CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/540/13

          Date of Institution:-    21.10.2013

          Order Reserved on:- 02.05.2024

                      Date of Decision:-      20.05.2024

IN THE MATTER OF:

Ms. Bulbul D. David

D/o Late Lt. Col. A. A. David.

R/o W-100, First Floor,

Greater Kailash Part-I,

New Delhi - 110048

.….. Complainant

VERSUS

ICICI Lombard Healthcare

ICICI Bank Tower,

Plot No.12, NanakramGuda,

Financial District Gachibowli,

Hyderabad – 500032

Also At:-

401-402, Interface Bldg; No.11,

Link Road, Malad (West),

Mumbai - 400064

.…..Opposite Party

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations thaton 03.07.2007 policy bearing no.4034/CHI/02360158/00/000 valid from 03.07.2007-02.07.2008 was taken from the OP. It was disclosed by her that she has an irregular bowel disease i.e. ulcerative colitis. The policy records the disease as “history of inflammatory bowel syndrome/hypothyroidism/hysterectomy as per-existing disease.” In 2009, a cheque of Rs.8429 dated 25.06.2009 was issued to the OP for the renewal of the policy. There was break in the policy. There was mistakes qua gender and date of birth in the policy which were got rectified. In August, 2011, she was hospitalized due to ulcerative colitis at St. Stephen hospital, Tis Hazari. The claim number 220100162937 of Rs.404250/- was lodged with the OP which was rejected vide letter dated 15.9.2011 under exclusion clause 3.1 of the terms and conditions of the policy. The claim was also rejected vide letter dated 01.11.2011. She has made several calls to the office of the OP but in vain. A legal notice dated 17.07.2013 was issued to the OP but in vain. Hence, this complaint.

2. The OP has filed the reply with the averments that the discharge summary issued by St. Stephen Hospital, Delhi shows that insured has been diagnosed with ulcerative colitis since 2003 and this disease was never disclosed to OP at the time of taking the policy. The claim falls under exclusion clause 3.1 on the terms and conditions of the insurance policy which led to the rejection of the claim. There is no cause of action in favour of the complainant. There is no deficiency of service on the part of OP.

3. The parties were directed to lead the evidence.

4. The complainant has filed her own affidavit in evidence wherein she has corroborated the version of complaint and placed reliance on the documents Ex.CW1/1 to 1/6 though exhibits are not put on the documents.

5. The OP has filed the affidavit of Sh. VikasGoyal, Legal manager, in evidence wherein he has corroborated the version of written statement and placed reliance on the documents Ex.RW1/A to 1/D.

6. We have heardthe Ld. Counsel for the parties and perused the entire material on record.

7. The issuance of policy RW-1/Aor Ex.CW1/1 on the basis of proposal form Ex.RW-1/3 is not in dispute. The complainant was hospitalized at St. Stephen Hospital, Delhi for the treatment of ulcerative colitis. She was discharged on 14.09.2011and discharge summary is Ex.RW1/C. A bill of Rs.4,04,250/- was raised by the hospital qua which claim was lodged with the OP. The claim was rejected vide letter Ex.RW1/D as her case comes under pre-existing diseases.

8. The discharge summary RW1/C shows that complainant has been on medical treatment since 2003 for large bowel and rectum with hypothyroidism (ulcerative colitis). The said disease comes under pre-existing disease under the terms and condition of the insurance policy and this fact is not even disputed by the complainant. This fact was never disclosed by the complainant at the time of the taking of the policy. The policy has been renewed. The disease ulcerative colitis is a pre-exiting disease. The pre-existing disease means a disease which was exiting prior to issuance of the policy first time. The complainant has been suffering from the said disease from 2003. The contract of insurance is based upon good faith. The complainant is bound to disclose all the material facts which  affects the issuance of the policy. The material fact has not been disclosed by the complainant to the OP and thereby guilty of suppressing the material fact from the OP. The OP has rightly repudiated under the exclusion clause 3.1 of the terms and conditions of the insurance policy. There is no deficiency of service or unfair trade practice on the part of OP in rejecting the claim and repudiating the policy.

9. In view of above discussion, the complainant has failed to substantiate the allegations as set out in the complaint and accordingly the complaint is dismissed.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 21.05.2024.