Sri Shyamal Gupta, Member

Present Appeal is directed against the Order dated 01-12-2017 of the Ld. District Forum, Kolkata-I (North), passed in CC/602/2014, whereof the complaint case has been dismissed.

The complaint case, in short, is that, the Complainants initially took a mediclaim policy from the National Insurance Co. Ltd. Subsequently, they ported the same to the OP No. 1.  In the year 2006, the Complainant No. 2 underwent cyst operation.  However, inadvertently the same was not mentioned to the National Insurance Co. Ltd. inasmuch as the same took place before the marriage of the Complainant No. 2.  Since the year 2006 till 2014, the Complainant No. 2 did not lodge any claim. On 19-02-2014, Complainant No. 2 was admitted at a private hospital due to acute intestinal obstruction and spent Rs. 30,400/- for such treatment.  After her discharge from the hospital, necessary claim was lodged with the OP Insurance Company.  The OP Insurer after sitting tight over their claim for a long period of time, ultimately terminated the insurance policy in question alleging suppression of material fact.  Against such backdrop, the instant complaint case was filed.

The OPs, on the other hand, by submitting WV stated that the Complainants concealed material facts about previous medical history of the Complainant No. 2 that she was diagnosed for Choledochal Cyst with Septicemia and early Pancreatitis and underwent necessary treatment for the same.  While taking the instant policy from these OPs, the Complainants, however,  did not disclose such fact.  Accordingly, the OPs rightly exercised their right to decline the claim by invalidating the said policy on account of misrepresentation and non-disclosure of material information.

Decision with reasons

Heard the Ld. Advocates of the parties and gone through the documents on record.

It is argued by the Ld. Advocate for the Respondents that in accordance with the terms and conditions of the subject policy, it was obligatory on the part of the Appellants to make candid disclosure about all their previous medical conditions.  Such inherent condition of the policy being not scrupulously fulfilled by the Respondents, the instant claim was not payable.  He also pointed out that in the proposal form there were questions requiring disclosure as regards ‘tumor – benign or   malignant, any alcer/growth/cyst’ and about ‘surgery undertaken in last 10 years’.  However, all the answers to such questions were given in the negative by the Appellant No. 1.  Stating that the Appellant No. 1 himself filled the proposal form and signed the same, being an educated person, he cannot claim that he was ignorant of his obligations under the policy.  Ld. Advocate for the Respondents, thus, denied any illegality/deficiency in service on their part.

Perusal of the record reveals that the Appellant No. 2 went under the knife for Choledochal Cyst in the year 2006. On the other hand, from the copies of treatment discharge certificate dated 21-02-2014, it transpires that the patient was admitted at the hospital with complaints of loose motion, vomiting and abdomen pain. 

It is true that, wittingly or otherwise, the Appellants did not disclose the past medical history of the Appellant No. 2.  Having said that, it is also a fact that there is nothing to show that such previous condition had any bearing in respect of the concerned medical condition for which the subject claim was staked. 

It appears from the documents on record that surgery was performed on the Appellant No. 2 for Choledochal Cyst in the year 2006 before her marriage.  Since the instant policy was taken post marriage, the possibility of ignorance of the Appellant No. 1, who signed the proposal form on behalf of other beneficiaries, about the past medical condition of his wife (Appellant No. 2) at that juncture cannot be ruled out as an absurd probability. 

Above all, there being nothing to show that said previous condition had any nexus with the concerned medical condition for which the subject claim was lodged, in my considered opinion; the Respondents had no business denying settlement of the claim of the Appellants.

Accordingly, I find enough merit in this Appeal.

Hence,

O R D E R E D

The Appeal stands allowed on contest against the Respondents with cost Rs. 10,000/- being payable by the Respondents to the Appellants.  Respondents shall settle the instant claim and further pay simple interest @ 9% p.a. over the said amount from the date of filing of the complaint case before the Ld. District Forum till full and final payment is made.  The impugned order is hereby set aside.