This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that OP1 is the General Insurance Company and OPs2 and 3 are the Branch office of the insurance company and complainant purchased one policy namely Travel corp plus (US$ 5 lac.) Overseas Travel Insurance Policy being No.OG-13-2401-9910-00015272 on 02-02-2013 from OP Bajaj Allianz General Insurance Co. Ltd., for the period from 20-02-2013 to 19-02-2014 for which the total premium is Rs.8724/- was paid.

          Fact remains complainant along with his wife and daughter on 19-02-2013 had an overseas tour programme from Kolkata to Australia vis-Singapore by flight No.SQ-5487/SQ-217 and date of return journey was on 29-04-2013 from Melbourne to Kolkata by flight No.SQ-238/SQ-516.  It is specifically stated that the date of departure was on 19-02-2013 and date of arrival on overseas country on 20-02-2013 and the scheduled date of return to India was 17-05-2013.

          On 20-02-2013 after arrival at the Singapore Airport, complainant suddenly fell at the toilet of the Singapore Airport and immediately he was taken under the treatment of the Singapore Changi International Airport at their medical centre namely Raffles Medical” where he was given some preliminary medical support for his further journey by flight and he was given some preliminary medications along with some clinical examinations namely CT scan was done as the complainant had head injury and said Raffels Medical have given the certificate of consultation where it was certified by the concerned attending doctor of the said medical unit of the Singapore Changi International Airport that inter alia “This is to certify that I have attended to the abovementioned for the following condition- (i) Syncopr for evaluation, (ii) Hyperglycemis-missed medication.

          After some preliminary treatment made by the medical unit of the Singapore Changi complainant was certified as fit to travel further on the same date i.e. on 20-02-2013.

          Complainant submits that on 20-02-2013 thereafter, he availed of the flight to Australia from Singapore and after that he returned to Kolkata and again he made a medical check up at RTLLCS Narayana Hrudeyalaya Hospitals where he had been advised for taking admission and after due check up his final diagnosis have been made that he has complete heart block, Type-diabetes mellitus and minor coronary artery disease, as a result of which he was admitted on 27-05-2013 and the permanent pacemaker implantation was done on 28-05-2013 by the said hospital and on 30-05-2013 he was discharged in a stable condition and it is pertinent to mentioned that discharge summary dated 30-05-2013 in the case history of the complainant it is categorically mentioned that complainant admitted with the complaints of 2 episodes of synopses and swelling of legs and on evaluation he was diagnosed to have complete heard block.  Echocardiography revealed dilated LV cavity with adequate systolic function, wild to moderate MR, wild PATT with EF 55 percent.  Coronary angiogram dove on 28-05-2013 showed minor coronary artery disease.  Permanent pacemaker implantation was done on 28-05-2013. Post procedural period was uneventful.

          Complainant further submitted that on 28-05-2013 permanent pacemaker implantation was done due to complete heard block of the complainant as well as minor coronary artery disease was shown, which is evident from the discharge summary issued by the Narayana Hrudeyalaya Hospitals on 30-05-2013.

          On 06-05-2013 complainant submitted the claim form before the OP authority claiming Rs.1046 Singapore Dollar (in Rupee Rs.47,560/-) only which was given by him during the overseas travel period at the Singapore Changi International Airport on 20-02-2013.

          Complainant further submitted that OP Authority vide their letter on 29-07-2013 repudiated the claim on the ground of non-disclosure of material information and under Exclusion Clauses is only stated.  The said OP Company have mentioned that complainant had past medical history of insulin dependent diabetes mellitus and hence present ailment i.e. syncope was due to hyper glyceria which is pre-existing in nature as the major complication of ailment existed before policy inception date.  It was further mentioned by the OP that they are unable to settle the expenses as the claim falls under policy exclusion clauses as mentioned in Clause 2.4 and 2.4.12 of the Standard Travel Policy Exclusion and as per their clause the company shall be under no liability to make payment to the complainant in respect of any claim directly or indirectly caused by based on, arising out of on howsoever attributable to any of the following so such sort of repudiation is completely baseless on the ground during his stay at Singapore he fell down and sustained injury but it was not due to any pre-existing disease and complainant had no such diseases prior to the treatment made by Narayana Hrudeyalaya Hospitals and that treatment at Singapore was due to sudden fall but not for any other cause.  So, in the above circumstances, complainant has prayed for release of the said amount by the OP and treating the said repudiation is uncalled for and have no ground in the result complainant prays for redressal against the OP.

          On the contrary OP by filing written statement submitted that no doubt complainant purchased the said policy that is overseas travel insurance policy and it was valid for the period from 20-02-2013 to 19-02-2014 and complainant lodged the claim to the tune of 1046.60 Singapore Dollar incurred by him at Singapore towards Syncope under evaluation after missed dose of insulin and complainant has a past history of diabetes mellitus and no doubt as per contract and terms and condition of the policy complainant is not entitled to get any such amount which the OP is not liable to pay as per clause and for non-disclosure of his pre-existing diseases at the time of taking this policy complainant is not entitled to get any claim and in fact complainant suppressed his diseases and came to this Forum for relief and only for gaining unlawfully some amount and in fact, there was no negligence and deficiency on the part of the OP because entire matter is judiciously decided giving proper attention of the clause and also the fact of non-disclosure of the pre-existing diseases.  At the same time this forum can only decided the negligence and deficiency on the part of the OP but that is not been proved by the complainant when repudiation was made on the basis of proper judgments of the authority including decision of the medical board of the OP.

          Further OP has denied the entire allegations of the complaint and in fact, as per Clause 2.4.12 Insurance Company will not cover – any medical condition or complication arising from it which existed before the commencement of the policy period, or for which care, treatment or advice was sought, recommenced by or received from a Physician and after going through the document it is clear that insured is a known patient of DM II and that he was taking insulin to control it and on that date missed his insulin dosage and hence was taken for treatment and in the present case it is well estimated that DM is pre-existing and insured was taking precaution of the same and for which the OP repudiated the claim of the insured by a letter dated 29-07-2013 and the reason behind the repudiation is clearly mentioned by the Insurance company in their letter so, there is no deficiency on the part of the insurance company which is a sine qua non for the jurisdiction of the Consumer Forum to be invoked so the complaint should be dismissed and in the above circumstances, OPs have prayed for dismissal of the complaint.

Decision with Reasons

After comparative study of the complaint and written version and also the arguments made by Ld. Advocates of both the parties and further considering the treatment sheet issued by the Singapore Changi International Airport Authority it is clear that the complainant on the very date of incident of 20-02-2013 at Singapore Airport toilet fell down and sustained head injury and there he was treated and form the treatment sheet it is clear that he missed his insulin doses and was treated and from that document it is clear that he was suffering from DM II and insured was taking insulin prior to that.  Truth is that complainant purchased the present policy on 12-02-2013 covering overseas tour programme starting from 20-02-2013 to 19-03-2014.  Admitted fact on 20-02-2013 he fell down in the toilet of Singapore Changi International Airport where he was treated and the doctor of Airport pointed out Syncope for evaluation and Hyperglycemis and also noted missed doses of insulin and considering that certificate of the doctor of Singapore Airport Authority it is clear complainant has been suffering from high sugar for which he has been taking insulin daily and in the said prescription it is specifically mentioned that patient had past history of DM II and he was in the habit of taking insulin daily.  So, it is clear that prior to purchasing the present policy complainant had been suffering from high sugar for which he used to take insulin doses and on the date of incident on 20-03-2013 complainant did not take any insulin dose and for missing of dose he fell down and sustained head injury.  Thereafter, he was released but considering subsequent event it is clear that, thereafter, after returning from foreign land he admitted that he was admitted to Narayana Hrudeyalaya Hospitals for treatment where he was admitted on 27-05-2013 and permanent pacemaker implantation was done on 28-05-2013 and on 30-05-2013 he was discharged by a suitable condition but in discharge summary on 30-04-2013 it is found that complainant is admitted with two episode of synopses and swelling of legs and on evaluation it was diagnosed to have complete heart block.  Echocardiography revealed dilated LV cavity with adequate systolic function etc. and from the said hospital record it is also found that he was suffering from diabetes mellitus and minor coronary artery disease and considering subsequent medical papers report of the doctor of Narayana Hrudeyalaya it is clear that complainant had been suffering from high sugar for which he had to take insulin daily and in fact on the date of incident at Singapore on 20-03-20913 he did not take insulin for which he fell down that means complainant suffered from high blood sugar long prior to purchasing the present policy and it is within the knowledge of the complainant that he used to take insulin daily and he was suffering from high blood sugar and cause of coronary artery disease was due to diabetes mellitus.  So, it is clear that complainant had been suffering from high blood sugar and so, the patient of used to take daily insulin dose and in absence of insulin dose he was unable to walk and several problems he used to feel if insulin is not taken by the complainant.

          Considering all the above facts and materials we are convinced to hold that complainant was a coronary patient for high blood sugar for which his pancreas did not produce insulin and for that reason insulin was injected daily by him for maintaining his entire daily life and the system of the body then it is clear that he was a patient of high blood sugar prior to purchasing of this policy on 02-02-2013.  Truth is that it was within the knowledge of the complainant that he had been taking insulin daily and he was suffering from the diabetes but complainant did not disclosed it at the time of taking this policy.  Whatever it may be policy condition is there that if any person is found sufferers from hypertension or high blood sugar prior to purchasing of the policy and this fact is not disclosed intentionally at the time of purchasing the policy and subsequently, after purchase of the policy if it is detected at the time of considering any claim of the insured that he suppressed the fact of his suffering from hypertension and high blood sugar and as per Clause 2.4.12 of the policy Exclusion Clause insured is not entitled to get any benefit.  No doubt as per judgment of the National Commission decision on 16-04-2007 in case of Brig. J.S. Bawa vs. New India Assurance Co. Ltd. reported in II(2007) CPJ 350 N.C. we find that the parties of a contract cannot go beyond contract and their parties are acted by the terms and condition of the policy and if it is detected that pre-existing disease of the insured was not disclosed at the time of purchasing the policy but it is proved subsequent to that in that case the insured cannot get any benefit of any claim.  Further we have relied upon the another judgment passed by Hon’ble Supreme Court in Civil Appeal No.5322 of 2007 decided on 20-11-2007 (P.C. Chacko and anr vs. Chairman, Life Insurance Corporation of India and ors. Wherefrom we have gathered that Hon’ble Supreme Court specially decided that contracts of insurance including the contract of life assurance are contracts of uberrima fides and every fact of materiality must be disclosed.  There is good ground of rescission and this duty to disclose continues up to the exclusion of the contract and covers any material alteration in the character of the risk which may takeplace to the proposal and acceptance and in view of the above judgment and the decision of the National Commission, Apex Court and also considering that principle which are applied in this case.  So, in the facts and circumstance we are convinced to hold that this complainant with full knowledge of suffering from high sugar and about his taking insulin daily did not disclose it at the time of taking this insurance policy and truth is that due to such high blood sugar his heart was affected and this is confirmed by the complainant because he has stated that after his return from foreign land he was admitted to Narayana Hrudeyalaya for checking and it was detected that he had been suffering from full heart blockage due to DM II.  Considering all the above facts and circumstances, we are convinced to hold that repudiation as made by the complainant was completely justified, reasonable and truth is that complainant intentionally suppressed his pre-existing disease, high sugar and taking of insulin daily prior to purchasing this policy not only that it is also proved from the medical certificate issued by the doctor of Singapore Changi International Airport that complainant was a patient of DM II and has daily habits to take insulin but on 20-03-2013 he did not take any insulin and for loss of dose he fell down.  So, it is proved that complainant has violated the terms and condition of the policy and for non-disclosure of his pre-existing diseases as per Exclusion Clause of 2.4.12 of the policy he is not entitled to get any claim.  In the light of the above observation we are convinced to hold that the repudiation as made by the OP was justified and legal and there was no deficiency, negligence or illegality on the part of the OP for which the complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs but without any cost.