DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (CENTRAL) ISBT KASHMERE GATE DELHI
CC/53/2018
No. DF/ Central/
Joginder Sharma
S/o Late Sh. Asha Ram
R/o H. No. B – 105,
Holi Chowk Punjabi Basti,
Baljeet Nagar, Delhi
.....Complainant
VERSUS
Cholomandalam
Branch Office at Plot No. 6,
Adjacent to Metro Pillar 81,
Pusa Road, Karol Bagh, New Delhi
…..Opposite Party
Coram: Ms. Rekha Rani, President
Sh. R.C. Meena, Member
ORDER
Sh. R.C. Meena, Member
1. Sh. Joginder Sharma(in short the complainant) has filed the instant complaint against the Cholamandalam (in short OP) U/s 12 of the Consumer Protection Act 1986 as amended up to date (in short the Act) pleading therein following facts :
2. Complainant had availed a health insurance policy bearing no. 2856/00203521/000/01 on membership No. A3189273 dated 06.10.2017 to 05.10.2018. He was admitted in the Apollo Spectra Hospitals 66A/2, New Rohtak Road, Karol Bagh, New Delhi on 16.08.2017 for his treatment and discharged from the hospital on 17.08.2017 but the hospital bills of Rs. 1,41,350/- have to be paid by the complainant despite of said insurance policy
on refusal of the opposite party for paying the said bills to the hospital. Hence, he has filed the instant complaint.
That the cause of action is arose on 6.10.2017 in favour of the complainant and against the opposite party and said complaint comes under the territorial and pecuniary jurisdiction of this Forum as per prayer in claim and this complaint is filed under the limitation on one year.
That the notice to the Opposite Party is sent and reply is received from the Opposite Party on 10.02.2018.
In support of his claim complainant has enclosed hospital bills, insurance policy, bills of medical store, discharge summary, treatment paper and intimation of cancellation of policy.
Complainant had prayed that his petition may be allowed with Principal and interest @12% with cost and legal expensive in the interest of justice.
3. The OP had filed his reply wherein he has stated that present complaint is totally vexatious, misconceived as the relief sought by the complainant in present complaint cannot be granted. The complainant had approached OP company for availing insurance policy. As per the process involved the complainant has submitted proposal form on the assurance of an Insurance Policy so as to provide insurance cover to himself, his wife and his children. The policy holder/complainant has signed and submitted the proposal form after going through the terms and conditions of the policy details of the policy were also explained to him by the sales representative. The Policy Holder had fully
knowledge of terms and conditions of the policy and only after gone through the application of the Insurance Policy thoroughly and properly had signed the proposal form.
4. Complainant has not mentioned any illness to all the queries asked from him whereby giving no correct information to the OP and concealing material fact of his health condition in the proposal form. On believing the above said declaration/information and detailed medical history provided by the proposer in the proposal form Policy No. 2856/00203521/000/01 was issued opted as per Proposal Form, to the proposer.
5. OP further stated that the policy kit containing all relevant documents were duly received by the policy holder thereby giving an opportunity to complainant/policy holder to verify and examine the benefit, terms and conditions of the policy taken by him. It is pertinent to submit that the complainant/proposer never approached the company stating that any information given in the documents in the policy kit was incorrect or any term and condition therein is not understandable or acceptable to him. As no objection was received from the complainant, therefore the complainant is strictly bound by the terms and conditions of the policy.
The proposal form is the bass of the Insurance Contract. The decision of the Insurance Company whether to grant insurance cover to the application/proposal solely depends upon the various facts disclosure information submissions declaration made by the applicant in the proposal form.
The various terms of Insurance/Contract which cover including the premium amount/capital amount etc. solely depends upon the various facts, disclosure
information, statements and declarations made by the applicant/proposer in the
Proposal Form. It is submitted that one great belief of the OP is further stated with reference to the policy and claims company have carefully review all the relevant documents submitted by the complainant through Hospital and though available with the Company with regard to the Insured member health conditions have been noted. It was noted that the said condition is material to the company from underwriting perspective and in view of the above suppression of material facts, it was confirmed that insured not entitled for any benefit under the policy and the premium paid stands forfeited.
6. The OP has been acted in good faith and there in no deficiency in service on the part of the OP and complaint of complainant is liable to be dismissed. Complainant is a diagnose of diagnosed case of ailment of HIV and ART and the same was not disclosed at the time of inception of the policy. OP had prayed that Hon’ble Forum may dismiss the present complaint filed by the OP. The same being completely baseless and grant of legal expenses in favour of OP.
7. Both the parties had filed affidavit of evidence and written arguments and have prayed that their case be decided on the basis of written arguments.
8. OP has argued that complainant’s letter expressed and nondisclosure of medical conditions and during scrutiny of the documents it is found that
complainant is a diagnosed case of HIV and ART since two years.
9. OP has further argued that complainant has also admitted the facts in this complaint about this disease and it is also submitted that non -disclosure of the material fact his claim was repudiated by the Insurance Company (OP). In view of his false and misleading statement the present complaint is liable to be dismissed.
10. On perusal of the discharge summary of the complainant it is mentioned that patient had a past history of taking ART since last two years which is not disclosed in the proposal form while taking insurance. In view of this non-disclosure of material information the contract of insurance become void and no claim is payable by the Insurance company.
11. As such the claim of complainant was rejected vide letter dated 17-08-2017 and policy was also cancelled on the ground of non-disclosure of the material fact vide letter dated 02-09-2018. However, the said medical condition was not disclosed at the time of inception of Policy and was deliberately hidden from the Company. It is submitted that the contract of insurance is based on utmost good faith. The complainant was aware of the medical condition but he has clearly stated ‘No’ in the proposal form. It is evident that the Complainant took the policy on a false promise in order to gain wrongfully from the company. Therefore, in view of the non-disclosure by the Complainant, the Complainant’s claim repudiated and Policy was rightfully terminated.
12. The OP had prayed that Hon’ble Forum may please be dismissed the complaint and grant cost of legal expenses in favour of opposite party.
Both parties have filed their evidence by way of affidavit. They have also filed written arguments and had requested to pass an order on the basis of written arguments.
13. OP has argued that they had wrote letter dated 02.09.2017 to the complainant, Reason for cancellation : Non disclosure of material facts (MR. JOGINDER SHARMA ; known case of HIV and on ART since 2 years)
The OP has further argued that complainant has also admitted the facts in the complaint about his disease and it is also submitted that on account of non-disclosure of the material facts his claim was repudiated by the Insurance Company. In view of his false and misleading statement the present complaint is liable to be dismissed.
14. On perusal of the discharge summary of the complainant it is mentioned that patient had a past history of taking ART since last 02 years. This information is not disclosed in the proposal form while proposing insurance. In view f the non-disclosure material information the contract of insurance become void and no claim is payable by the Insurance company.
15. Complainant is a known case of HIV and he had taken treatment for HIV Virus which is outside the scope of the policy cover hence the claim is in admissible as per the general exclusion clause 9.
16. OP has also cited judgements in his favour namely ‘‘Satwant Kaur Sandhu vs. New India Assurance Company Ltd. (2009) 8 SCC 316’’ ‘‘Mrs. Shnyni Valsan Pombally Vs. State Bank of India (Revision Petition No. 3947 of 2013).
17. On the perusal of the documents of complaints the insured was suffering from HIV since 2 years as per the history recorded in the discharge summary, this information is not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy.
18. In view of the above discussion we are of the opinion that the repudiation of the claim of three bills by OP and termination of policy is justified and the complaint is dismissed. Copy of this order be sent to the parties. File be consigned to record room.
Announced this05th Day ofOctober2020.
