Sri Swapan Kumar Mahanty, President.
This is an application u/s.12 of the C.P. Act, 1986.
Brief facts of the case are that the complainant was admitted to Columbia Asia Hospital on 27-09-2015 for Dengue Treatment and discharged on 06-10-2015. The OPs issued pre-authorization letter of Rs.15,000/- for availing cashless facility. The hospital bill amount exceeded Rs.1,00,000/- for which the OPs rejected the cashless facility on the ground of “Non-disclosure of material facts/Pre-existing ailments “at the time of proposal. Complainant submitted his claim vide No.90142705 to the OP1 Religare Health Insurance but the OPs repudiated the claim on the ground of “Non-disclosure of material facts/Pre-existing ailment”. Complainant alleged that he was not admitted to hospital for any disease caused by or related to hypertension. The repudiation of the OPs is not justified and the attitudes of the OPs tantamount to deficiency in service for which the complainant has suffered mental agony. Hence, the consumer complaint.
The OPs have contested the case by filing a joint written version contending inter alia that the complaint is not maintainable either in law or on facts. The specific case of the OPs is that the complainant had taken an Insurance Policy bearing No.10121990 and such policy covering the complainant and his daughter. The policy was further renewed for the period from 04-07-2015 to 03-07-2016 subject to certain terms and conditions. The OPs initially approved the cashless facility of Rs.15,000/- to the complainant subject to furnishing necessary documents. Complainant did not disclose the pre-existing ailment i.e. hypertension at the time of taking policy. The cashless facility of the complainant was denied in terms of clause 6.1 of the policy. Again the reimbursement claim of the complainant was rejected on the selfsame ground. The discharge certificate dated 06-10-2015 of the complainant shows past Medical and Surgical History “K/C/O HTN” and the complainant himself in his letter admitted the fact of suffering hypertension. Thus, the claim of the complainant is not tenable. Accordingly, the OPs have prayed for dismissal of the complaint.
On the pleadings of the parties the following points have been raised for the sake of proper and effective adjudication of the case.
- Is the Consumer Complaint maintainable in its present form and in law?
- Are the OPs deficient in rendering services to the complainant?
- Whether the OPs have repudiated the claim wrongfully or illegally?
- Is the complainant entitled to get relief as prayed for?
Decision with Reasons
Points No.1 to 4 :
All the points are taken up together for the sake of convenience and brevity in discussion.
Both parties have tendered evidence through affidavit. They have also given reply against the questionnaire set forth by their adversaries. Both parties also filed Brief Notes of Arguments.
It remains undisputed that the complainant had taken an insurance policy bearing No.10121990 and such policy covering the complainant and his daughter. It is also true that they said policy was valid for the period from 04-07-2015 to 03-07-2016. There is no dispute that complainant was admitted to Columbia Asia Hospital on 27-09-2015 as per advice of Dr. Sujit Saha for the treatment of dengue and initially claimed for cashless pre-authorization for Rs.15,000/-. Complainant was discharged from Columbia Asia Hospital on 06-10-2015 and lodged claim of Rs.1,77,945/- as reimbursement but his claim was rejected in terms of clause No.6.1 of the policy. On perusal of photocopy of Health Insurance Policy under the heading General Terms and Conditions we find that “If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy holder or insured person or any one 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”.
We have also perused photocopy of Proposal Form – CARE annexed with the written version and find that the complainant given answer to the following questions :-
Pre-existing Disease Details :-
Treatment for any illness/injury :- No No.
Has anyone been under any medication/ :- No No.
Tablets for any illness/injury
The Discharge Summary dated 06-10-2015 issued by Columbia Asia Hospital goes for show that complainant was admitted with Dengue NS1 positive and treated under Dr. Sujit Saha. The Significant Past Medical and Surgical History is written “K/C/O HTN”. Accordingly, the OPs cancelled the Health Insurance Policy on the ground of “Non-Disclosure of Material Facts/Pre-Existing Ailments at the time of Proposal. Complainant had a history/known case of Hypertension since 2007 and this fact was not disclosed at the time of taking Policy”. Complainant himself admitted in his letter addressed to OP2 (annexed with the written version) that his blood pressure detected in 2007 and due to work pressure his blood pressure rise just above the normal. Thus, the complainant/insured having suppressed the fact that he was suffering from Blood Pressure since 2007 which was within his knowledge.
The core question for consideration is whether the fact that at the time of taking out the Mediclaim Policy, the Policy Holder was suffering from Blood Pressure is a material fact and, therefore, on account of non-disclosure of this fact in the proposal form, the OPs/Insurer is justified in law in repudiating the claim of the complainant.
Having bestowed our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer of the question posed has to be in the affirmative. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalization. Nonetheless, it is a contract of insurance falling in the category of contract, uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. The obligation to disclose necessarily depends upon the knowledge of the possesses. Therefore, we cannot say that complainant is not aware of the above ailment of hypertension, when he took the Mediclaim Policy. Contract of insurance is based upon the principle of good faith. It is the obligation of complainant/Insured to disclose each and every fact to insurer at the time of taking the policy. The decision of the insurer is totally dependent upon this fact, whether to underwrite the risk involved in the policy or not and in case there is suppression of material facts by the insured deliberately and consent of the insurer has been obtained by not disclosing the correct particulars then the contract of insurance can be avoided on account of exercise on misrepresentation by insured. The insurer might not have issued the policy to insured after knowing his pre-existing disease. It is not the case of the complainant that the contents of the proposal form was not disclosed to him when he filed in the proposal form and he is not aware of the same. Complainant being an Advocate signed the declaration being part of the proposal form, wherein he made the statement disclosing true facts of the proposal form. The Hon’ble Supreme Court in the case of Satwant Kaur Sandhu – vs.– New India Assurance Company Ltd. reported in IV(2009) CPJ 8 (S.C.) observed as follows :-
“If the proposer has knowledge of any fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasize that any inaccurate answer will entitle the insurer to repudiate his liability, because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract on Insurance”.
In the light of the above observation, we hold that there is no case of deficiency in service has been established and the OPs/Insurer has rightly repudiated the claim of the complainant on the ground of suppression of material facts. Thus, the consumer complaint is not maintainable in its present form and in law. Therefore, the complainant is not entitled to get any relief as prayed for. Accordingly, all the points under determination answered in the negative.
In the result, the case merit fails.
Hence,
Ordered
That the complaint case be and the same is dismissed on contest against the OPs but without any cost.
Let copy of the final order be handed over to the parties when applied for
