Per :- Mr. Deshpande, President Place : BANDRA JUDGMENT The Complainant had taken health insurance policy from the Opposite Party – Cholamandalam MS General Insurance Company Ltd., which was effective from 11/7/2005 to 10/7/2006. After expiry of this period, the Complainant purchased health policy from the Opposite Party – Insurance Company; which was effective from 11/7/2006 to 10/7/2007 and the sum assured was of Rs.1,00,000/-. [2] According to the Complainant, in the month of April/May-2006, she started experiencing menorrhagia (excessive uterine bleeding), which did not recede for long time and she was hospitalized during the period 11/9/2006 to 18/9/2006 and was required to undergo abdominal hysterectomy. The Complainant submitted a claim to the Opposite Party – Insurance Company; for reimbursement of medical expenses in sum of Rs.33,575/- and the Opposite Party – Insurance Company; repudiated the claim on the ground that it was a pre-existing disease and not admissible as per the general exclusion clause in the policy. There had been a correspondence between the Complainant and the Opposite Party – Insurance Company; and the Complainant preferred an appeal before the Insurance Ombudsman, but there also met with the same fate and ultimately, the Complainant filed present complaint before this Forum making allegations of deficiency in service on the part of the Opposite Party – Insurance Company; and sought recovery of an amount in sum of Rs.33,575/- together with interest thereon and compensation. [3] Pursuant to the notice of appearance issued by this Forum, the Opposite Party – Insurance Company; appeared and contested the complaint by filing its affidavit of written version of defence and took stand that certificate dtd.18/8/2006, issued by Dr. Mehta’s Maternity Home, Borivali (East), Mumbai; a copy of which is produced on the record, clearly revealed that the Complainant was a case of menorrhagia since 1 ½ years with history of treatment. According to the Opposite Party – Insurance Company; inception of insurance policy was in the month of July-2005 and since the problem of menorrhagia had started from the month of March-2005, it was a pre-existing disease. This fact was suppressed by the Complainant while submitting the proposal form. Therefore, exclusion clause was rightly made applicable and thus, the Opposite Party – Insurance Company; justified its action of repudiation of the Complainant’s claim. [4] The Complainant filed her rejoinder to the written version of defence filed by the Opposite Party – Insurance Company. She also filed her affidavit of evidence and copies of relevant documents. Parties to the complaint proceeding also filed their respective written notes of arguments. [5] We have gone through the pleadings, affidavits and documents as well as written notes of arguments filed by the parties. [6] We take the points that arise for our consideration and record our findings there-against as below:- Sr. No. | Points for consideration | Findings | 1. | Whether the Complainant has proved that the Opposite Party – Insurance Company; is guilty of deficiency in service on account of repudiation of her claim? | NO | 2. | Whether the Complainant is entitled to the relief sought in the complaint? | NO | 3. | What order? | The complaint stands dismissed. |
REASONS FOR FINDINGS [7] Alongwith its written version of defence, the Opposite Party – Insurance Company; has produced on the record a copy of the proposal form filled in by the Complainant, a copy of renewal notice issued to the Complainant and a copy of the cheque under which premium was paid by the Complainant on 6/7/2006. The Opposite Party – Insurance Company; has also produced on the record a copy of the insurance policy. On going through the renewal notice, it is seen that the date of commencement of the insurance policy was 11/7/2005 ending on 10/7/2006 and renewal date was 11/7/2006. This is how the Complainant tendered a cheque dtd.6/7/2006 towards premium for the year 2006-07. The Complainant has produced on the record a copy of the insurance policy at Exhibit-A, which reveals that the policy was effective for the period 11/7/2006 to 10/7/2007. These facts are material in the context of ground of repudiation, which came to be mentioned by the Opposite Party – Insurance Company; in its repudiation letter. [8] A copy of repudiation letter dtd.3/10/2006 is produced on the record by the Complainant, at Exhibit-B, which shows that the Opposite Party – Insurance Company; repudiated the claim on the ground that the Complainant was suffering from menorrhagia since the month of March-2005 and it was before inception of insurance policy and thus, pre-existing disease, which falls under Exclusion Clause No.C-1 of the policy document. Repudiation letter, a copy of which is produced on the record at Exhibit-B, shows that the certificate produced by the Complainant revealed that hospitalization was for the period 11/9/2006 to 18/9/2006 in a non-network hospital and the documents revealed that the Complainant was admitted with a complaint of menorrhagia since last 18 months. The fact that the Complainant was suffering from menorrhagia before 18 months prior to hospitalization i.e. since March-2005 does not require discussion because in paragraph (04) of the complaint itself, the Complainant has admitted the fact that the Complainant had health problem of menorrhagia (excessive uterine bleeding) in the month of March-2005 which continued till July-2005. This statement in paragraph (04) of the complaint amounts to candid admission on the part of the Complainant as regards the fact that she was suffering from menorrhagia since the month of March-2005 i.e. prior to inception of insurance policy. [9] Turning to the provisions contained in the policy document, Clause-C thereof, relates to ‘General Exclusions’ and Clause-C/1 reads as follows:- “Any Pre-Existing Condition or related condition for which care, treatment or advice was recommended by or received from a Doctor or which was first manifested prior to the commencement date of the Insured’s first Individual Health Insurance Policy with the Insurer. However, this exclusion shall cease to apply to such pre-existing condition if the Insured has maintained an Individual Health Insurance Policy with the Insurer for a consecutive 3-year period and no claim, care, treatment or advice has been recommended by or received from a Doctor in relation to such Pre-Existing Condition during that 3-year period.” [10] Reading of Clause No.C/1 shows that this exclusion clause was not to be applicable if, the Insured has maintained an Individual Health Insurance Policy with the Insurer for a consecutive three year period before the treatment leading to submission of claim. In the present case, three years period was not completed, and therefore, the exclusion clause would be squarely applicable. As pointed out above, as per the admission on the part of the Complainant, in paragraph (04) of the complaint itself, she was suffering from menorrhagia since the month of March-2005. This fact was conveniently suppressed by the Complainant while filling in the proposal form, a copy of which is annexed to the written version and therein the Complainant replied all the questions in the negative, thereby indicating that before tendering the proposal form, she had no health problem of any nature what-so-ever. Needless it to say that contract of insurance is ‘uberium fides’ and the proposer – the Insured; is expected to make bonafide & true statements while submitting the proposal form. Any statement leading to suppression of material fact results into vitiating the insurance policy. Consequently, Section-45 of the Insurance Act, 1945; becomes application to such situation. Reference in this regard can be usefully had to decision of the Apex Court in Life Insurance Corporation of India Vs. Smt. Asha Goel & Anr. ~ (2001)-SCC-160. [11] The Complainant, in her written notes of arguments, has tried to explain that it was not a serious ailment and should not have been considered by the Opposite Party – Insurance Company; to repudiate her claim. However, that does not appear to be the case because the Complainant had taken treatment at a hospital at Mira Road, Thane; and this fact is mentioned in paragraph (04) of the complaint. It was for the same disease i.e. menorrhagia. Therefore, the justification offered by the Complainant is not at all convincing. [12] In addition to above, the Complainant tried to mislead the Forum by suppressing the fact that the insurance policy, which was effective from 11/7/2005 to 10/7/2006 was renewed by her. Averments in paragraph (03) of the complaint articulate concealed attempt on the part of the Complainant to show that for the year 2006-07 it was altogether new policy and not a renewed policy. However, the copy of renewal notice produced on the record by the Opposite Party – Insurance Company; reveals that the policy was purchased in the month of July-2005 and renewed in July-2006. Inception of policy has been mentioned in the certificate of insurance. Therefore, the Complainant is not a bonafide consumer and the claim has been rightly repudiated by the Opposite Party – Insurance Company. With this, we proceed to pass the order as below:- ORDER The complaint stands dismissed. No order as to costs. Parties shall be informed accordingly, by sending certified copies of this order.
| | [HONORABLE Mrs.DEEPA BIDNURKAR] Member[HONORABLE Mr. J. L. Deshpande] PRESIDENT[HONORABLE MR.V.G.JOSHI] Member | | 
