant’s Appeal challenging the order dated 02-11-2017, passed by the Ld. District Forum, Kolkata-I (North) in CC/321/2014, dismissing the complaint case filed by him.

Brief facts of the case are that the Appellant and his wife took three mediclaim policies in the year 2005 from National Insurance Co. Ltd. and in the year 2006, his wife went under the knife in connection with cyst operation.  The Complainant, however, did not lodge any claim in respect of such operation.  Subsequently, in the year 2013, the Complainant ported the policy from National Insurance Co. Ltd. to the OPs.  On 29-07-2013, Complainant’s wife was operated upon for removal of Fibroid cyst.  Claim lodged in this regard, however, was not only repudiated by the OPs alleging suppression of material fact, they also terminated the insurance policies; hence the complaint.

The OPs, on the other hand, submitted that on 18-07-2013, a cashless request was received from the Woodlands Hospital Ltd., Kolkata in respect of the patient, namely, Mrs. Twinkle Poddar, wife of the Complainant, who got admitted with c/o Menorrhagia and diagnosed as Fibroid Utreas and underwent Lap Myomectomy and accordingly, an initial approval of Rs. 40,000/- was given to the hospital.  Subsequently, final approval was given for Rs. 1,06,875/-.  After settlement of the aforesaid claim, another request with regard to pre/post claim for a sum of Rs. 1,42,298/- was received by the OPs on 19-08-2013.  In response to the said claim, after reviewing the papers, some information was solicited from the Complainant.  Since no reply was given by the Complainant, they sent reminder letters to him.  Ultimately, on receipt of reply from the Complainant on 18-09-2013 and after reviewing the documents, the said claim was rejected for non-disclosure of information in the proposal form.  The Complainant ported the policies suppressing the fact that his wife underwent Ovarian Cystectomy in the year 2006. Such suppression was in gross violation of the IRDA guidelines and rules thereunder.  As the Insurance Policies were secured by the Complainant on the basis of such suppression and/or non-disclosure of material information, the same ought to be terminated on that score alone, apart from non-response to the queries raised by the Insurance Company. They claimed that the instant claim was rightly repudiated by them.

Decision with reasons

We have attentively heard the submission advanced by the Ld. Advocates of the parties and gone through the documents on record.

Undisputedly, the Appellant took some mediclaim policies from National Insurance Co. Ltd. in the year 2005 and cyst operation was done on his wife in the year 2006. 

It goes to show that the patient, Smt. Twinkle Poddar was not suffering from any pre-existing disease, but the disputed cyst operation was performed while the previous mediclaim policies were in vogue with the National Insurance Co. Ltd.

According to the IRDA Circular bearing no. IRDA/HLT/MISC/CIR/030/02/2011 dated 10-02-2011, all Insurers issuing health insurance policies shall allow for credit gained by the insured for pre existing condition(s) in terms of waiting period when he/she switches from one Insurer to another or from one plan to another, provided the previous policy has been maintained without break.

In such circumstances, it is not understood, how such non-disclosure of 7-year old cyst operation could stand in the way of settlement of the subject claim. Since Appellant’s wife was not suffering from any pre-existing disease in the strictest term of the word, we are of considered view that, the Respondents had no legitimate right to repudiate the his claim. 

In view of this, we totally disagree with the findings of the Ld. District Forum.

Hence,

O R D E R E D

The Appeal stands allowed on contest against the Respondents with a cost of Rs. 15,000/- being payable by the Respondents to the Appellant.  Respondents shall withdraw the termination letter dated 18-02-2014 being issued by them and settle the instant claim within 40 days from today along with simple interest @ 9% p.a. over the said sum from the date of filing of the complaint case till full and final payment is made. The impugned order is hereby set aside.