1. This complaint case has been filed against the O.Ps u/s 12 of Consumer Protection Act against the O.P. who illegally, improperly and arbitrarily denied and repudiated the claim of the complainant causing loss, damages to the tune of Rs 1,44,757 and simultaneously void the policy.
2. The complainant’s case in brief is that the O.P. is a body corporate constituted under Company Act to carry out General/ Life Insurance business as well as Individual Mediclaim Policy (Pariwar Medi claim, Insurance business, hospitalization benefit policy). The complainant after payment of adequate premium worth Rs 1,25,000 purchased the ICICI Pru Health Saver Policy bearing no. 11012870. It is essential to mention that the O.P. received the proposal form on 14.01.09 and accordingly issued this policy on 21.01.09 which is valid and effective till the complainant attains his age of 75 years.
3. During the subsistence of the above stated policy, the complainant for the first time felt some problem in his body on 31.03.17 at Indore Madhya Pradesh. He was admitted in emergency ward of Unique Angioplasty. As the complainant was not satisfied fully so he was taken care of in the said Hospital and with the advice of the Doctor, he moved for Narayan Institute of Cardiac Sciences at Bangalore.
4. At the pre - stage of medical treatment at Narayana Institute of Cardiac Sciences Bangalore, the doctor on the basis of the report of Indore Hospital initially was of opinion that the complainant patient has to undergo Angioplasty. Under such perception the complainant applied through the insurance desk of the O.Ps available at Narayana Institute of Cardiac Sciences at Bangalore which in its first instance sanctioned Rs 1,75,000. But later on the doctor of Narayana Insititute of Cardiac Sciences Bangalore were of the opinion that the complication of the complainant can be cured through medicine. Considering the opinion of the doctor, the complainant returned the sanctioned amount worth Rs 1,75,000 to the O.Ps and deiced to meet the expenses firstly form his fund and then to claim it from the O.Ps on actual basis.
5. The complainant was treated at Narayana Institute of Cardiac Sciences, Bangalore where it was diagnosed LCX- Non dominant, proximal LCX has 50-60% stenosis and after treatment the complainant submitted the claim of Rs 1,44,757 before the O.Ps along with relevant documents including the medical treatment bill as required by the Insurance company on 09.05.17. But the O.P. vide letter dt. 05.06.17 wrongly and illegally rejected the claim of the complainant and also declared the policy no. 11012870 void simply on the ground of non - disclosing the myocardial bridge LAD (Left Anterior descending).
6. The act of the O.P. is nothing but a patent and glaring deficiency in services rendered by the O.Ps and it is a patent negligent act of the O.Ps for which the complainant has suffered mental tension, agony, harassment. It is further submitted that in the year 2005 in a routine test the complainant underwent angiography in which report everything was found normal and fine but mentioned in myocardial bridge in one of the arteries LAD and accordingly the complainant was told that this myocardial bridge is from birth and is totally harmless.
7. It is further submitted that the heart is made of muscles called myocardium. The heart muscle like every other organ or tissue in body needs oxygen rich blood to survive. Blood is supplied to the heart by the coronary arteries which sit on the surface of the heart. A myocardial bridge is a band of heart muscle that lies on top of a coronary artery instead of underneath it. According to medical science, myocardial bridge is totally harmless and patient with myocardial bridge have it from birth and most never know they have the condition.
8. It is further submitted that the said myocardial bridge never caused any symptoms to the complainant either from his childhood or in the year 2005 or from 2005 to 2017 and further it is submitted that the myocardial bridge is in a different artery (LAD left Anterior Descending) whereas the problem that occurred in April 2017 is in totally different artery (LXC Left circumflex). There is no nexus between the myocardial bridge and the problem occurred in 2017. In 2005 the LCX was found normal.
9. It is further stated that it is a settled principal of law of Insurance that the policy cannot be taken in question after lapse of three years. In this particular case, the policy was taken in the year 2009 whereas the problem in the body occurred in 2017. Due to willful act of deficiency and negligent of the O.Ps the complainant has been deprived off from availing the amount worth Rs 1,44,757 and the O.Ps has enjoyed the said amount and is also enjoying the same causing loss of interest to the complainant.
10. The complainant has hired the service of the O.Ps by paying the insurance premium amount as consideration of the services and as such the complainant comes under the purview of the consumer as defined under consumer protection act.
11. The complainant submitted the proposals form and paid the premium amount at Dumka and the O.P. also handed over the policy to the complainant at Dumka after being processed. The cause of action arose at Dumka and the O.P. also resides and carries its business at Dumka which is within the territorial jurisdiction of this Forum and the claim amount as mentioned in the complaint petition is also within the pecuniary jurisdiction of this commission.
12. The complainant has claimed following reliefs :-

1. To issue an order directing the O.P. to pay Rs 1,44,757 on account of account of incurred medical expenses.
2. To issue an order directing the O.Ps to pay Rs 2,00,000 as compensation on account of mental tension, agony, harassment caused to the complainant due to the deficiency and the negligent act of the O.Ps.
3. To issue and order directing the O.Ps to continue the policy no. 11012870
4. To issue an order directing the O.Ps to pay the interest upon Rs 1,44,757 @ 12% from 09.05.17 till the payment.
5. Payment of cost of litigation of Rs 10,000 to the complainant.

13. The O.P. No. 1 and 2 appeared on 28.10.17 and submitted his reply/ show cause stating therein that ICICI Prudential Life Insurance Co. having its registered office at 1089, Appasaheb Marathe Prabhadevi, Mumai 400025 is a company registered under companies act, 1956 and under section 3 of the Insurance Act 1938, carrying on life insurance business. It is further submitted that this Hon’ble Forum has no jurisdiction to entertain the present complaint. The insurance contract which culminated into the policy forming subject matter of the complaint is invalid, void – ab – initio inoperative and unenforceable. Therefore the present complaint is liable to be dismissed. And the present complaint is not maintainable. The subject policy has been obtained by the Life Assured fraudently, dishonestly and by misrepresentation and suppressing his medical history of myocardial bridge mid left artery descending diagnosed during coronary angiography done on 17.06.05 i.e; prior to issuance of policy and untrue statement made in the proposal form coupled with other material facts. Thus there is no deficiency in services on the part of the O.Ps while rendering services to the Life Assured nor were the O.Ps indulged into any unfair trade practices while rejecting the claim. Consequently the complaint is liable to be dismissed.
14. The present complaint is false, frivolous, vexatious and is gross abuse of process of law. Thus, the complaint is liable to be dismissed under section 26 of the consumer protection act. It is further submitted that if the Life Assured failed to disclose the true and correct material facts to the insurer then the contract of insurance between the life assured and the insurance company stands vitiated and the life assured or any person claiming under it is not entitled for any benefits under the said policy.
15. In the present case, the complainant/ life assured had knowingly, willfully and fraudlently suppressed his medical history of myocardial bridge mid left artery descending which was prior to issuance of policy diagnosed during coronary angiography done on 17.06.05 prior to issuance of the policy. Had these facts would have been disclosed by the life assured in the proposal form the policy would never have been issued. That since the non – disclosure if this material facts had a direct impact on the underwriting decision of the company the claim was repudiated. The said intentional non disclosure of material fact at proposal stage clearly indicates that the life assured had obtained the subject policy only with an intention to induce the O.Ps to issue the insurance policy on his life.  
16. It is pertinent to mention that if the suppression of the fact that the Life Assured had a myocardial bridge in LAD was indeed immaterial then what was the need for the doctors to even mention the same while treating the assured in 2017 and the complainant has approached this Hon’ble Commission with unclean hands and the present suit is liable to be dismissed on these grounds alone.
17. It is further submitted that clause 8 of exclusion for hospitalization insurance benefits the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any insured persons in connection with or in respect of 5 pre – existing conditions unless stated in the proposal form and specifically accepted by the company and endorsed thereon.  Pre – existing conditions means a condition for which prior to the policy commencement date or policy revival date the insured persons had signs or symptoms of any disease or injury which would have caused any ordinary prudent man to seek treatment was recommended by or received from a medical practitioner or the insured person had undergone medical tests or investigation.
18. Any investigation or treatment of any disease, disorder, complication or ailment arising out of or connected with the pre – existing disease shall be considered part of that pre – existing conditions. And in the present case, the O.P. received the claim statement from 09.05.17 along with medical documents informing about the complainant’s hospitalization which occurred on 04.04.17 for treatment of coronary artery disease. On assessment at the claims stage it was found that the complainant has undergone coronary angiography on 17.06.05 which revealed myocardial bridge mid left artery descending which was prior to issuance of policy. The complainant failed to disclose the said condition to the company at the time of signing the proposal form.
19. The complainant  despite being fully aware about the fact regarding myocardial bridge mid left artery descending detected during angiography in 2005 has intentionally suppressed the fact in the proposal form with an intention to induce the O.P. to issue the policy which otherwise would not have been issued if the pre – existing disease would have been disclosed by the complainant. The present hospitalization claim of the complainant is directly related to his pre – existing ailment which was diagnosed in 2005 and which was not disclosed by him in the proposal form. Apart from that the complainant can avail free look period within 15 days from accepting the policy.
20. In his show cause the O.P. has cited many decisions relating to the state forum and national forum also. But in his show cause the O.P. has admitted this fact that it issued the policy ICICI Pru Health Saver to the complainant with policy no. 11012870 to the complainant and sum assured Rs 5,00,000 and risk commencement dt. 21.01.09 and total premium paid Rs 1,25,000 but in the status he has clearly mentioned that the policy is null and void. But it does not mention that on which date it was declared null and void. He has also admitted this fact that on 09.05.17 the O.P. received the two claimant statement forms from the complainant informing that the life assured was first hospitalized in unique hospital from 31.03.17 to 05.04.17 and thereafter in Narayana Institute of Cardiac Science from 06.04.17 to 08.04.17 and claim the expenses incurred during the hospitalization.
21. After the investigation of the claim of the complainant and during investigation at the claim stage it was revealed that the complainant was first admitted in Unique Super Specialty Hospital on 31.03.17 with complains of shortness of breath – acute and past history of K/C/O Mild myocardial bridge in LAD. The complainant was advised PTCA (Percutaneous Transluminal Coronary Angioplasty) but he refused and was discharged in stable condition on 05.04.17. It is pertinent to note that the discharge summary also mentions the fact that the complainant has a history of Mild myocardial bridge in LAD. Thereafter the complainant got admitted in Narayana Institute of Cardiac Science on 06.04.17 with history of known case hypertension , S/P CAG 2005 – myocardial Bridging in LAD and S/P CAG (03.04.17) significant LCX disease. Angiogram was done on 07.04.17 which showed 50% LCX stenosis.
22. Further he was advised Thalium for viability/ inducible/ stunning myocardium. It is submitted that the clinical discharge summary of Narayana Institute it has been categorically mentioned that the complainant was diagnosed with Mild myocardial bridge in LAD in 2005. It was further submitted that in view of the foregoing facts and based on the ground of intentional non disclosure of pre – existing disease, untrue statement contained in the proposal form the O.Ps repudiated the claim of complainant and voided the policy and intimated the said facts to the complainant vide his repudiation letter dt. 05.06.17.
23. It is further submitted that O.P. in its rejection letter dt. 05.06.17 purely as gesture of goodwill, offered a sum of Rs 97,295.59 as fund value under the policy and sent a blank discharge voucher to be duly filled and signed by the complainant for reasons best known to him failed to sign on the discharge voucher and sent it to the O.P. and therefore the fund value was retained with the O.P.
24. The Life Insured has not disclosed the full, complete and correct facts regarding his past medical history which was pre – existing conditions and thus the complainant has come to the court with unclean hands and is not entitled to the health claim submitted by him. As such the claim of the complainant was repudiated by the O.P. legally, validly, properly and on justifiable ground. The complainant is not entitled to get nay reliefs as claimed and the claim petition of the complainant is liable to be dismissed.
25. The main point for the determination in this case is whether the complainant is entitled to get any relief or reliefs as claimed!

                                                                             Findings

The complainant in support of his case has filed following documentary evidence which are as follows : -

Exhibit 1 – is the photocopy of letter issued by the O.P. dt. 05.06.17 in which he has repudiated the claim of the complainant. Total 3 sheets.

Exhibit 2 – is the diagram photocopy by Unique Super Specialty Centre dt. 03.04.17 regarding the mild bridge and also cardiac catheterization report. Total 5 sheets.

Exhibit 3 – is the photocopy of prescription issued by Narayana Institute of Cardiac Science  dt. 06.04.17 and angiogram report consultation summary. Total 5 sheets.

Exhibit 4 – is the photocopy of bill invoice issued by Unique Super specialty Centre, Indore. Total 19 sheets.

Exhibit 5 – is the bill cum receipt issued by Narayana Institute of Cardiac Science. Total 11 sheets.

Exhibit 6 – is the report of Cardiac Cathetarisation dt. 17^th june’ 05. Total 4 sheets. i.e; report of angioplasty.

Apart from that the complainant has filed his affidavit as witness as CW1 Manoj Kumar Modi.

The O.P. 1 and 2 has not filed any oral or documentary evidence in support of his defense but he has simply filed the affidavit of Md. Saffuddin Branch manager of ICICI Pru Health Life Insurance Company. This evidence is fully rewrite of showcause.

The O.P. in his show cause has filed the list of documents along with his show cause but none of the documents has been filed by him. I personally asked the learned council for the O.P. regarding the document mentioned in the list of documents of his show cause but he has not given any satisfactory answer. He only assured that he will produce the documents but till today he has not submitted a single document before this commission.

26. Heard the Learned Counsel of both the parties and also perused the case record, evidences oral and documents adduced on behalf of both the parties. From carefully scrutinizing and analyzing the evidences the following points are admitted facts. The policy which was issued to the complainant by the O.P. i.e; Policy no. 11012870 ICICI Pru Health Saver to the complainant on 21.01.09 is admitted fact. One thing is admitted fact that the complainant first admitted in Unique Super Specialty Centre, Indore on 31.03.17 and thereafter in Narayana Institute of Cardiac Science, Bangalore on 06.04.17. It is also admitted fact that the complainant claims the Medi claim expenses and sent the claim form to the O.P.
27. The main points for the dispute is that the O.P. repudiated the claim of the complainant on 05.06.17 and also declared the policy void merely on the ground that the complainant has concealed material facts that prior to taking the Insurance policy he was diagnosed with myocardial bridge and as such he has violated the pre – existing conditions of the policy and suppressed the material facts and the complainant intentionally, willfully and fraudently suppressed his medical reports of myocardial bridge and on this ground he has repudiated the claim of the complainant and also declared the policy void - ab - initio.
28. I think the complainant has stated in his complaint petition on page 3 (X) that in the year 2005 in a routine test he underwent angiography in which report everything was found normal and fine but mentioned in myocardial bridge in one of the arteries LAD and accordingly the complainant was told that this myocardial bridge is from birth and is totally harmless. It is further submitted that the heart is made of muscles called myocardium. The heart muscle like every other organ or tissue in body needs oxygen rich blood to survive. Blood is supplied to the heart by the coronary arteries which sit on the surface of the heart. A myocardial bridge is a band of heart muscle that lies on top of a coronary artery instead of underneath it. According to medical science, myocardial bridge is totally harmless and patient with myocardial bridge have it from birth and most never know they have the condition.
29. It is further submitted that the said myocardial bridge never caused any symptoms to the complainant either from his childhood or in the year 2005 or from 2005 to 2017 and further it is submitted that the myocardial bridge is in a different artery (LAD left Anterior Descending) whereas the problem that occurred in April 2017 is in totally different artery (LXC Left circumflex). There is no nexus between the myocardial bridge and the problem occurred in 2017. In 2005 the LCX was found normal.            
30. Admittedly the complainant has gone routine checkup and in one angiography report in 2005 which is Exhibit 6 dt. 17^th June’05. In that report everything was found normal except left anterior descending myocardial bridge and Exhibit 2 is the diagram regarding the myocardial bridge.
31. It is also admitted fact by the complainant that he has never felt any complication but was routine checkup in 2005 in which this abnormality was found by the Doctor and it is also clear by the doctor and he told him that this myocardial bridge is from birth and is totally harmless and after that the complainant never complaint any complications till 2017, i.e; 2005 – 2017 that is about 12 years. And after 9 years of taking the policy the complications developed the complainant failed the problem in April 2007 which is totally different artery (i.e; LCX Left Circumflex).
32. Moreover the Myocardial bridge (LAD Left) is not a disease rather abnormality which is from the birth of the complainant. For that the complainant never felt any difficulty or any problem.  Further, non – disclosing this fact in 2005 during angiography myocardial bridge does not amounts concealment of material facts of pre – existing conditions of the policy.
33. It is further submitted that the complainant in the year 2017 he developed some problem for which he was admitted firstly to Unique super hospital at Indore as per Exhibit 2 angiography report clearly indicates LCX proximal 90% stenosis with thrombus. Here in this report LAD mild bridge was also shown. Exhibit 3 is also check angiogram report of Narayana Institute of Cardiac Sciences in which LCX in which LCX Non dominant proximal LCX has 50 – 60% stenosis.
34. Apparently the problem that occurred in April 2017 is totally in different artery LCX( Left circum flex) and there is no nexus between the myocardial bridge and the problem occurred in 2017. Without considering above facts the O.P. denied and repudiated the claim of the complainant which is deficiency and negligency in the services.
35. So far as the declaring the policy as void by the O.P. is concerned on 05.06.17 on this point the complainant has clearly stated that it is settled principal of law of Insurance that the policy cannot be taken in question after lapse of three years. Here it is admitted fact that the policy was taken by the complainant in the year 2009 and the O.P. declared the policy void through its letter dt. 05.06.17 that is after the lapse of 9 years from the issuing of the policy which is much belated and time barred.  On the umbrella of non – disclosing of medical history or concealment of material facts the Insurance Co. cannot be left free to declare the policy void. He must give the proper and sufficient reason for verifying edge and truthness of the policy declared of the complainant in his proposal form and the O.P. has not used his agency for this act and merely on the paper filed by the complainant at the time of claim and payment of the bill the O.P. declared the policy void – ab – initio and repudiated the claim of the complainant which is totally illegal, unjustifiable and the act of the O.Ps is arbitrary, improper and illegal.
36. From the above discussion we come to the conclusion that the O.P. has willfully, illegally, improperly denied and repudiated the claim of the complainant and also declared the policy void – ab – initio only to save money from the payment of the policy. It is therefore, we

                                                                       Ordered

                                That the O.P. No. 1 and 2 is hereby directed to pay of Rs 1,44,757 /- to the complainant. The O.P. No. 1 and 2 is hereby directed to pay Rs 2,00,000 /- as compensation on account of mental tension, agony and harassment to the complainant due to deficient and negligent act of the O.Ps. The O.P. No. 1 and 2 is also directed to pay interest @ 12% p.a. on the awarded amount to the complainant from 09.05.17 till payment. The O.P. No. 1 and 2 are also hereby directed to pay cost of litigation of Rs 10,000 /- to the complainant. The O.P. No.1 and 2 are also hereby directed to continue the policy no. 11012870 of the complainant.

                              All the payments should be made within 45 days from this order failing which the complainant is entitled to a get above amount through process of court.

                                          Let a copy of this order be served to both the parties free of cost. Let this document be deposited in the record room and to be shown on the website of the commission.