PER MR.B.S.WASEKAR, HON’BLE PRESIDENT

1)                    The present complaint has been filed by the complainant under section 12 of the Consumer Protection Act, 1986. According to the complainant, his mother Mrs.Jayshree Arun Bagadia was covered under Extra Care Policy of the opponent/Insurance Company.  She was admitted in Zynova Hospital from 23^rd November, 2013 to 28^th November, 2013. She was shifted to Hinduja Healthcare Surgical Hospital on 28^th November, 2013 for treatment of unstable Angina with massive pulmonary emobolism.  She expired on 10^th December, 2013.  The complainant submitted the claim on 2^nd January, 2014 for Rs.8,58,832/-.  It was repudiated by the opponent on the ground of pre existing clause and non disclosure of ailment which was pre existing since twenty years.  The complainant submitted two medical certificates showing that hypertension is not a predisposing factor for pulmonary embolism. The policy was issued in continuity with the policy of National Insurance Company Limited since the year-2003. The claim is within policy period therefore the complainant has filed this complaint to direct the opponent/Insurance Company to pay the claim of Rs.8,58,832/- with interest. 

2)                The opponent appeared and filed written statement.  It is submitted that the claim was rightly repudiated on the ground of non disclosure of pre existing illness vide letter dated 16^th May, 2014.  The complainant submitted complaint before the Insurance Ombudsman and the same was rejected.  The mother of complainant was suffering from hypertension since last twenty years.  It was pre existing illness but it was not disclosed in the proposal form.  It was the risk factor which was not disclosed in the proposal form therefore the claim was repudiated.  There is no deficiency in service on the part of the opponent therefore the complainant is not entitled for the relief as claimed.

3)                After hearing both the parties and after going through the record, following points arise for our consideration.

POINTS

REASONS

4) As to Point No.1 & 2 :- The policy is not disputed.  The claim was repudiated on the ground of non disclosure of pre existing illness in the proposal form.  The complainant has not challenged that his mother was suffering from hypertension at the time of submitting proposal form.  It is not disputed that this pre existing illness was not disclosed in the proposal form.  According to the complainant, he has submitted two medical certificates issued by Dr.C.P.Shah and Dr.Sameer Garde.  As per these certificates, systemic hypertension is not a predisposing factor for pulmonary embolism.  According to the opponent, hypertension is one of the factor which was not disclosed by the complainant in the proposal form.  Non disclosure of existing illness is breach of the policy condition.  The learned advocate for the opponent has placed reliance on the judgment to Hon’ble National Commission in Revision Petition No.2314 of 2012, in the case of C.N.Mohan Raj –Versus- M/s. New India Assurance Company Limited, decided on 8^th October, 2012. In para 14 of the judgment, the Hon’ble National Commission has held has under :

Para 14 : Thus, looking from any angle, I have no hesitation in coming to the conclusion that the statement made by the petitioner/insured in the proposal form as to the state of his health was palpably untrue to his knowledge.  Thus, there was clear suppression of the material fact with regard to the health of the insured, and therefore, respondent was fully justified in repudiating the insurance contract.

The learned advocate for the opponent has further placed reliance on other judgment of the Hon’ble National Commission in Revision Petition No.447 of 2011, in the case of United India Insurance Company Limited –Versus- Dharam Dev Verma, decided on 5^th April, 2013.  In para 16 of the judgment, the Hon’ble National Commission has laid down as under :

Para 16 : From the totality of the facts and circumstances brought on record, it would appear that petitioner had suffered certain ailment in the year-1994 but did not disclose about the disease at the time of taking the mediclaim policy in question. Contract of insurance is based on utmost bonafide and faith which in our opinion, respondent has not stood up at the time of taking of policy. The fact remains that respondent has suppressed material facts in regard to his pre-existing ailments at the time of taking of policy and thus has not approached the Consumer Forum with clean hands.

Identical facts are before us.  The complainant failed to disclose the existing illness in the proposal form therefore his claim was rightly repudiated by the opponent.  There is no deficiency in service on the part of the opponent.  Therefore, the complainant is not entitled for the relief as claimed.  Hence, we proceed to pass the following order.

ORDER

1. Complaint stands dismissed.
2. Parties are left to bear their own costs.
3. Inform the parties accordingly.

Pronounced on 5^th May, 2016