THE PRESIDENT

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

WEST TRIPURA : AGARTALA

 

CASE No. CC- 05 of 2020

 

Sri Sujit Debnath,

S/O- Sri Rajendra Debnath,

Narsingarh, South Bagadi,

Near TIT College, P.S. Airport,

District- Tripura West. .......….................Complainant.

 

-VERSUS-

 

1. Appollo Munich Health Insurance Co. Ltd.

Corporate Office: 1st Floor, SCF-19,

Sector-14, Gurgaon-122001, Hariyana,

(To be represented by its Authorized person).

 

2. The Manager,

Appollo Munich Health Insurance Co. Ltd.,

Agartala Branch Office, 2nd Floor,  

Techno Building, Mantri Bari Road, 

Agartala, West Tripura- 799001.

 

3. The Branch Manager,

Axis Bank, Usha Bazar Branch, 

P.S. Airport,  West Tripura.

P.O. Agartala, Airport-799009.

 

4. ILS Hospital, Agartala, 

Capital Complex Extension,

P.S. N.C.C. West Tripura -799010,

(To be represented by its authorized person),

 

5. Fortis Hospitals Kolkata,

730, An andapur, EM By Pass Road,

Kolkata, West Bengal 700107,

(To be represented by its authorized person). .................Opposite Parties.

 

 

    __________PRESENT__________

 

 SRI RUHIDAS PAL

PRESIDENT,

  DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION

      WEST TRIPURA, AGARTALA. 

 

Dr (SMT) BINDU PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

SRI SAMIR GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.

 

 

 

C O U N S E L

 

For the Complainant : Sri Bhaskar Debroy,

  Sri Alak Datta,

  Sri  Pulak Saha,

  Sri Anjan Debnath,

  Learned Advocates.     

For the O.P. No.1 & 2 : Sri Sampad Choudhury,

  Learned Advocate.

 

For the O.P. No.3 : Smt. Pushpita Chakraborty,

  Learned Advocate.

 

 

 

JUDGMENT  DELIVERED  ON :  23.02.2022

 

J U D G M E N T

The Complainant's case in short is that the complainant is a reputed person. On 12.03.2019 the complainant purchased a Health Insurance policy from the respondent company through Axis Bank, Usha Bazar Branch(O.P. No.3) vide policy no-151600/11228/AX00184538 covered with the Health insurance of personal illness of the complainant. During filling up the policy form the complainant disclosed everything about the existing health condition to Appollo Official namely Joydeep Banik in presence of Branch Manager, Axis Bank, Usha Bazar Branch and paid Rs.9999/- to the O.Ps and accordingly acknowledgment is issued by the O.P. No.1. As per terms and condition of the said policy the complainant insured for Rs.3,00,000/- for treatment with the period on and from 28.01.2019 to 27.01.2020. On 10.09.2019 the complainant was feeling unwell and accordingly on 11.09.2019 he went to ILS Hospital, Agartala and as per the advice of the doctor the complaint admitted in ILS, Hospital Agartala. During admission the complainant informed the hospital authority about his health insurance. Till 13.09.2019 the complainant was admitted in the ILS Hospital, Agartala and after several clinical investigation the doctor opined that the complainant is suffering from 'Renal Centre Carcinoma(left Kidney)' and referred him for higher centre for further evaluation and management. On 13.09.2019 the complainant has been discharged from the ILS hospital but at the time of discharge hospital authority informed that the O.P. no.1 has declined to pay the bill amount of Rs.37,212/- and the complainant has to pay the whole amount in cash. As per advice of the doctor of ILS hospital the complainant went to Kolkata on 14.09.2019 and visited the chamber of doctor S.K. Baishya and finally as per his advice on 17.09.2019 he admitted in the Urology department of Fortis Hospital, Kolkata. After diagnosis the doctor confirmed SOL in left kidney suggestive of RCC and as per the advice of the doctor on 18.09.2019 surgery has been done to remove the left kidney(left Laparoscopic radical Nephrectomy done under general anesthesia). He was treated in the Fortis hospital till 23.09.2019. On 23.09.2019 he was discharged with the advice to follow up the treatment under the supervision of said hospital till 30.09.2019. On 23.09.2019 at the time of discharge the officials of the said cash counter informed that the O.P. No.1 refused to pay the bill amount without citing any reason. Finding no other alternative complainant paid the entire bill amount of Rs.1,92,361/- by taking loan from his relatives. And returned to Agartala on 30.09.2019. After returning home the complainant on several occasions visited the office of the respondents and narrated the facts and circumstances and sought for appropriate remedy and also sent several mail communication to the respondents but the O.P. did not pay any heed on the request of the complainant. On 04.11.2019 the O.P. No.1 sent one mail communication to the complainant in reply. In the said reply O.P. stated that the claim of the complainant is not payable and the policy is cancelled due to Non disclosure and concealment of facts, which is false fabricated and wild story made out by the O.P. only to deprive the complainant from his legal entitlements. Due to the negligent conduct and deficient service of the O.Ps the complainant had to spent huge money and other expenses and also suffers mental agony for which the complainant is entitled to get compensation. Hence complainant filed this complaint for getting relief.  

 

2. After receipt of notice O.Ps appeared and filed their respect written objections. O.P. No.1 and 2 in their written objection have stated that the answering O.P. submits that the present complainant filed by the complainant is entirely vague, false vexatious and frivolous without merit and it is an abuse of Consumer Protection Act, 1986 and the same ought to be dismissed with cost. That the present complaint has been filed by the complainant only to injure the goodwill and reputation of O.P. No.1 & 2. It is also stated by the O.P. that the commission has no jurisdiction to entertain the present complaint. Since, the policy was obtained by the complainant by suppressing his past medical history since 2016 i.e., before policy inception, the insurance contract which culminated into the policy forming subject matter of the present complaint is in-valid, void-ab-initio, inoperative and unenforceable.

O.P. No.3  in their written objection stated that the instant petition is not maintainable in its present form and nature. There is no cause of action in the instant petition. The complaint petition is bad for non-joinder of necessary parties. In regard to para no. 1, 2, 3, and 4 of the complaint petition the O.P. No.3 submitted that there is nothing to say as it is matter of records. It is also stated by the O.P. No.3 that the complainant himself must proof by submitting all the relevant papers regarding claim. There is no deficiency of service on the part of the O.P. No.3. O.P. No.4 & 5 are proforma parties.  

 

3. EVIDENCE ADDUCED BY THE PARTIES:-

Complainant submitted his examination in chief on affidavit as P.W. Complainant also filed some documents(7 nos) vide firisti dated 04.01.2020 in support of his case.  

On the other hand, O.P. No.1 and 2 filed examination in chief on affidavit of one Saswata Banerjee as O.P.W. Also filed 7 documents in support of their case.  

One Sri Parthideb Bhattacharjee, Branch Head, Axis Bank, Usha Bazar Branch has filed examination in chief on affidavit on behalf of the O.P. No.3. 

 

4. POINTS TO BE DETERMINED: - 

(i) Whether the complaint is maintainable in law?

(ii) Whether there is deficiency of service on the part of the O.Ps?

  (iii) Whether the complainant is entitled to get compensation/ relief as prayed for?

 

5. ARGUMENTS: - 

On the date of argument complainant as well his engaged counsel was absent. Only Learned Advocate Mr. Sampad Chouhdury was present on behalf of the O.P. No.1 and 2. Accordingly we heard Mr. Choudhury. Written argument is also submitted on behalf of the O.P. No. 1 and 2. At the time of argument Mr. Choudhury submitted that the complainant had with malafide and dishonest intention, concealed the material facts to twisted and distorted the facts and misleaded the Commission by filing this complaint. The complaint deserves outright dismissal. Mr. Choudhury further submits that since the policy was obtained by the complainant by suppressing his past medical history of Ankylosing Spondylities since 2016 i.e., before policy inception: the insurance contract which culminated into the policy forming subject matter of the present complaint, is invalid void-ab-initio, inoperative and unenforceable. Therefore, the present complaint is liable to be dismissed. Mr. Choudhury further submitted that it is settled law that insurance is a contract based on complete good faith and any suppression of material facts would be breach of such contract and the insurer would be  justified in repudiating the claim, once  such suppression is established. 

None was present on behalf of the O.P. No.3, 4 and 5 at the time of argument.

 

6. DECISION AND REASONS THEREOF:-

All the points are taken up together for convenience. We have carefully gone through the pleadings submitted by both the parties. We have also gone through the un-exhibited documents. On perusal of the documents we find that there was intentional suppression of past medical history of Ankylosing spondylities since 2016 that is before the policy inception of the complainant. The said intentional non-disclosure of material facts goes to the root of the matter vitiating the subject policy and rendered it invalid, void-ab-initio and unenforceable. There is settled principles of law that intentional suppression of past medical history indicates breach of contract of insurance policy. 

 

7. After over all appreciation of pleadings as well evidence adduced by the parties, we are in the opinion that the complainant suppressed material facts at the time of entering into the insurance contract. So, we do not find any deficiency in service on the part of the O.Ps. Hence, complaint is dismissed as devoid of merit. No costs.

Announced.

 

 

 

SRI R. PAL

PRESIDENT, 

DISTRICT CONSUMER  

DISPUTES REDRESSAL COMMISSION,

WEST TRIPURA, AGARTALA. 

 

 

 

Dr (SMT) B. PAL

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION, 

  WEST TRIPURA,  AGARTALA.

 

 

 

SRI S. GUPTA,

MEMBER,

  DISTRICT CONSUMER 

DISPUTES REDRESSAL COMMISSION

  WEST TRIPURA,  AGARTALA.