BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION
AT HYDERABAD.
F.A. 417/2008 against C.C. 921/2006, Dist. Forum-I, Hyderabad
Between:
1) The New India Assurance Company Ltd.
Rep. by its Regional Manager
Regional Office, 1st Floor
3-1-2A, Opp. S.B.H., Habsiguda
Hyderabad. *** Appellant/
O.P. No. 3
2) The New India Assurance Company Ltd.
New India Assurance Building
87, M.G. Road, Fort, Mumbai-400 001
Rep. by its Chief Manager *** O.P. No. 1
3) Heritage Health Services Pvt. Ltd.
1102, Raheja Chambers,
11th Floor, Free Press Journal Road
Nariman Point, Mumbai-400 021. *** O.P. No. 2
(Ops 1 & 2 are not necessary parties)
And
W. Ramanatham, S/o. Late W. Ramaiah
Age: 65 years, Chartered Accountant
R/o. 516, 1-8-50/H,
Krishnanagar Colony
Pantherghast Road,
Secunderabad-500 003. *** Respondent/
Complainant.
Counsel for the Appellants: Smt. S. N. Padmini
Counsel for the Resp: M/s. K. Venkataramana.
CORAM:
HON’BLE SRI JUSTICE D. APPA RAO, PRESIDENT
&
SMT. M. SHREESHA, MEMBER
TUESDAY, THIS THE SIXTEENTH DAY OF NOVEMBER TWO THOUSAND TEN
Oral Order: (Per Hon’ble Justice D. Appa Rao, President)
*****
1) This is an appeal preferred by the opposite party No. 3 the insurance company against the order of the Dist. Forum directing it to pay Rs. 58,986/- with interest @ 9% p.a., together with costs of Rs. 2,000/-.
2) The case of the complainant in brief is that he took an Overseas Medi-claim policy for Rs. 58,596/- covering the period from 18.11.2005 to 16.5.2006. He visited USA on 9.11.2005. While so on 23.1.2006 he had rectal bleeding and after taking necessary treatment he became normal. He spent about Rs. 58,986/-, and when he sought for refund of amount by way of legal notice dt. 26.8.2006 for which they did not respond. Therefore he claimed Rs. 58,986/- paid towards professional charges towards his medical treatment and costs.
3) The insurance company resisted the case. It admitted issuance of policy to cover the insurance for the period of visit from 18.11.2005 to 16.5.2006 to US. It had repudiated the claim as he was suffering from Rectal bleeding since long time even prior to taking of the policy which was not disclosed in the proposal form. Non-disclosure of material fact is one of the exclusions of the policy. The very letter submitted by him on 9.5.2006 would reveal that in 2004 itself he had internal haemorrhoids. He did not claim for his treatment. In the narrative notes of Dr. Kevin Larsen, M.D., 701, Park Avenue, Minnie Polis dt. 18.1.2006 wherein he mentioned that the complainant had rectal bleeding with past history of long standing haemorrhoids which were treated conservatively in India besides that he was suffering from hypothyroidism and mild diabetes mellitus type-II. He was under medication of thyroxin, losinopril, metaformine drugs. Thus the complainant had suppressed all these ailments and obtained overseas medi-claim policy. Therefore it alleged that the complainant was not entitled to any amount and prayed for dismissal of the complaint with costs.
4) The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A11 (a) marked while the appellant did not file any documents.
5) The Dist. Forum after considering the evidence placed on record opined that the appellant did not file any medical record and that the repudiation was unjust and therefore directed it to pay Rs. 58,986/- with interest @ 9% p.a., together with costs of Rs. 2,000/-.
6) Aggrieved by the said order the appellant preferred the appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective. The very record Ex. A5 filed by the complainant discloses that he had rectal bleeding with past history of long standing haemorrhoids, hypothyroidism and mild diabetes mellitus type-II which he has suppressed and therefore not entitled to any amount. The repudiation was just and therefore prayed that the complaint be dismissed.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
8) It is an undisputed fact that the complainant had taken Overseas Medi-claim policy covering the period from 18.11.2005 to 16.5.2006 to cover the visit of the complainant in USA. The complainant had spent Rs. 58,986/- for his treatment for rectal bleeding in Minnie Polis, USA. The very complainant filed letter Dt. 16.3.2006 issued by Dr. Kevin Larsen, MD., Assistant Professor Internal Medicine, University of Minnesota, Hennepin County Medical Centre, Internal Medicine Clinic. It shows that the complainant came to his clinic on 18.1.2006, with a history of many days of rectal bleeding. His examination did not show an obvious site of bleeding, but he was anaemic. Standard of care is to refer patients with anaemia and a history of rectal bleeding to colorectal surgeon for evaluation of haemorrhoids. He was referred to Dr. Jeffery Morken. In the narrative notes appended to the certificate dt. 18.1.2006 there was a mention “Mr. Kudali has had five to six days of bright red blood per rectum.
He has had longstanding history of haemorrhoids, which were treated in India conservatively. His past medical history is significant for haemorrhoids as well as hypothyroidism, mild diabetes mellitus type-2” In the assessment there was a mention : “Bright red blood per rectum. Mest likely, this is internal haemorrhoids as he was previously diagnosed with proctoscopy in India.”
(emphasis supplied)
The complainant has undoubtedly suppressed his ailments. When he has been suffering from such ailments he ought to have informed the same before taking the policy.
9) It is settled proposition of law reiterated in P.C. Chacko & anr Chairman, Life Insurance Corporation of India reported in III (2008) CPJ 78 (SC) the Supreme Court held:
“The purpose for taking a policy of insurance is not, in our opinion, very material. It may serve the purpose of social security but then the same should not be obtained with a fraudulent act by the insured. Proposal can be repudiated if a fraudulent act is discovered. The proposer must show that his intention was bona fide. It must appear from the face of the record. In a case of this nature it was not necessary for the insurer to establish that the suppression was fraudulently made by the policy holder or that he must have been aware at the time of making the statement that the same was false or that the fact was suppressed which was material to disclose. A deliberate wrong answer which has a great bearing on the contract of insurance, if discovered may lead to the policy being vitiated in law.”
When he did not inform the ailments which were existing for the last several years, it would amount to suppression of material fact which would entail insurance company to repudiate the policy. Ex. A1 would itself show that he had suppressed all these ailments. Therefore, we are of the opinion that the complainant is not entitled to the amount. The Dist. Forum did not consider the evidence in proper perspective. The order is liable to be set-aside.
10) In the result the appeal is allowed setting aside the order of the Dist. Forum, consequently the complaint is dismissed. No costs.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
Dt. 16. 11. 2010.
*pnr
“UP LOAD – O.K.”
