Petitioner was the opposite party before the District Forum, where the respondent / complainant had filed a complaint alleging deficiency in service on the part of the petitioner Insurance Company. Briefly stated the facts of the case are that the respondent / complainant was the beneficiary of a group Medi-claim Policy covering the risk of his wife and two minor sons, named, Amandeep and Anshul. During the life of the policy, complainant’s son Amandeep developed some heart disease for which he was admitted in Escort Heart Institute for which the complainant incurred an expenditure of Rs.1,41,615/-. Upon preferring the claim before the Insurance Company, it was repudiated on the ground that it was a pre-existing disease. It is in these circumstances, a complaint was filed before the District Forum, who after hearing the parties and perusal of material on record, allowed the complaint and directed the petitioner to pay a sum of Rs.1,41,615/- as claimed by the complainant alongwith interest @18% p.a. from 14.02.99 till final realisation. Petitioner was also directed to pay Rs.10,000/- for causing physical and mental agony. Cost of Rs.1,000/- was also awarded. Aggrieved by this order, the petitioner filed an appeal before the State Commission, which was dismissed, hence this revision petition before us. Upon admission, the respondent / complainant had not appeared despite service and receipt of Rs.5,000/- directed to be paid by us to respondent / complainant to enable him to come and defend the case. One more opportunity was also given for the respondent to appear yet no one is present, hence respondent / complainant is ordered to be proceeded ex-parte. We heard the Ld. Counsel for the petitioner and also perused the material on record. There is no dispute that in the discharge summary under the heading resumé of history, the following is recorded:- “Resumé of History Mast. Amandeep is a 2 year old male child who is a case of acyanotic congenital heart disease. He was detected to have ASD at the age of 3 – 4 months. He was advised further investigations. In view of his symptomatic status and ECHO findings he was advised surgery.” It cannot be disputed that the history of the child of having been affected with ASD, when he was 3 – 4 months’ old, would have been given by the father or the relative of the child Amandeep. It is also not in dispute that the child was taken to the hospital on 4.11.98 when he was two years old. In our view, what was the child’s health status when he was 3 – 4 months’ old, would come out only from the relation of the child. This is a record of a hospital duly signed by the Doctors concerned, hence it cannot be brushed away. In the aforementioned circumstances, it would be a clear case of suppressing the material information with regard to the health of Amandeep at the time of taking the policy, which would amount to suppression of material fact, thus, negatin g the benefits flowing from the Policy to the insured. In the aforementioned circumstances, we are unable to sustain the order passed by the District Forum affirmed by the State Commission, which is contrary to the law laid down in a catena of judgement. This revision petition is allowed and the complaint is dismissed.
......................JASHOK BHANPRESIDENT ......................B.K. TAIMNIMEMBER | |