PRESENT
Complainant by Adv. Smt. Warunjikar Present.
Opponent Ex-parte.
ORDER
(Per- Mr. S. D. MADAKE, Hon’ble President. )
1. The complainant has taken Medi-claim policy namely CARE bearing policy No. 10052358 for a period of one year i.e. 30 Nov. 2013 to 29.11.2014 for a sum of Rs. 10,00.000/- ( Ten lacs). The policy covers complainant and his wife Mrs. Anjana H. Shaha. He paid premium of Rs.24,875/- to opponent Insurance company.
2. Smt. Anjana shaha was admitted in somaiya ayurvihar ASI an Institute of oncology for the complaints of lump in the right breast and cyst on the left breast on 25.4.2014. She was having pains just 15 to 20 days prior to admission in the hospital.
3. The complainant’s wife was under care of Dr. Deshpande who has performed surgery Right modified radical mastectomy with left breast. She was to undergo 21 sessions of chemotherapy during April to Nov. 2014. The expenses incurred towards Surgery and treatment of chemotherapy are mentioned Rs. 8,56,592/- ( Eight lacs fifty six thousand five hundred ninety two).
4. The complainant incurred expenses of Rs.1,60,501/-(One lac sixty thousand five hundred one ) towards treatment of chemotherapy of 10 to 14 during Dec. 2014 to March, 2015.
5. The complainant submitted claim to opponent which was rejected on the ground of “ non disclosure of Hyperlipidemia since 2005 on regular treatment and known case of allergic asthama since 2005” relying on clause 6.1 of policy.
6. The complainant alleged that there is no nexus between the current ailment and hyperli- pidemia and allergic asthama for which Smt. Anjana Shaha had received treatment in 2005.
7. The complainant alleged that, opposite party started refusing even to accept the claim forms from 7th session of chemotherapy. It is stated that, opponent went to such an extent of even terminating due policy by forfeiting the amount of premium paid by complainant.
8. The complainant sent two letters on 11.8.2014 and 14.8.2014 for amicable settlement with no positive response form Insurer.
9. The complainant approached Insurance Ombudsman, however the claim was rejected on 5.6.2015 by passing award. The complainant stated that, opp. is under an obligation to consider as to whether alleged non disclosure has any nexus between the said suppression and present treatment.
10. The complainant prayed for direction to Insurance company to pay Rs.8,56,592/- to complainant for treatment taken for a period between 25.4.2014 to 21.11.2014. He prayed for award of amount of Rs. 1,00,000/- towards treatment for twenty to fourteen sessions of chemotherapy.
11. The complainant prayed for direction to opponent to pay Rs.5,00,000/- (Rupees Five lacs only) as compensation and Rs.50,000/- ( Fifty thousand ) as cost.
12. On 19.1.2016 the forum after hearing partly the argument of learned Adv. Warunjikar, directed to submit copy of terms and condition of the medical claim of 2005. The complaint was admitted on 2.2.2016.
13. The opponent did not appear even after receipt of the notice. We passed order to proceed ex-parte against opponent on 28.6.2016 and matter was adjourned for filing on record affidavit of evidence of complainant.
14. On 22.8.2016 the complainant filed affidavit of evidence and written argument. On 15.9.2017 complainant filed on record documents relating to Insurance and papers relating to treatment.
15. We have perused all the documents filed on record by complainant. The Insurance company rejected the claim on 30.5.2014 relying on clause 6.1 Non disclosure of Hyperlipidemia since 2005 on regular treatment and known case of allergic asthoma since 2005.
16. The Insurance company stated in the letter that claim is not payable as per policy terms and conditions. It is also mentioned that Insurance company always want to be fair in processing and settlement of claim. It is noted that claim is rejected after due consideration of the facts and circumstances. The company considered review applications and intimated complainant by letter dated 3.7.2014 and 10.7.20174.
17. The Insurance ombudsman observed that it is the duty of a person to reveal all the important facts about health are pre-existing conditions. It is held that failure of complainant to mention same to insurer amounts to suppression of material information entitling the company to deny liability arising under policy.
18. The complainant filed on record the certificate issued by Somaiya Auurvihar Asian Institute of oncology. The said certificate is signed by Dr. Ramakant K. Deshpande. Who has given treatment to Anjana Sheth.
19. Dr. R.K. Deshpande certified that Anjana Sheth is not on any treatment for allergic asthama since 2005. It is stated that Hyperlipidemia is not a causative connection with her current claim of carcinoma Breast.
20. The documents show that complainant has been taking insurance policy since eight years. There is no evidence to prove that said statement in the proposal was made fraudulently. There is no nexus between the suppression of fact and the treatment taken by the complainant in respect of the present claim.
21. As per the law laid down by Hon. Supreme court misstatement by itself is not material for repudiation of policy unless the same is material in nature. The complainant stated on oath that his wife was never required to take treatment for nine years after 2005 for allergic asthma.
22. The opposite party failed to file written statement to show that complainant is not entitle for said claim, which is supported by expert opinion. The case proceeded ex-party against opp.
23. In the result we hold that opp. is not justified to issue notice of cancellation of policy and also cannot deny the legitimate claim of complainant. The complainant is entitle for the amount as per terms of policy from Insurance company. We award interest by way of compensation on the amount and reasonable cost.
24. In the result, we pass the following order.
ORDER
1. Consumer Complaint 4/2016 is partly allowed.
2. The opponent is directed to pay amount of Rs.8,56,592/- ( Eight lacs fifty six thousand five hundred ninety two ) incurred by
complainant during insurance period for treatment of Anjana Sheth with interest @ 8 % p.a. from the date of filing complaint, after
verifying the receipts of payment made by complainant to Insurance company.
3. The opponent is directed to pay cost of Rs.10,000/-( Ten thousand) to complainant.
4. Copy of this order be sent to both parties.
