This is an application u/s.12 of the C.P. Act, 1986.

          Complainant by filing this complaint has submitted that he purchased one policy being No.SEB000000300100 from OP1 to secure his future life through OP2 as intermediary on 07-02-2013 and at the time of taking the policy complainant was properly examined and being satisfied about the terms and condition and also getting good medical report OP allowed complainant to hold the above named policy. Complainant paid premium up to 2015 as settled by the OPs.

          It is stated very specifically by the complainant that he has been suffering from diabetes for twenty years and at the time of availing the policy he disclosed the same to the OPs.

          Subsequently, complainant on 22-04-2013 complainant became seriously ill and admitted to Fortis Hospital Ltd. and so, undergone medical treatment on 22-04-2013 to 26-04-2013 and incurred an expenditure of Rs.1,10,771/- and after discharge complainant approached the OPs to pay the expenditure incurred in the hospital  as per policy term.  But the OP refused to make payment vide their letter dated 31-05-2013.

          Subsequently, complainant on 03-06-2013 wrote a letter to the OP1 to recall the notice on 31-05-2013 and also asked them to make the payment of expenditure which the complainant incurred in the hospital for his treatment and which he also entitled to get as per policy.  But even then OP did not respond and so, for negligent and deficient manner of service of the OP complainant has preferred this complaint for proper redressal.

          On the other hand, OP by filing written statement submitted that complainant and OP are acted by terms and condition of the policy and admitted fact that complainant has been suffering from high blood sugar for 20 years before opening the policy but complainant did not disclose it and so, there is no question of examination of the complainant at the time of purchasing the said policy.

          Moreover from the medical report of Fortis Hospital Ltd. for the period from 22-04-2013 to 26-04-2013 it is proved that complainant had been suffered from diabetic and hypertension since last 15 years.  So, complainant is known cause of hypertension and diabetes since 15 years that has been proved and admitted by the complainant and fact remains complainant was hospitalized for cellulitis is a complication of diabetes which was preexisting and same was prevailing long before the policy since inception and the hospital authority clearly stated that there was a known cause of type-2 diabetes and hypertension and the medical history of the complainant is unity in the said treatment sheet it is produced by the OP.

          Fact remains ailment namely Cellulitis is a complication of diabetes which is preexisting clause policy.  Therefore, OP regretted to consider his claim and inability to consider the claim and in view of the above the claim was not admissible as per terms and condition of the policy but fact remains complainant deliberately conceal the fact in the proposal form by denying about any preexisting disease and ailment and with mala fide intention to claim amount from the OP.  That it is the duty of the complainant to disclose the fact with regard to state of the health of the complainant was not given properly by the complainant in the application form and if complainant would give correct status of his health in that case in surer can make prudent decision to undertake the risk or not and practically material regarding his health status was very important and essential and relevant information in the context of the risk to be covered by the insurer and considering all the above fact the OP repudiated the claim for suppressing the fact and material regarding the status of the health on the date of purchasing the policy and so the complainant is not entitled to any relief and there was no negligence and deficiency on the part of the OP.

Decision with Reasons

In the present particular case on meticulous study of the complaint including the written version of the OP and the materials it is undisputed fact that complainant has been suffering from hypertension and diabetics for long 15 years preceding to purchasing the policy.

          At the same time it is settled principle of law as it is found from the ruling reported in II(1999) CPJ 13 Supreme Court that “Insurance Policy to the insurer and insured represents on contract between the parties the insured again claim anything more than what is covered by the insurance policy that being so the insured always to go strictly in accordance with the statutory limits or terms of the policy expressly settled out therein.”  And at the same time the policy shall be void and all premium shall be paid forfeited to the company in the event of misrepresentation, mis-description and or non-disclosure of any material fact.

          Considering this principle of law and also the admission of the complainant in the complaint that he had been suffering from diabetes for last twenty years we are convinced to hold that it was the duty of the complainant but disclose his health status in the application form at the time of purchasing the policy and in this regard we have gone through the policy document wherefrom it is found complainant filed the application form in which he has specifically mentioned against column specified name of the disease, illness, disablement suffer/suffering from – N.A. and that form was signed by the complainant which is marked as Exhibit-5 of the OP and from the said claim application form it is found that relying upon such statement and disclosure of the health status of the complainant the policy was issued having  its validity period from 07-12-2013 to 06-02-2015.  If we really upon that document and the terms and conditions of the policy we find that complainant willfully did not disclose his ailment that is pre-existing disease – hypertension and diabetes was as per terms and conditions of the policy complainant’s policy is avoid for declaration of misrepresentation of fact also suppressing the truth about his health.

          Moreover, as per clause regarding pre-existing disease complainant is not entitled to any benefit for hospitalization.

          In this present case after considering the material document and discharge certificate it is found that he is admitted for the treatment of Cellulitis and in this regard after stating his particular disease Cellulitis it is found that it is inflammation, infection of the skin characterized most commonly by the heat, redness, pain and swelling and occasionally by malaise, chills and headache.  Abscess and tissue dissolution usually follow if antibiotics are not taken.  Development of celluloids treatment is to add proper antibiotic including the warm shocks and this disease is caused only in the case of patient who are suffering from diabetes and fact remains in the present case the present Cellulitis was caused due to said past history of sugar and continuous suffering from sugar and hypertension and doctor has confirmed that in his discharge certificate also.

          Considering the entire materials on record and particular document of the complainant in his complaint and also the vital report of the doctor after discharge we are confirmed that disease was preexisting and such a disease is common to present who are suffering from hypertension and diabetes.  After thorough study of the materials and documents and record it is found that complainant is falsely stated that he reported to the OP about his preexisting disease and diabetes but after considering the application form filed by the OP for purchasing the insurance policy we find that his common version in the complain t is completely false because in the application he did not disclose it rather he disclosed that he was not suffering from any sort of disease.  So, we are confirmed that complainant is not disclose the material fact regarding the status of his health and actually suppress the status of his health that it is the fact then core question for consideration is whether the fact at the time of taking the present policy he was suffering from any chronic diabetes or not.  But already we have gathered and already complainant has admitted in the application that he has been suffering from diabetes and hypertension prior to purchase in the policy for twenty years preceding to filing the application form for purchasing the policy.  Then it is clear it was failure of the part of the complainant to disclose the material fact.  Therefore, on the account of non-disclosure of the fact for the proposal form insurance company is or was justified in the law in repudiating his claim of the complainant.

          Moreover, the spirit of the policy is to assure the policy holder in respect of one expenses pertaining to injury, accident or hospitalization thus it needs little emphasis that when the information on a specific aspect is asked for in the proposal form, and assured him under a solemn obligation to make a true and full disclosure of the information of the subject which is within the knowledge and it is not for the proposer to determine whether the information sought for material for the purpose of the policy or not but of course the obligation to disclose existence only to the facts which are known to the obligation and not what he ought to have known so the obligation but disclose unnecessarily depends upon only of one possesses.  If this principle of law is applied in that case it is found in that case complainant was suffering from preexisting disease like hypertension, blood sugar more than twenty years preceding the application form for the policy and when that is the fact there is no ground to give benefit under any circumstances and practically after considering the entire fact we found that when the complainant suppressed the material truth with intention to get the benefit of the policy then the entire policy is void and in such circumstances OP rightly repudiated the claim and when the complainant is not entitled to get benefit in respect of that policy in future also.

          Thus complaint fails.

Hence,

Ordered

That the case be and the same is dismissed on contest against the OPs but without cost.