Order No. 12 dt. 10/01/2019
The case of the complainant in brief is that the complainant while enjoying the insurance policy of o.p. became ill and he was admitted for the treatment of dengue in ILS Hospital, DumDum and paid the necessary expenses incurred by him during his stay at the said hospital. The complainant had the facility of cashless benefit and he had no pre existing disease at the time of obtaining the policy. At the time of his treatment in the said hospital diabetes was detected. While the complainant came to learn that he was suffering from diabetes he went to o.p. to give information, but o.p. did not cooperate with him. The complainant thereafter tried to communicate with o.p. through email, but no response was found. After recovery from the said illness the complainant submitted the medical bills and prescriptions to o.p. but o.p. denied to disburse the claim with the remarks “duty of the policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statement ……… or any material information having been withheld by you or any one acting on your behalf under this policy”. The complainant on several occasions wanted to know from o.p. whether there is any special way of updating the insurance about the medical condition after taking the policy, but the complainant did not get any feedback from o.p. The complainant was admitted in the said hospital for the ailment of dengue and Type-II diabetes and o.p. disburse the claim amount in favour of the complainant. But when in the year 2017 the complainant was further admitted in the said Hospital for chronic unrecoverable pneumonia and uncontrolled Type-II diabetes o.p. refused to disburse the claim in favour of the complainant. On the basis of the said fact it was categorically stated that there is deficiency in service on the part of the o.p. and as such, the complainant filed this case praying for direction upon the o.p. for reimbursement of the medical bills amounting to Rs.1,56,000/- along with compensation and litigation cost.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.p. on receipt of the health claim from the complainant along with the medical documents of ILS Hospital, DumDum for the treatment undergone by him from 04/10/2017 to 14/10/2017 wherein the insured complainant was treated for dengue fever, pneumonia and uncontrolled Type-II diabetes. On careful investigations of medical documents procured by o.p. company as well as from the medical documents submitted by the assured during the claim stage it was evident that the assured had pre existing medical history of Type-II diabetes since 20 years and was on medication for the same. The o.p. also stated that after scrutinizing the medical papers it was found that it was a case of pneumonia with uncontrolled T-II DM and he was suffering from T-II DM since 20 years. On the basis of the said fact because of suppression of the material fact at the time of obtaining the policy the claim of the complainant was repudiated and the policy document was also cancelled. On the basis of the said fact o.p. filed several documents stating interalia that the complainant suppressed his pre existing disease at the time of obtaining the policy and accordingly, the claim of the complainant was not entertained and as such, o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy at the relevant point of time?
- Whether the complainant suppressed the material fact at the time of obtaining the policy?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant while enjoying the insurance policy of o.p. became ill and he was admitted for the treatment of dengue in ILS Hospital, DumDum and paid the necessary expenses incurred by him during his stay at the said hospital. The complainant had the facility of cashless benefit and he had no pre existing disease at the time of obtaining the policy. At the time of his treatment in the said hospital diabetes was detected. While the complainant came to learn that he was suffering from diabetes he went to o.p. to give information, but o.p. did not cooperate with him. The complainant thereafter tried to communicate with o.p. through email, but no response was found. After recovery from the said illness the complainant submitted the medical bills and prescriptions to o.p. but o.p. denied to disburse the claim with the remarks “duty of the policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statement ……… or any material information having been withheld by you or any one acting on your behalf under this policy”. The complainant on several occasions wanted to know from o.p. whether there is any special way of updating the insurance about the medical condition after taking the policy, but the complainant did not get any feedback from o.p. The complainant was admitted in the said Hospital for the ailment of dengue and Type-II diabetes and o.p. disburse the claim amount in favour of the complainant. But when in the year 2017 the complainant was further admitted in the said Hospital for chronic unrecoverable pneumonia and uncontrolled Type-II diabetes o.p. refused to disburse the claim in favour of the complainant. On the basis of the said fact it was categorically stated that there is deficiency in service on the part of the o.p. and as such, the complainant filed this case praying for direction upon the o.p. for reimbursement of the medical bills amounting to Rs.1,56,000/- along with compensation and litigation cost.
Ld. lawyer for the o.p. argued that o.p. on receipt of the health claim from the complainant along with the medical documents of ILS Hospital, DumDum for the treatment undergone by him from 04/10/2017 to 14/10/2017 wherein the insured complainant was treated for dengue fever, pneumonia and uncontrolled Type-II diabetes. On careful investigations of medical documents procured by o.p. company as well as from the medical documents submitted by the assured during the claim stage it was evident that the assured had pre existing medical history of Type-II diabetes since 20 years and was on medication for the same. The o.p. also stated that after scrutinizing the medical papers it was found that it was a case of pneumonia with uncontrolled T-II DM and he was suffering from T-II DM since 20 years. On the basis of the said fact because of suppression of the material fact at the time of obtaining the policy the claim of the complainant was repudiated and the policy document was also cancelled. On the basis of the said fact o.p. filed several documents stating interalia that the complainant suppressed his pre existing disease at the time of obtaining the policy and accordingly, the claim of the complainant was not entertained and as such, o.p. prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant obtained the policy from o.p. and during the subsistence of the said policy he became ill and he was treated at ILS Hospital, DumDum. After recovery he submitted the medical bills to o.p. for reimbursement of the medical expenses, but o.p. repudiated the claim of the complainant. On the basis of the said fact the complainant filed this case with the prayer for reimbursement of the medical bills. It is relevant to mention here that the complainant after filing the evidence o.p. put questionnaire to the complainant asking whether the complainant was suffering from diabetes for the last 20 years. The complainant failed to answer the questionnaire put by o.p. The o.p. in the evidence also stated that the complainant suppressed his pre existing disease and obtained the policy, but the complainant after receiving the evidence did not put any questionnaire to o.p. Therefore, the evidence of o.p. corroborating the fact of illness of suffering Type-II diabetes for the last 20 years remained unchallenged. Since the complainant failed to controvert the said allegations by producing any document or evidence to controvert the said allegation of o.p. As per the provisions of Regulation 11(1) and Regulation 11(3) of IRDA Regulation, 2002 it is the bounden duty of the assured to disclose all material information to the insurance company at the time of obtaining the policy. Since the complainant suppressed the said fact and on the basis of the judgment pronounced by Hon’ble Supreme Court in Satant Kaur Sandhu –Vs.- New India Assurance Co. Ltd. SC 2776(2006) whereby it was decided that furnishing all material information required by the insurer to decide whether to accept or decline, to undertake the risk, and in the event of acceptance of the risk, to determine the rates, terms and conditions of a cover to be granted and observed that in a contract of insurance any fact which would influenced the mind of prudence insurer in deciding whether to accept or not to accept the risk is a material fact. If the proposer has knowledge of such fact he is obliged to disclose particularly while answering questions. Since the assured suppressed the material fact of suffering illness of Type-II diabetes for the last 20 years before obtaining of the policy and he was on medication, therefore, on the basis of the suppression of pre existing disease the insurance company rightly repudiated the claim of the complainant. In view of the facts and cirsumstances as stated above, we hold that the case filed by the complainant has got no merit and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.70/2018 is dismissed on contest without cost against the o.p.
