Complainant by filing this complaint has submitted thatcomplainant, his wife and his two sons namely SayanMajilya and SubirMajilya were insured under medi-claim policy towards health insurance and the certificate of insurance bearing certificate/policy No. SE00014107000100 was issued by Royal Sundaram Alliance Insurance Company Limited through op no.2 and period of coverage of the insurance was for two years i.e. from 30.06.2011 to midnight of 29.06.2013 and complainant already paid the premium amount of Rs. 79,689/- towards health insurance under scheme approved by IRDA and under the said policy the complainant and his family members individually is entitled to get hospitalization benefit to the tune of Rs. 5,00,000/- and personal accident benefit to the tune of Rs. 10,00,000/-.

          That on 02.05.2013 complainant and his student Bipradas Ghosh were going to Kolkata in his Private Car bearing Honda City bearing Registration No. WB0253033 and the said car was driven by complainant.  But unfortunately when a dog appeared before the said car, he tried to swerve to the right but leading to a crash and the complainant’s student Bipradas Ghosh died on the spot and the complainant was seriously injured.  Thereafter complainant was admitted to Apollo Gleneagles Hospital at 58, Canal Circular, Kolkata – 700054 on 02.05.2013 with multiple fractures on his person.  The wife of the complainant Mrs. Anita Majilya communicated to the op no.2 through/over phone on 03.05.2013 i.e. after the date of accident and intimated the said fact and op no.2 assured the complainant’s wife that they would talk to the hospital authority and moreover the wife of the complainant also informed the said accident of the complainant to the op no.2 on 06.05.2013 through E-mail and requested them to make arrangement of the cashless benefit against the said policy bearing policy No. SE00014107000100 as early possible.  But no positive response came from the part of the ops.

          Fact remains that complainant was admitted to the Apollo Gleneagles Hospital on 02.05.2013 and was treated under Dr. Buddhadeb Chatterjee who underwent operations and after a long struggle with death, the complainant became normal in part and he was discharged from the hospital on 23.05.2013 and complainant incurred Rs. 5,38,636/- towards treatment cost.  From the period of treatment wife of the complainant sent a letter to op no.2 on 15.05.2013 requesting to take the necessary measures for reimbursement of the amount of the benefit and also assured the op no.2 that she would contact with the office of the op no.2 when she shall have to come along with discharge certificate and necessary documents after the patient would be discharged.

          Thereafter op no.2 received a letter dated 15.05.2013 of the complainant.  But during the period of treatment of the complainant in the hospital, no response came from the op what tantamounts to negligence and deficient manner of service and unfair trade practice on the part of the op.

          After discharge of complainant from the hospital on 23.05.2012 lodged a complaint against the op after observing and requesting the op to settle the claim as early as possible.  But very surprisingly ops repudiated the claim vide a letter dated 28.06.2013 on the ground that insured is a known case of Hypertension since 16 years which is prior to policy inception and pre-existingdisease, hence the policy cancelled as per policy Clause which also tantamounts to deficiency in service and unfair trade practice.  But on receipt of the repudiation letter on 28.06.2013 Anita Majilya requested the op to look into the matter and reconsider the claim but till today no fruitful result came from the part of the op therefore for adopting unfair trade practice by the op, complainant was compelled to file this complaint before this Forum for proper relief and for directing the ops to release Rs. 5 lakhs as expenditure cost incurred by the complainant and other compensation.

          On the other hand op no.1 by filing written statement submitted after getting intimation of the claim this op sought for medical documents from the complainant and after discreet perusal of claim papers, this op found out that the complainant is known case of hypertension since last 4 to 5 years and arotie stenosis for last 16 years and this fact was not revealed to the op while opting for insurance policy.  But this factor should be revealed in front of op at the time of opening the insurance policy and complainant concealed the same and did not disclose the same in the proposal form as filled by the complainant while taking the policy and as a result the claim of the complainant is inadmissible under the policy terms and for which it was repudiated and moreover in the claim from treating Dr. Partho Bhattacharya has mentioned that complainant was suffering from hypertension since 4 to 5 years but the relevant excerpt of the past medical history of complainant as noted by the treating doctor in the claim form is reproduced before this Forum.  It is further submitted that it is found that utmost good faith must be observed by the contracting party and good faith forbids either party from non-disclosure of the fact which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary and as per settled principal of law the assured must disclose to the insurer all facts material to an insurer’s appraisal of the risk which are known deemed to be known by the assured but neither known nor deemed to be known by the insurer and breach of this duty by the assured entitles the insurer to avoid the contract of insurance so long as he can show that the non-disclosure induced the making of the contract on the relevant terms and no doubt insurance is a contract of speculation.

          So, the present repudiation was justified, legal and for which the complainant’s allegation against ops are false and baseless and onlyfor grabbing money the complaint is filed and for which the complaint should be dismissed.

          On the other hand op no.2 Standard Chartered Bank by filing this written version submitted that complainant is not a consumer of the op no.2 and op no.2 is noway related with the insurance matter.  But op no.2 is a bank.  But as facilitator in between the complainant and op no.1, he acted.  But there is no privity of contract between the answering op and the complainant.  So all the claim made by the complainant is tenable against insurance company not against bank for which the present complaint should be dismissed against the op no.2/bank.

Decision with reasons

          On proper consideration of the complaint including the written version and also arguments as advanced by the Ld. Lawyers of both the parties and also relying upon the document as filed by the complainant, it is found that op no.2 is no way related or any connection with the present consumer dispute because op is a bank who only as facilitator help the complainant to purchase the said insurance policy of Royal Sundaram Alliance Insurance Co. (op no.1).  In respect of this consumer dispute there is no relationship in between the complainant and op no.2 as consumer and service provider.  So, against op no.2 this complaint is not maintainable and for which this complaint against op no.2 should be dismissed.

          But now we have entered into the consumer dispute in respect of the claim of the Medi claim policy as made by the complainant to the op to the tune of Rs. 5 lakhs against admitted medi-claim policy bearing No. SE00014107000100.  Truth is that op no.1 has not denied about the incident about his sufferings and treatment at Apollo Gleneagles Hospital and also spending a sum of Rs. 5,38,686/-.  But their only claim is that claim was repudiated on the ground that complainant was suffering from hypertension for last 15 to 16 years and it is noted in the discharge summary.  But complainant did not disclose at the time of purchasing the said policy in the year 2011.  To determine this dispute we have gathered that no doubt the claim made by the complainant about accident, about treatment, about admission to the Apollo Gleneagles Hospital by the complainant is not denied by the op no.1.  But they reported to the complainant on 28.06.2013 that the claim was repudiated on the ground that complainant has been suffering from hypertension since 16 years just prior to policy inception and it was pre-existing disease which was not disclosed at the time of proposing in the insurance.  So, claim was repudiated.

          In this regard medi-claim intimation form which was submitted by the complainant or in the discharge summary there is no note that complainant has been suffering from hypertension or etc. from 15 to 16 years or 4 to 5 years.  But hypertension was detected at the time of diagnose and truth is that after accident such sort of hypertension is often found.  Further there was no statement of the complainant’s doctor that he was suffering from blood pressure for 15 to 16 years prior to this accident and there is no such documents that complainant was never examined by any doctor for any hypertension or any other.  So, called pre-existing disease as claimed by the op is not proved by such document by any means whatsoever and at the same time there is no document to show by the op that patient was taking medicine for hypertension for some time and fact remains the complainant at the time of accident was aged about 50 years.  But for the sake of argument if it is accepted that complainant was suffering from hypertension for 15 to 16 years but for that reason he did not suffer from any physical ailment and for such connected disease he was admitted to hospital for treatment.  But present treatment was only for the accident for which he suffered several fractures. In this regard it is to be mentioned that hypertension does not amount to suppression of material fact because hypertension is usually a lifestyle disease including blood sugar and it can easily be controlled with conservative medicine and there is no evidence or such material produced by the op to the effect that due to hypertension and for his major past illness this fracture caused.

          So, it is clear that the op has searched out a fake ground for repudiation and fact remains that such an allegation that he was suffering from hypertension is completely baseless ground for repudiation and in this regard we have also relied upon the judgement of National Commission passed in Appeal No. 579/2007 disposed of on 04.10.2012 by Hon’ble Justice AshokeBhan, President and Hon’ble Vinita Ray, Member and relying upon that judgement and including the defence of the op we are convinced to hold that there is no question of holding that the fractures were caused for alleged hypertension and there is no such evidence produced by the op that Hypertension was so acute or high that it was responsible for complainant’s fracture/injury or accident. 

          Keeping in view of the above facts we are convinced to hold that the repudiation as made by the ops is completely baseless, fabricated and it has become a practice of the private insurance companies to repudiate the claim of the mediclaim insured in most of the cases showing their reasons pre-existing disease, blood pressure and sugar.  But in any case ops have not able to prove in this case that effect of hypertension is the proximate cause of fracture or injury.  So, we are convinced to hold that present repudiation is unethical, uncalled for and no at all judicious.  But it is common disease of the ops to repudiate such claim in such a manner.  But fact remains that complainant paid huge premium for two years term medi claim policy i.e. a sum of Rs. 79,689/- and at the time of receiving the policy op swallowed the premium and ops were very cordial.

          But at the time of disposing of their petition they are very much arrogant which is proved from the present case.  Most interesting factor is that it is completely a road accident.  So, invariably complainant is entitled to personal accident benefit and this matter was overlooked by the ops and that is the business of the private insurance companies like this op.  They open insurance policy only for the purpose of swallowing or grabbing the premium but they are not giving the benefit of the insurance policy and it is the common practice of the present op company almost all the cases because this Forum handled so many cases of the op insurance companies and their only defence is hypertension, sugar etc. 

          In the light of the above observation and considering materials on record we are convinced to hold that complainant is entitled to entire claim amount i.e. Rs. 5,00,000/- and ops are bound to pay the same along with interest in view of the fact present repudiation was baseless and without any foundation and fact remains op no.1 has adopted unfair trade practice which is proved.  In view of the above fact and circumstances we are convinced to hold that complainant’s allegation against op no.1 is well proved.

          So, complaint is succeeds against the op no.1 but fails against op no.2.

          Hence, it is

ORDERED

          That the complaint be and the same is allowed on contest with cost of Rs. 10,000/- against op no.1 and same is dismissed on contest against op no.2 but without any cost.

          Op no.1 is hereby directed to pay the medi-claim amount of Rs. 5,00,000/-along with interest  at the rate 8percent p.a. w.e.f. 23.05.2013 and till its full payment to the complainant and decretal amount shall be paid by the op no.1 within 15 days from the date of this order failing which for non-compliance and disobeyance of Forum’s order op no.1 shall have to pay penal damages  at the rate  Rs. 500/- per day till full satisfaction of this decree and penal damages if collected it shall be deposited to this Forum.

          Op no.1 is directed to comply the order very strictly failing which penal action u/s 27 of C.P. Act 1986 shall be started against op no.1 for which further penalty and fine shall be imposed.