Order No.  15  dt.  03/07/2017

       The case of the complainant in brief is that the complainant obtained a mediclaim policy being no.10004119 issued by o.p. no.1. The complainant in the year 2012 transferred and renewed his mediclaim policy in favour of o.p. nos.1 and 2 from the previous insurance company viz. Star Health and Allied Insurance Co. and accordingly o.p. nos.1 and 2 issued a policy certificate in continuation of the previous policy with the Star Health and Allied Insurance Co. The policy covered between the period on 1.12.12 to 31.12.13 and the sum assured was Rs.2 lakhs. In the last week of Oct. 2013 the complainant fell ill and as per advice of the doctor the complainant took admission in the hospital and he incurred an expenditure of Rs.85,531/- plus Rs.3000/-. The complainant after his recovery submitted the claim to o.p. no.1. The complainant again fell ill in the 1^st week of Nov. 2013 and he was admitted in the hospital and incurred an expenditure of Rs.1,66,153/- plus Rs.2500/-. After being discharged from the hospital the complainant submitted the bills but after the expiry of a few months the complainant did not get any response from o.p. no.1. Subsequently on 10.1.14 the complainant received a letter wherefrom he came to learn that the claim of the complainant was repudiated. On the basis of the said fact the complainant filed this praying for direction upon the o.ps. to settle the claim of the complainant and also to pay compensation of Rs.2 lakhs and litigation cost etc.

            The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the complainant submitted proposal form duly filled up and signed by him. As per the proposal form the proposed insured person has to provide all the information required therein correctly and/or truly. In the proposal form there was a question put by o.p. insurance company “Is there any member proposed to be insured suffering from any illness or disease? If yes provide details”. The answer to this question was “No”. Therefore by not declaring the correct and accurate information at the time of proposing for the referred policy, the complainant  has acted in breach of clause 6.1 of the policy and the complainant at different times lodged the claim for reimbursement of the expenses to the tune of Rs.1,70,000/-. The complainant did not disclose in the proposal form or during the pre policy medical test, that he had already suffered diabetes mellitus, PPI in 2003, OTCA in 2005 and pulmonary TB with haemodialysis in the year 2005 and all related questions were answered in negative. The o.ps. realized the same from the documents submitted by the complainant at the time of claims. Since the complainant at the time of opening the policy suppressed the material fact and as per the clause 6.1 of the policy terms the claim made by the complainant was repudiated. In view of the facts and circumstances as stated above, o.ps. prayed for dismissal of the case.

            On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant had the policy the relevant point of time?
2. Whether the complainant suppressed the material fact regarding his pre existing disease?
3. Whether the repudiation made by the insurance company was justifiable?
4. Whether there was any deficiency in service on the part of o.ps.?
5. 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 being a senior citizen had he policy with Star Health and Allied Insurance Co. and subsequently with the merger of the said policy with o.p. no.1 the complainant continued the mediclaim policy and obtained the policy from o.p. no.1. During the subsistence of the policy the complainant got seriously ill and he was admitted to the hospital and he underwent treatment on different occasions viz. in the last week of Oct. 2013 and also in the 1^st week of Nov. 2013. On both occasions the complainant had to take admission in the hospital. After undergoing the treatment the complainant had to bear huge expenses and after recovery the complainant submitted the bills to o.p. no.1 for reimbursement, the bills were not sanctioned by o.ps. and no reply was given. The complainant on numerous occasions made correspondences with o.ps. but o.ps. failed to give any reply. Subsequently after the lapse of several months the complainant received a letter from o.p. no.1 that his claim was repudiated and the said communication was made on 10.1.14. After coming to know of the said fact the complainant became astonished and subsequently filed this case praying for direction upon the o.ps. for considering the bills submitted by the complainant as well as for other reliefs.

            Ld. lawyer for the o.ps. argued that it is not any dispute that the complainant was not a policy holder at the relevant point of time. Ld. lawyer also emphasized that at the time of obtaining the policy the complainant ought to have disclosed the illness suffered by him prior to obtaining the policy. The complainant at the time of pre policy medical examination did not disclose that he suffered serious nature of diseases for which he had to undergo for treatment at different hospitals. Since the complainant did not disclose the disease suffered by him earlier the pre policy test was conducted in routine manner. Subsequently with the submissions of the bills and the documents annexed by the complainant wherefrom it is evident that the complainant had to take admission in B.M. Birla Hospital and in the discharge documents it was stated that the complainant had undergone various treatment at different times and the said fact was suppressed by the complainant. In view of the said fact as per clause 6.1 of the policy terms if any untrue or incorrect statements are made and there has been a misrepresentation, misdescription or non disclosure of any material particular or any material information having been withheld or any fraudulent means or devices are used by the policy holder or insured person or anyone acting on his / her behalf the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the company. On the basis of the said fact and after coming to know the suppression of pre existing disease the bills of the complainant were not allowed and the claim was repudiated. There was no deficiency in service on the part of o.ps. and accordingly o.ps. prayed for dismissal of the case.

            Considering the submissions of the respective parties it is an admitted fact that the complainant is the holder of the mediclaim policy under o.p. no.1 and the policy was valid when the complainant fell ill and admitted to different hospitals for his treatment. It is also admitted fact that the complainant immediately after his recovery from his illness submitted bills to o.ps. for reimbursement. It is also an admitted fact that after receiving the medical bills o.ps. meticulously examined the bills. It is also an admitted fact from the documents filed by the complainant that at the time of applying for the policy the complainant did not disclose any disease for which the policy was issued accordingly. The relationship between the policy holder i.e. insured and the insurer depends on utmost good faith. The complainant should have disclosed the material information before taking the policy, not providing information led to the violation of not only the terms of the contract but also the basic principles of insurance. As per clause 6.1 of the terms and conditions of the policy the non disclosure of any material particularly any disease violated the said clause and as per exclusion clause 6.1 the insurance company denied the claim of the complainant. The insurance company came to know of the previous ailments of the complainant from the documents filed by the complainant himself i.e. discharge certificate whereby it was mentioned that he had undergone treatment for suffering of diabetes mellitus, PPI in 2003, PTCA in 2005 and pulmonary TB with haemodialysis in the year 2005 and all health related questions were answered in negative. After coming to know of the said fact o.ps. repudiated the claim of the complainant. In this respect we can rely on a decision as reported in 2016(4) CPR 471 (NC) wherein it was held that the insurer was justified in repudiating the claim on account of false statement made by the assured in the proposal form. Having regard to the facts and circumstances of the case and the materials on record we hold that the claim made by the complainant is not tenable and the repudiation made by o.ps. was justifiable one and accordingly, the case as filed by the complainant is not maintainable and the same is to be dismissed. Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.468/2014 is dismissed on contest without cost against the o.ps.

            Supply certified copy of this order to the parties free of cost.