DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/83/2016
No. DF/ Central/
Gaurav Srivastava,
V-269, Street No.20, Vijay Park, Maujpur,
Delhi-110053
…………..COMPLAINANT
VERSUS
1.M /s Apollo Munich Health Insurance Co. Ltd
1st Floor, 6 8r, 7 B. K. Roy Court,
Asaf Ali Road, New Delhi-1 10002
(Through its Managing Director / Directors)
2. M / s Family Health Plan TPA Ltd.
Plot No.-277, 1St Floor, Udyog Vihar,
Phase-IV, Gurgaon, Haryana-l22010
…..OPPOSITE PARTIES
ORDER
Vikram Kumar Dabas, Member
- Sh. Gaurav Srivastava, ( in short the complainant) has filed the instant complaint U/s 12 of the Consumer Protection Act 1986 as amended upto date (in short the Act) against M/s Apollo Munich Health Insurance Co. Ltd (in short the OP1) and M / s Family Health Plan TPA Ltd. (in short the OP2) stating therein that he had taken cash less medical insurance policy namely “Optima Restore Insurance Policy” for a sum insured Rs.3,00,000/- from OP1 bearing no. 110100/11121/6000076547 covering him and his wife Mrs Shalini Kumari from 29/01/2013 to 28/01/2014 and had paid premium of Rs 6,874/- in respect of the said policy. On 10/06/2013 complainant’s wife Mrs. Shalini Kumari due to abdominal distension from one month was admitted at Fortis Memorial Research Institute, Sector-44, Gurgaon and diagnosed with “Extensive Endometriosis with Anemia” and discharged on 15/06/2013. It is further stated by the complainant that when the hospital applied for cashless facility for the complainant against the above referred policy for the treatment of his wife the same was not approved and the he had to bear the whole hospitalization and other expenses amounting to Rs.1,30,775/ from his own pocket. The complainant lodged the claim of Rs.1,30,775/- with opposite party no.2 on 25/06/2013 vide ref. no.01/mc/gau.2013-14 and submitted all the required documents. On 30/ 10/2013 the claim of the complainant was arbitrarily rejected vide ref. no. FHPL-CL-FT-05 by opposite party no.1 due to reason “medical history details of Serous Cystadenoma in 2007 is not revealed at the time of issuance of the policy in the proposal form and the claim is repudiated due to Non-disclosure and concealment of facts under section 5 u of policy terms and conditions which is unjust and unlawful. Hence the complaint seeking direction to the OPs as under:
(i) Bring forth the entire record of the case to this Hon’ble Forum.
(ii) To direct the opposite parties to make payment of Rs.l,30,775/-of medical claim.
(iii) To direct the opposite parties another sum of Rs.2,00,000/- as compensation for pain, sufferings, mental agony, physical inconvenience, mental physical harassment, social embarrassment, mental torture, and
immense distress.
(iv) To allow the cost of litigation expenses of Rs.21,000/-.
(v) Any other relief or remedy to which this Hon’ble Forum may deem fit and proper may also be passed in favour of the complainant and against the OPs.
- On receipt of notice the OP1 appeared and contested the claim vide its written statement and has reiterated that the insured had made a misstatement about the state of his health and , therefore, the claim lodged by the complainant has been rightly repudiated by it. It is stated that complainant is not entitled any relief as he has concealed the fact and OPs have been writing letters (dated 26.09.2013,08.10.2013 and 23.10.2013) to complainant to provide relevant documents to enable it consider his claim but the complainant had deliberately not provided said documents. It is further stated that the insured has concealed the fact that his wife was suffering from pre-existing disease and had a history of Rt Ovarain Cystectomy in 2007 prior to obtaining policy and prayed for dismissal of the present complaint with heavy cost.
- Vide order dated 02.12.2016 OP2 was proceeded with ex-parte.
- We have heard Sh. Sanjeev Behl counsel for the complainant and Mr. Rohit counsel for the OP.
5. The learned counsel for the OP has forcefully contended that the OP had rightly repudiated the claim filed by the complainant as the complainant was guilty of misstatement about the state of health of insured. He has contended that the complainant had concealed material facts about the previous ailment of the insured and therefore the contract of insurance stood vitiated. Due attention has been drawn to the discharge summary prepared at Fortis Memorial Research Center/ Hospital , Gurugram in respect of the insured. Attention has also been drawn to the past history recorded in the discharge summary which shows that the insured had suffered from dysmenorrhea in the past. The past history also shows that the insured had taken anti tubercular treatment (ATT) for a period of 6 months and had been operated upon in 2007 for right ovarian cystectomy. Attention has also been drawn to the proposal form wherein the complainant was specifically asked about the state of health of the insured especially with regard to the detection of a cyst to which the complainant had replied in the negative. The learned counsel contends that the complainant was guilty of suppression of material facts and had he disclosed about the fact of operation in 2007, the OP might not have consented to the contract of insurance.
6. We have considered the contentions raised on both sides and we tend to agree with the learned counsel of the OP that the complainant had not acted in good faith and had failed to disclose material facts at the time of purchase of the policy. In view of the contention raised by the learned counsel for OP we are of the considered opinion that the OP was justified in repudiating the claim of the insured who suffered from a pre-existing disease which the complainant had failed to disclose. We , therefore, see no merits in their case. Accordingly the complaint is dimssed.
Announced on this Day of February 2018.
