Sri Shyamal Gupta, Member

In this Appeal, the Order dated 20-11-2018 of the Ld. District Forum, Kolkata-I (North) passed in complaint case bearing no. CC/382/2017 has been challenged by the Appellants, M/s Star Health & Allied Insurance Co. Ltd.

The Dispute

Dissatisfied with the decision of the Appellants to reject their insurance claim, the instant complaint case was lodged before the Ld. District Forum by the Respondents.

Appellants’ case

Ld. Advocate appearing on behalf of the Appellants submitted that the Respondent No. 2 violated Condition No. 7 of the Insurance Policy by suppressing her pre-existing medical condition before the Appellants.  Taking strong exception to such non-disclosure of material fact by the Insuree, the Appellants not only rejected the instant claim, but also returned the premium amount to the Respondents.

Respondents’ defence

The Respondents vehemently denied any wrongdoing and termed their claim as a bone fide one. 

My Findings

On minute scrutiny of the documents on record, it transpires that the insurance policy contained an Exclusion Clause and in terms of Condition No. 3(b) of the said Clause, the Appellants had no liability whatsoever to reimburse a claim lodged for treatment of Hepatobiliary gall bladder and pancreatic calculi for the first two years of continuous operation of insurance cover.

In this case, as I found, the date of inception of the policy was 06-10-2016 and the Respondent No. 2 took admission at the hospital on 19-12-2016.  The medical condition of the patient was finally diagnosed as Cholelithiasis together with Cirrhosis of Liver.

Be it mentioned here that, Cholelithiasis is the medical name for hard deposits (gallstones) that may form in the gallbladder. It, thus, boils down to the fact that the instant claim pertained to gall bladder treatment of the Respondent No. 2.

Conclusion

Above being the discernable position of this case, in my considered opinion, Appellants had no obligation at all to settle the instant claim of the Respondents.  Repudiation of the instant claim, under these facts and circumstances, appears quite justified. I, therefore, set aside the direction of the Ld. District Forum to settle the instant claim by the Appellants.

However, I cannot endorse the decision of the Appellants to suo motu cancel the subject policy.  Not a solitary piece of document is placed on record by the Appellants wherefrom it can be conclusively ascertained that the patient was indeed suffering from any pre-existing disease, e.g., Dilated Cavities with Global Hypokinesia, systolic dysfunction. Merely because some of the pathological tests carried out in the month of December 2016 were suggestive of the fact that the patient had developed certain medical conditions warranting indoor treatment at a hospital, it is no definite proof of the fact that the patient had any prior knowledge about the same at the time of taking the subject policy. 

In this connection, I am tempted to state that at the time of taking the subject policy, the incumbent was 59 years old.  Therefore, it was but natural for the Appellants to remain at their toes to satisfy themselves fully about the well being of the incumbent beneficiary. If they did not preach abundant precaution at that time, the fault lies with them.

Insofar as no medical paper pertaining to the Respondent No. 2 pre-dated 06-10-2016 is placed on record from the side of the Appellants, I am inclined to direct the Appellants to revive the subject health policy on payment of due premiums without any kind of penalty/revival charges. Appellants shall intimate, within 45 days hence, the actual premium amount payable by the Respondents to revive the subject policy and on payment of due premiums, they shall do the needful.

The instant order of the Forum below, accordingly, stands modified as above.  The Appeal stands allowed in part.