J U D G E M E N T         

              The door of this Forum has been knocked by the Complainant, for redressal arising out of the consumer dispute as per the Consumer Protection Act, 1986.

               In laconic, the case stated in the complaint, is that, the Complainant No. 1 had obtained a Health Insured Policy, vide No. OG–10–2417–8409–00000166 on 24.11.2009 from the Opposite Party of Rs. 1,00,000/- only which covered the medical expenses of himself and his wife the Complainant No. 2 for the period from 18.11.2009 to 17.11.2010 and had paid a sum of Rs. 5,237/- only as premium to the Opposite Party through the agent and became the consumer under the Opposite Parties.

                The Complainant No. 2 had admitted into Apollo Geneagles Hospital, Kolkata, on 17.12.2009 and after proper treatment was discharged on 21.12.2009 and the entire cost of the said treatment was borne by the Insurer Opposite Party on basis of cashless benefit.

              Thereafter the Complainants renewed the said Insurance Policy by paying a sum of Rs. 4,976/- only as further premium on 27.10.2010 under the Policy No. OG–11–2417–8409–00000145 for the period from 18.11.2010 to 17.11.2011.

              After renewal of the said Policy the Complainant No. 2 again felt illness and had further admitted at the AMRI Hospital 25.05.2011 and after treatment was released from the Hospital on 31.05.2011. But at this time the Insurer Opposite Parties intentionally and willfully did not pay the cost of treatment of Rs. 21,887/- only of the Complainant No. 2. Thereafter the Complainant No. 2 was attacked by ophthalmic decease and under instruction of the local eye specialist went to Sankar Netralaya, at Chennai and had admitted thereon for proper treatment on 09.02.2010 and was discharged on 11.02.2010 and the Complainant incurred the cost of Rs. 32,804/- only.

              The Complainant No. 1 sent several letters to the Opposite Parties requesting them to pay the entire cost of treatment under the Policy ensured by the Opposite Party.

              The Complainant further renewed the said Health Insurance Policy being No. OG–11–2417–8409–00000145 by paying the premium amount of Rs. 6,296/- only by a cheque dated 10.11.2011. But the Opposite Parties did not yet paid the cost of the treatment of the Complainant what amounts deficiency and/or negligence in rendering service towards him, for which he has to suffer harassment and mental agony and prayed for compensation. Hence, this case is filed seeking adequate redressal.

                Resisting the complaint, the Opposite Party No. 1 & 2 filed the Written Version denying each and every allegation made by the Complainant in the petition of complaint contending inter alia, that the Complainant has no cause of action, and is not maintainable either in fact or in law and is totally false.

               The specific case of the Opposite Party, in terse, is that, the Insurance policy is a contract between the Insurer and the Insured person and based on principles of good faith. The Complainant had duly fill up the proposal form and a policy was duly issued vide Policy No. OG–10–2417–8409–00000166.

                But during continuation of the said policy it was known to the Opposite Parties that the Complainant had a prior history of diabetes which has never been disclosed by the Complainant in the proposal form which was duly filed up by the Complainant before obtaining the said policy and if the said fact of pre existing decease would have been disclosed by the Complainant, the Opposite Parties would had made the proper assignment of risk and considering the same the Opposite Party might have cancelled the said Policy or had charged the higher premium. So the claim was rightly repudiated by the Opposite Party Insurance Company for suppressing the material facts which was clearly mentioned in the terms and conditions of the said Policy issued. The Opposite Parties had informed the Complainant the actual reason for non payment of the claim and for this repudiation the Opposite Party was no way held responsible.

               Thus the Opposite Parties never intended to deceit the Complainant by any means, therefore there was no negligence or deficiency on part of the Opposite Party in rendering the service towards the Complainant and the Opposite Parties prayed for dismissal of the case.

                              Points for Consideration

   1. Is the complaint maintainable under the C. P. Act ?

   2. Was there any negligence or deficiency in service on the part of the O.P ?                            

   3. Is the complainant entitled to get the relief as prayed for ?

                                          Decision with reasons

               All the points are taken up together for consideration for convenience and brevity.

               The main dispute between the Complainant and the Opposite Party is that whether the Complainant is entitled to get the entire claim of the treatment cost of Rs. 54,691/- only from the Opposite Parties or not.

               In coming into conclusion regarding the present dispute we have gone through the Complaint and Written Version and also critically appreciated the material documents on record and we have gathered that admittedly Complainant is a consumer under the Opposite Party by obtaining a Insurance Policy from the year 2009 which is still in force.

               The record reveals that the Complainants stated that the Complainant had admitted to the Apollo Geneagles Hospital, Kolkata, on 17.12.2009 and was discharged on 21.12.2009 and the entire treatment cost was borne by the Insurer Opposite Party on basis of cashless benefit which was never denied or disputed by the Opposite Parties.

               Thereafter the Complainant renewed the Policy and further admitted in the AMRI Hospital, but this time the Opposite Parties refused to meet up the claim by cashless benefit. The Complainant further alleged that the treatment cost of the Complainant No. 2 at the Sankar Netralaya, Chennai was also been repudiated by the Opposite Parties which was also never denied or disputed by the Opposite Parties.

              It is revealed from the record that the Opposite Parties admitted the fact that they had repudiated the said claim of the Complainants by filing their Written Version but challenged that the repudiation had been done rightly on the ground that the Complainant No. 2 had a prior history of diabetes which was never disclosed by the Complainants in the proposal form which was duly filed by the Complainant before obtaining the said policy.

              The photocopies of the documents filed by the Complainant reveals that nowhere in the ‘Discharge Summary’ of the Sankar Netralaya, Chennai or any other hospital it is specifically expressed or written that the Complainant No. 2 had/has been suffering from diabetes for long period from before 2009 as the said Policy was obtained by the Complainant No. 1 in the year 2009.

               But the Opposite Parties submitted the photocopies of the documents wherefrom it is revealed that one doctor named Dr. (Mrs.) T. Thingnak, SNO (Sg) of A.P. issued a ‘Certificate’ in a plain paper wherein it is specifically written that the Complainant No. 2 had/has been suffering from diabetes since 2007 for which she was advised for specialized surgical eye treatment. But fact remains that the said Ld. Doctor did not prefer to issue the said ‘Certificate’ in her own letter headed paper or also did not prefer to issue the said ‘certificate’ in the paper headed by any recognized hospital. The ‘certificate’ did issue by the said doctor in just a plain sheet of paper only. So, it has no evidentiary value in the eye of the law.

              Moreover, such ‘Certificate’ was not produced in original by the Opposite Parties before the Forum for which the Forum cannot be able to determine the authenticity of the said ‘Certificate’ and the said ‘Certificate’ was not attested also.

               Materials on record reveal that, the Opposite Parties had also filed the ‘Discharge Summary’ of the AMRI Hospital wherein it is written that the final diagnosis of the said AMRI Hospital was diabetic kidney disease, hyperlipidemia and hypothyroidism. But nowhere in the said ‘Discharge Summary’ issued by the AMRI Hospital it is found that the diabetes disease has been continuing from 2007 or before 2009, i.e. before obtaining the said Policy as alleged by the Opposite Parties. Thus the Opposite Parties has miserably failed to prove that the Complainant No. 2 has been suffering from any pre existing disease before obtaining the said Policy and the Complainant No. 1 did not disclose the same. So, the Opposite Party shall never be avoided thier liability towards the Complainants and the Opposite Parties are still liable to pay the claim amount of the Complainants.

              Therefore, in the light of the above discussion, we are of the opinion that the Complainant is entitled to get the relief as prayed for and consequently the points for consideration are decided in affirmative.

               In short, the Complainants deserve success.

              In the result, we proceed to pass

                                                                                                       O R D E R 

              That the complaint be and the same is allowed on contest against Opposite Party No. 1 & 2 with cost of Rs. 10,000/- only payable by both the Opposite party to the Complainant within one month from the date of this order.

              That the Opposite Parties jointly and severally is directed to pay the sum of Rs. 54,691/- only to the Complainants as claimed by the Complainants as cost of the treatment within one months from the date of this ‘Order’.

               The Opposite Parties are jointly and severally directed to pay a sum of Rs. 6,000/- only to the Complainants as compensation for harassment and mental agony within one months from the date of this ‘Order’.       

              In the event of non compliance of any portion of the order by the Opposite Party within a period of one month from the date of this order, the Opposite Party shall have to pay a sum of Rs. 100/- per day, from the date of this order till its realization, as punitive damages, which amount shall be deposited by the Opposite Party in the State Consumer Welfare Fund.

              Let copies of the order be supplied to the parties free of cost when applied for.