1. This revision petition has been filed by Ashish Rana, Petitioner herein and Respondent before the State Consumer Disputes Redressal Commission, U.T. Chandigarh (hereinafter referred to as the State Commission) being aggrieved by the order of that Commission which had allowed the appeal of M/s Star Health and Allied Insurance Co. Ltd., Respondent herein and Appellant before the State Commission, by setting aside the order of the District Forum. 2. Briefly, the case of the Petitioner/Complainant is that his father Ashok Kumar Rana (hereinafter referred to as the Insuree) had taken a health insurance policy, namely, Senior Citizens Red Carpet Insurance Policy for a sum of Rs.2.00 Lakhs by paying premium of Rs.9326/- for the period from 28.12.2010 upto 27.12.2011 with the understanding that Insuree could avail of various benefits, including in-patient hospitalization, fees of doctors, cost of diagnostic tests, cost of drugs, emergency ambulance charges etc. During the validity of the policy, on 16.09.2011 Insuree was admitted in Alchemist Hospital, Panchkula due to pain in the abdomen and fever and he was shifted to the ICU on the same day but he passed away on 18.09.2011 reportedly due to severe metabolic acidosis leading to multi organ failure. Respondent/Insurance Company was informed about the admission of the Insuree on 16.09.2011 and was assured that the charges for the hospitalization would be paid by the Respondent/Insurance Company as the benefits of the policy were of cashless nature. However, since 17th and 18th of September, 2011 were Saturday and Sunday respectively, Respondent/Insurance Company requested Petitioner/ Complainant to bear the expenses from his own pocket and assured that he would be indemnified later. Believing this promise made by the Respondent/Insurance Company, Petitioner/Complainant paid an amount of Rs.97,523/- through his credit card to the hospital and thereafter supplied the necessary documents to the Respondent/Insurance Company while filing his claim. However, the Respondent/Insurance Company went back on its assurance and repudiated the claim on the ground that the Insuree had withheld material information regarding his health by concealing the fact that he had Hairy Cell Leukemia at the time of his taking the insurance policy. This was challenged by the Petitioner/Complainant on the ground that at the time of his filing the claim, there was no evidence of this disease and, therefore, the claim was illegally and arbitrarily repudiated. Since despite this Respondent/Insurance Company refused to settle the claim, Petitioner filed a complaint before the District Forum on the ground of deficiency in service and requested that Respondent/Insurance Company be directed to pay him (i) sum of Rs.97,523/- alongwith 18% interest per annum from the date of payment; (ii) compensation of Rs.1.00 Lakh towards mental agony and harassment; and (iii) litigation costs of Rs.21,000/-. 3. Respondent/Insurance Company in its written rejoinder contended that the complaint was not maintainable on the ground that the Insuree had not approached the District Forum with clean hands and had suppressed material information regarding his earlier state of health in the proposal form and since the contract of insurance is based on the principle of utmost good faith, the claim was rightly repudiated. 4. The District Forum after hearing the parties directed the Respondent/Insurance Company to pay the Petitioner/Complainant 70% of the claim of Rs.97,523/- as per Clause 5 of the ‘Exclusions’ of the policy, compensation of Rs.25,000/- and litigation costs of Rs.10,000/-. 5. Being aggrieved, Respondent/Insurance Company filed an appeal before the State Commission. 6. The State Commission after hearing the parties and considering the evidence produced before it allowed the appeal and set aside the order of the District Forum by concluding that the Insuree had suppressed material information regarding his pre-existing diseases in the insurance proposal form, including Hairy Cell Leukemia and Diabetes. 7. Hence, the present revision petition. 8. Counsel for the Petitioner/Complainant made oral submissions, in which he contended that the State Commission erred in concluding that the Insuree had suppressed material information regarding his state of health because at the time of his taking the policy, Insuree was not suffering from any disease, including Hairy Cell Leukemia. It was further submitted that the Insuree had rightly replied in the negative to queries in the proposal form as to whether he was suffering from Cancer, Chronic Kidney Disease, CVA/Brain Stroke, Alzheimer Disease etc. and the contention of Respondent/Insurance Company that the information that had been supplied by Alchemist Hospital that Insuree took treatment for PTCA in 2000 and Hairy Cell Leukemia in 2002 from PGIMER, Chandigarh, has not been confirmed by affidavits of the concerned doctors and, therefore, the medical history recorded in the clinical reports should not be taken into consideration. Further, even if the Insuree had suffered from Hairy Cell Leukemia, he had recovered from this disease after his treatment from PGIMER, Chandigarh at the time of his taking the insurance cover and, therefore, there was no suppression or concealment of material facts at the time of filling up of the proposal form since he was not suffering from any disease at that time. 9. We have considered the submissions made by Counsel for the Petitioner/Complainant and have also gone through the evidence on record. From a perusal of the proposal form, we note that the Insuree had replied in the negative in respect of various ailments listed therein, including Cancer. On the other hand, there is credible evidence on record that the Insuree was a known case of Hairy Cell Leukemia with a history of PTCA and that he had taken treatment for the same in PGIMER, Chandigarh in 2002. We further note that at the time of Insuree’s admission in the Alchemist Hospital, these facts were clearly recorded in the clinical notes at Annexure R-7. We are not in agreement with the contention of Petitioner/Counsel for Petitioner that even if it is admitted that Insuree had taken treatment for Cancer in PGIMER, Chandigarh, the fact that he had been cured at the time of taking the insurance cover in 2010 does not amount to suppression of material information. From a perusal of the proposal form, it is an admitted fact that against the column whether the Insuree suffered from any disease/illness irrespective of whether hospitalized or not or sustained any accident, the Insuree had clearly replied ‘No’, which amounts to non-disclosure and misstatement of material facts, for which information was specifically sought. The Hon’ble Supreme Court in P.C. Chacko And Anr. Vs. Chairman, Life Insurance Corporation of India [III (2008) CPJ 78 (NC)] had clearly laid down that non-disclosure and misstatement of facts in the proposal form had a great bearing on contracts of insurance which are based on the principle of uberrima fides i.e. utmost good faith between the parties and that this justifies repudiation of a claim. In the instant case, we agree with the finding of the State Commission that Respondent/Insurance Company was justified in repudiating the claim on the ground of suppression of material facts by the Insuree. 11. We, therefore, uphold the order of the State Commission and dismiss the revision petition. No costs. |
