ORDER Dated: 03.11.2016
Dr. Vikram Kr. Dabas, Member
1. This complaint was filed on 04.12.2014 wherein the complainant has alleged
that he had taken a medical insurance policy no-P/161213/01/2015 /000158
for his parent namely Mr. Devender Jain and Mrs Kamini Jain and has paid a
premium of Rs. 32090/- for the period 27.05.2014 to 26.05.2015 for total
insurance cover of Rs. 500000/-. It is alleged by the complainant that in the
policy certificate, the OP1 have mentioned that the insured person suffered
from pre-existing disease without his / his parent’s consent. It is also alleged
by the complainant that the insured person did not undergo any medical
treatment. He got his parents examined by the doctor who reported his
parents normal and certified that they were not suffering from any type of
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diseases. The complainant contacted the OPs numerous times to make
correction in the policy but to no avail pleading deficiency in service on the
part of the OPs the complainant prayed that OPs be directed to refund the
policy amount of Rs. 32,090/- along with interest @ 24% p.a. , Rs. 1,00,000/-
as compensation and Rs. 21,000/- as cost of litigation.
2. The OPs have contested the complaint and have filed their written statement.
In the written statement the OPs have submitted that the complainant has not
come with clean hands and the complaint is false , vague , baseless and
misconceived and is liable to the dismissed. It is submitted by the OPs that
the policy was issued to the insured on the information furnished by their son
i.e. the complainant. It is also submitted by the OPs that the complainant did
not inform about the medical examination of the insured and hence no
representative of the OP was present at the time of medical examination and
even the original check up documents were not supplied to the OP for
verification. OP1 has further submitted that the complainant wrote a letter to
the OP for refund of the money deposited with them after about 6 months of
taking the policy. It is further submitted by the OP2 that they were
considering the request of the complainant and will make the correction in
the policy if the complainant was interested in continuing the policy. OP1 has
denied that the complainant had suffered pain and agony on account of
issuance of the policy and has prayed for dismissal of the complaint. OP2 has
filed a separate written statement and has denied the averments made therein.
4. Rejoinder to the written statement of OPs was filed by the complainant
reiterating the averments made in the complaint and controverting with and
denied those made in the written statement.
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5. In the evidence filed by way of affidavit , the complainant has reiterated the
contents of the complaint and has exhibited photocopy of the policy along
with photocopy of proposal form (Ex. CW1/A) , photocopy of relevant
medical documents (Ex. CW1/B to CW1/M) and copy of the mail to OP1
(Ex. CW1/N) . In the affidavit of evidence the OPs have supported the
contents of their written statement.
6. We have heard arguments advanced at the bar and have perused the record.
7. An insurance contract is entered on the basis of a proposal form submitted by
the proposer who wants to obtain an insurance policy. In the present case a
copy of the proposal form executed by the complainant has been placed on
record vide Ex. CW1/A A perusal of the form makes it amply clear that
there is no mention that the insured were suffering from any pre existing
disease. The OPs have not placed on record any documents to prove that the
insured was suffering from any pre-existing disease. It was incumbent on the
OPs to have explained as to how they have mentioned in the policy that the
insured were suffering from pre existing diseases. Indeed OPs has admitted
in its written statement that they have inadvertently mentioned about the
existence of the pre-existing disease in the case of the insured in the policy.
This is clear from a reading of para 8 of the written statement of OP1 and
relevant portion of para 8 is reproduced below:
“…………………It is submitted that the
complainant bring to the notice of OP about the pre-
existing disease mentioned in the policy after about 6
months of taking the policy. It is also submitted that the
complainant also wrote a letter to the OP to refund of the
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money which was deposited with OP. It is further
submitted that the complainant has availed the policy for
about 6 months and no complaint was made regarding
any of service.
It is very important to mention here that the OP is
considering on the letter of the complainant and if he is
interested to continue the policy with the OP , the
correction will be done in the policy as per the terms and
conditions of the policy.”
8. A perusal of the above para makes it amply clear that OP1 was prepared to
carry out the necessary correction in the policy provided the complainant
agreed to the continuance of the policy. This was nothing but a case of arm
twisting being resorted to by the insurance company. It has falsely
mentioned in the policy that the insured was suffering from pre-existing
diseases. It was obligatory on their part to have canceled such a policy which
was based on incorrect facts unilaterally incorporated by it. We therefore
hold that the OP1 was deficient in rendering service to the complainant.
Accordingly we direct OP1 as under:-
1.To cancel the policy in question and refund the premium amount of Rs.
32090/- to the complainant along with interest @ 10% p.a. from the date of
institution of the complaint till payment.
2.To pay a sum of Rs. 15,000/- as compensation for pain and agony suffered
by the complainant.
3.To pay a sum of Rs. 5000/- as cost of litigation fee.
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9.The above amount shall be paid by OP1 to the complainant within 30 days
from the date of this order failing which OP1 shall be liable to pay interest
on the entire awarded amount @ 10% p.a. from the date of this order till the
date of payment.
10.Copy of this order be made available to both the parties as per law. File be
consigned to record room.
Announced on ……….
MEMBER MEMBER
