Date of Filing : 10/09/2014
Order No. 16 dt. 01/12/2017
The case of the complainant in brief is that the complainant obtained the mediclaim policy from the National Insurance Company Ltd. Subsequently the policy was changed from National Insurance Company o.p.1. In the year 2006 the o.p. 2 underwent an operation but the said fact was informed to the o.p.1. The complainant went on paying of premium regularly to the insurance company. But the complainant never claimed any medical reimbursement bill from the o.p. The wife of the complainant became ill on 19.02.2014 and she was admitted to ILS Hospital due to acute intestinal obstruction. After treatment she was discharged on 21.02.2014 incurring an expenses Rs.30,400/-. After recovery the complainant made a claim from the o.p.1 but the same was rejected by o.p.1 since the o.p.1 alleged that there was suppression of fact of history of any disease at the time of obtaining from the insurer i.e. o.p.1. The o.p.1 after receiving the medical papers from the complainant check the medical bills and also contact with the Nursing Home wherefrom the history of the patient was received by the insurance company. The complainant further stated that at the time of obtaining policy the complainant due to his mistake failed to disclose the earlier operation underwent by his wife complainant no.2 and the said fact was brought to the notice of the o.p.1 during the subsistence of the said policy. Since the o.p.1 did not take note of the said fact and by adopting the unfair means the claim of the complainant was repudiated. On the basis of the said fact the complainant filed this case praying for direction upon the o.p.1 for reimbursement of medical bill of the complainant no.2 as well as compensation and litigation cost.
O.ps 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 the mediclaim policy and was later ported to Optima Restore Floater Policy from Apollo Munich Health Insurance Company. The complainants at the time of applying to the insurance company agreed, acknowledged and accepted the terms and conditions provided in such insurance policy. One of the terms of the insurance policy was that at the time of entering into such policy the insured must disclose any previous ailment which he/she might suffer or has suffered. Non-disclosure of such information shall entail repudiation of such insurance claim of the insured and termination of the policy by giving 30 days notice to the policy holder. The complainant made a claim for reimbursement of medical expenses to the tune of Rs.30,398/-. The complainants did not disclose that the complainant no.2 had undergone a surgery in the year 2006 for treatment of choledocl cyst with septicemia although there was specific question in the proposal form and they admitted such non-disclosure. For suppression of pre existing disease the claim of the complainant was repudiated. It was also stated that 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 the same was also rejected. The complainants did not come with clean hands and as such the o.ps prayed for dismissal of the case.
On the basis of the pleadings of the respective parties following points are to be decided:-
- Whether the complainants had the policy with the o.p1?
- Whether the complainants suppressed the material fact at the time of obtaining policy?
- Whether the complainants prayed for medical reimbursement of Rs.30,398/-?
- Whether there was any deficiency in service on the part of the o.ps?
- Whether the complainants will be entitled to get any 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 obtained the mediclaim policy from the National Insurance Company Ltd. Subsequently the policy was changed from National Insurance Company o.p.1. In the year 2006 the o.p. 2 underwent an operation but the said fact was informed to the o.p.1. The complainant went on paying of premium regularly to the insurance company. But the complainant never claimed any medical reimbursement bill from the o.p. The wife of the complainant became ill on 19.02.2014 and she was admitted to ILS Hospital due to acute intestinal obstruction. After treatment she was discharged on 21.02.2014 incurring an expenses Rs.30,400/-. After recovery the complainant made a claim from the o.p.1 but the same was rejected by o.p.1 since the o.p.1 alleged that there was suppression of fact of history of any disease at the time of obtaining from the insurer i.e. o.p.1. The o.p.1 after receiving the medical papers from the complainant check the medical bills and also contact with the Nursing Home wherefrom the history of the patient was received by the insurance company. The complainant further stated that at the time of obtaining policy the complainant due to his mistake failed to disclose the earlier operation underwent by his wife complainant no.2 and the said fact was brought to the notice of the o.p.1 during the subsistence of the said policy. Since the o.p.1 did not take note of the said fact and by adopting the unfair means the claim of the complainant was repudiated. On the basis of the said fact the complainant filed this case praying for direction upon the o.p.1 for reimbursement of medical bill of the complainant no.2 as well as compensation and litigation cost.
Ld. Lawyer for the o.ps argued that the complainant is the holder of the mediclaim policy and was later ported to Optima Restore Floater Policy from Apollo Munich Health Insurance Company. The complainants at the time of applying to the insurance company agreed, acknowledged and accepted the terms and conditions provided in such insurance policy. One of the terms of the insurance policy was that at the time of entering into such policy the insured must disclose any previous ailment which he/she might suffer or has suffered. Non-disclosure of such information shall entail repudiation of such insurance claim of the insured and termination of the policy by giving 30 days notice to the policy holder. The complainant made a claim for reimbursement of medical expenses to the tune of Rs.30,398/-. The complainants did not disclose that the complainant no.2 had undergone a surgery in the year 2006 for treatment of choledocl cyst with septicemia although there was specific question in the proposal form and they admitted such non-disclosure. For suppression of pre existing disease the claim of the complainant was repudiated. It was also stated that 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 the same was also rejected. The complainants did not come with clean hands and as such the o.ps prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant ported their insurance policy from the National Insurance Company Ltd to o.p.1 insurance company in the year 2014 and the policy covered for the period from 25.01.2014 to 24.06.2015. 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 complainants were aware of such policy terms. As per the terms and conditions of the policy u/s Clause 5(u) of the said insurance 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 top 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 the 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.602/2014 is dismissed on contest against the o.ps without cost.
Supply certified copy of this order to the parties free of cost.
