Per Shri Dhanraj Khamatkar, Hon’ble Member This appeal takes an exception to an order dated 18/11/2003 passed by District Forum, Central Mumbai in consumer complaint No.61/2000. The husband of the complainant had taken joint mediclaim policy along with complainant and his son from the opponent. The policy is bearing No.48/99/14088 and the period of the policy was from 17/08/1999 to 16/08/2000. At the time of taking policy, the complainant was well and healthy. However, on 27/10/1999 she had vomiting and headache. Hence, investigations were carried out in the Bombay Hospital and renal failure was detected. Initially, she had treated by Dr.S.P. Trivedi, Nephrologist along with Dr.R.K. Garg, Urologist of the Bombay Hospital for renal failure and thereafter, she had taken treatment from Dr.Bharat Shah, Nephrologist and Dr.Sharad Sagde, Urologist of the Hinduja Hospital. She was admitted in the Hinduja Hospital on 15/11/1999. She has filed mediclaim on 06/01/2000 with the opponent. However, opponent repudiated the claim on 16/03/2000 without assigning valid reason on the ground that she has suppressed material fact while taking policy. Considering the repudiation of claim by the opponent as deficiency in service, the complainant has filed a consumer complaint praying for `1,50,000/- amount due and payable under the policy and further `1 Lakh for causing mental harassment. 2. The opponent/Insurance Company had contested the complaint by filing written version contending therein that they have issued mediclaim policy to the complainant upon submission of the proposal form. The opponent/Insurance Company further contended that at the time of submitting the proposal form, the complainant had not disclosed the vital information regarding her health. They further contended that the business of the insurance is carried out on the basis of utmost good faith and it was the duty of the complainant to disclose all the facts relating to her health. The opponent/Insurance Company further contended that the complainant had filed a claim immediately after 70 days of issuance of policy and hence, claim was referred to their Panel Doctor-Dr.M.S. Kamath, who clearly opined that chronic renal failure by its very definition is an ailment of long standing and in existence for a long period i.e. at least about 1-2 years and he opined that claim of the complainant cannot be allowed. It is further contended by the opponent that in the proposal form under column-13 which pertains to diabetes or any urinary disease, the complainant has answered in negative. They further contended that the complainant was already suffering from chronic disorder for about one or two years prior to taking of mediclaim policy. Therefore, opponent/Insurance Company has prayed that complaint be dismissed as there is no deficiency on the part of the opponent/Insurance Company. 3. District Forum after going through the complaint, written version filed by opponent, evidence filed by both the parties on affidavits and pleading of their Advocate and Authorised Representative came to the conclusion that while taking the policy, the complainant was not aware about the fact of renal failure and hence, she has not suppressed any material information and allowed the complaint directing the opponent-appellant/Insurance Company to pay an amount `1,50,000/- along with interest @ 9% p.a. from 16/03/2000 i.e. the date of repudiation till its realization and costs of `250/-. It is against this order that the opponent/Insurance Company has filed an appeal. 4. We heard Mrs.K.R. Trivedi, Advocate for the appellant/Insurance Company and Mr.Goyal, A.R. of the respondent/complainant. 5. Admittedly, respondent had taken policy bearing No.48/99/14088 from the opponent/Insurance Company and the policy is valid from 17/08/1999 to 16/08/2000. It is also an admitted fact that during period of the policy, the respondent went to the Bombay Hospital on 27/10/1999 for vomiting and headache and in the investigation, it is detected that there was renal failure. The appellant has taken stand that while taking policy, the respondent has not furnished true information regarding her health and thereby suppressed the material information. The appellant/Insurance Company had not produced any evidence to prove that disease of renal failure was suppressed by the respondent while taking policy. The appellant/Insurance Company is relying on the opinion given by their Panel Doctor- Dr.M.S. Kamath. Dr.Kamath has stated in his report that he has examined the case papers of the Bombay Hospital and made inquiry with the doctors. In his report Dr.Kamath has opined that chronic renal ailment is a long standing and in existence for a long period. The papers relied upon by Dr.Kamath no where mentioned that she was aware of the fact that she was suffering from renal failure. The opponent/Insurance Company had not adduced any evidence to prove that at the time of filling of the proposal form, the complainant was having renal failure and knowingly she has suppressed this material fact. From the evidence adduced by the respondent, it is established beyond doubt that the fact that respondent was suffering from renal failure came to her notice after investigation made by doctors of Bombay Hospital on 27/10/1999. Even in investigation done by doctors, there is no iota of evidence to prove that before taking policy the respondent was having renal failure and she has suppressed this fact while taking policy. District Forum after taking into consideration the evidence on record had passed the order and we find that the order passed by the District Forum is just and proper. We do not find any substance in the appeal. We hold accordingly and pass the following order :- -: ORDER :- 1. Appeal stands dismissed. 2. The order of the District Forum is hereby confirmed. 3. Copies of the order be furnished to the parties. Pronounced Dated 31st July 2012. |
