Order No. 18 dt. 02/11/2017
The case of the complainant in brief is that the complainant opened a policy with the o.p. in the year 2006. The wife of the complainant had a cyst operation but due to mistake the complainant failed to mention about the said operation. Since the year 2006 – 2013 the wife of the complainant did not make any claim from the o.p. insurance company. On 29/07/2013 the wife of the complainant admitted to Woodland hospital for surgery of fibroid cyst and a cashless benefit of Rs. 1,06,875/- was sanctioned. The complainant claimed the Rs. 1,42,258/- which was pre and post-doctor’s consultation fee was claimed. The o.p.s after receiving the said letter terminated the policy of the complaint and also informed the complainant that the premium paid by the complainant has been forfeited for suppressing the fact regarding operation had taken place in the year 2006. It was stated by the complainant that the action of the o.p.s was illegal and as such the complainant filed this case praying for direction upon the o.p.s to withdraw the letter of termination dt. 18/02/2014 and to settle the claim of the complainant, The complainant prayed for damages of Rs. 5,00,000/- and Rs. 20,000/- for litigation cost.
O.p.s contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant is the holder of a health insurance policy with hospitalization benefits under the o.p. 1, insurance company after having it transferred from National Insurance Company in 2003 and the said policy had been renewed from time to time. On 18/07/2013 the cashless request was received from Woodland Hospital Ltd., Kolkata for the patient, Twinkle Poddar who was admitted there for fibroid uterus and estimated cost was Rs. 1,06,875/-. The insurance company initially approved Rs. 40,000/-. Final approval was accorded after receiving the bill of Rs. 1,06,875/-. After settlement of the said claim another claim was made of Rs. 1,42,298/-. The o.p. 1, insurance company sought for some documents from the complainant. But the complainant did not provide those documents. Subsequently, an intimation was received from the complainant on 18/09/2013 and after reviewing the documents the claim of the complainant was rejected on 03/10/2013 on the ground that the patient underwent bilateral ovarian cystectomy in 2006 details of which were not given in the proposal form. The claim was therefore not accepted and closed and the complainant never disclosed the said operation and biopsy report. For suppression of material fact willfully the policy issued to the complainant was cancelled and the said fact was intimated to the complainant. The complainant subsequently prayed for reconsideration of the said decision. But he same was also rejected. The complainant did not come with clean hands and as such the o.p.s prayed for dismissal of the case.
On the basis of the pleadings of the respective parties following points are to be decided :-
- Whether the complainant was the holder of mediclaim policy under the o.p. 1 ?
- Whether the complainant failed to provide the necessary information at the time of obtaining policy ?
- Whether there was any deficiency in service on the part of the o.p.s ?
- 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 opened a policy with the o.p. in the year 2006. The wife of the complainant had a cyst operation but due to mistake the complainant failed to mention about the said operation. Since the year 2006 – 2013 the wife of the complainant did not make any claim from the o.p. insurance company. On 29/07/2013 the wife of the complainant admitted to Woodland hospital for surgery of fibroid cyst and a cashless benefit of Rs. 1,06,875/- was sanctioned. The complainant claimed the Rs. 1,42,258/- which was pre and post-doctor’s consultation fee was claimed. The o.p.s after receiving the said letter terminated the policy of the complaint and also informed the complainant that the premium paid by the complainant has been forfeited for suppressing the fact regarding operation had taken place in the year 2006. It was stated by the complainant that the action of the o.p.s was illegal and as such the complainant filed this case praying for direction upon the o.p.s to withdraw the letter of termination dt. 18/02/2014 and to settle the claim of the complainant, The complainant prayed for damages of Rs. 5,00,000/- and Rs. 20,000/- for litigation cost.
Ld. Lawyer for the o.p.s argued that the complainant is the holder of a health insurance policy with hospitalization benefits under the o.p. 1, insurance company after having it transferred from National Insurance Company in 2003 and the said policy had been renewed from time to time. On 18/07/2013 the cashless request was received from Woodland Hospital Ltd., Kolkata for the patient, Twinkle Poddar who was admitted there for fibroid uterus and estimated cost was Rs. 1,06,875/-. The insurance company initially approved Rs. 40,000/-. Final approval was accorded after receiving the bill of Rs. 1,06,875/-. After settlement of the said claim another claim was made of Rs. 1,42,298/-. The o.p. 1, insurance company sought for some documents from the complainant. But the complainant did not provide those documents. Subsequently, an intimation was received from the complainant on 18/09/2013 and after reviewing the documents the claim of the complainant was rejected on 03/10/2013 on the ground that the patient underwent bilateral ovarian cystectomy in 2006 details of which were not given in the proposal form. The claim was therefore not accepted and closed and the complainant never disclosed the said operation and biopsy report. For suppression of material fact willfully the policy issued to the complainant was cancelled and the said fact was intimated to the complainant. The complainant subsequently prayed for reconsideration of the said decision. But he same was also rejected. The complainant did not come with clean hands and as such the o.p.s prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that in the year 2012 the complainant was opted from the erstwhile insurance company being National Insurance Company to the Optima Restore Family Floater insurance policy of Apollo Munich Health Insurance Company for a period 18/04/2012 to 17/04/2013. At the time of opening the policy with the o.p. the complainant was provided with the policy kit. One of the terms of the policy was that at the time of entering into such policy the insured must disclose any previous ailment which he or she might have suffered and the complainant was aware of such policy term. Clause 5(u) of the policy reads as follows “We may at any time terminate this policy on grounds of misrepresentation, fraud, non-disclosure of material facts or non-co-operation by the policy holder or any one acting on behalf of the insured person.” It is an admitted fact that the patient, i.e. the wife of the complainant had undergone bilateral ovarian cystectomy in 2006 details of which were not given in the proposal form. In view of such non-disclosure the claim of the complainant was rejected. The complainant was asked to show cause before cancellation of the policy but no cogent ground was mentioned by the complainant for which the policy had to be rejected. Since there was violation of the terms and conditions of the policy and in the proposal form for obtaining policy the complainant failed to disclose the earlier operation underwent by the wife of the complainant thereby we hold that the o.p. insurance company rightly cancelled the said policy. The complainant thereafter prayed for re-consideration of the said cancellation of the policy but the same was also rejected and communicated to the complainant. It appears from the materials on record that the complainant deliberately suppressed the material fact at the time of obtaining policy and subsequently with the detection of the suppression of the material fact the policy was cancelled by the o.p. Since o.p. insurance company did not commit any illegality for which the complainant will get any relief from this Forum. 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, it is ordered,
that the case no. 321 of 2014 is dismissed on contest against the o.p.s without cost.
Supply certified copy of this order to the parties free of cost.
