Date of Filing : 31/03/2015
Order No. 18 dt. 29/11/2017
The case of the complainant in brief is that the complainant was approached by the agent of o.p. insurance company for availing of Senior Citizen Red Carpet Insurance Policy of o.p. for getting the mediclaim facility for the senior citizen. The complainant being the senior citizen availed of the said policy. The complainant paid the policy premium for the year 2014 - 2015 covering the insurance period from 3.7.14 to 2.7.15, the sum assured for the complainant being Rs.2 lakhs for each of them and a sum of Rs.4 lakhs as group insurance for both the complainant as well as his spouse. The complainant’s wife suffered health deterioration and she was admitted to Belle Vue Clinic on 14.8.14 and she was discharged on 18.8.14. The complainant submitted a bill for medical reimbursement to the tune of Rs.2 lakhs and the complainant received a letter disallowing the claim of the complainant for reimbursement of the hospital expenses. Subsequently the complainant received another letter from o.p. by cancelling the policy relating to the complainant’s spouse form 2.1.15 for non disclosure of material fact. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. for allowing the claim of the complainant of Rs.2 lakhs towards the sum assured and compensation of Rs.8 lakhs.
The o.p. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.p. issued a Senior Citizen Red Carpet Insurance Policy covering the complainant and his spouse Smt. Shila Bajoria for the sum insured of Rs.2 lakhs for the period from 3.7.14 to 2.7.15. The said policy was renewed from earlier policy of National Insurance Co. Ltd. As per terms of the said policy settlement of the claim is inter alia subject to application co pay clause of 30% which shall be borne by the policy holder in each and every claim. The rights and liabilities of the parties are strictly circumscribed by the contract of insurance and only such contractual rights can be enforced which has been settled by Hon’ble National Commission in various judgments. The insured was admitted to Belle Vue Clinic on 14.8.14 for the treatment of dilated cardiomyopathy, systolic dysfunction, diabetic neuropathy and chronic liver disease. The complainant submitted surgical pathological report and various discharge summaries pertaining to the treatment underwent during the period 2008, 2010 and 2012 i.e. prior to the inception of the policy. Because of the disease suffered by the complainant prior to the said policy and the medical history was very much existed much earlier to submitting proposal and the complainant did not disclose the abovementioned medical history which tantamounts to misrepresentation / non disclosure of material fact. Since the terms and condition no.7 of the policy was violated and thereby the claim of the complainant was not entertained. The o.p. after scrutinizing the medical reports of the spouse of the complainant cancelled the policy and premium was returned to the complainant on pro rata basis. There was no deficiency in service on the part of o.p. and accordingly o.p. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy with o.p. at the relevant point of time?
- Whether the insured suffered illness for which she was treated at Belle Vue Clinic and submitted a medical bill to o.p. for reimbursement?
- Whether the repudiation made by o.p. was justifiable one?
- Whether there was any deficiency in service on the part of o.ps.?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant was approached by the agent of o.p. insurance company for availing of Senior Citizen Red Carpet Insurance Policy of o.p. for getting the mediclaim facility for the senior citizen. The complainant being the senior citizen availed of the said policy. The complainant paid the policy premium for the year 2014 - 2015 covering the insurance period from 3.7.14 to 2.7.15, the sum assured for the complainant being Rs.2 lakhs for each of them and a sum of Rs.4 lakhs as group insurance for both the complainant as well as his spouse. The complainant’s wife suffered health deterioration and she was admitted to Belle Vue Clinic on 14.8.14 and she was discharged on 18.8.14. The complainant submitted a bill for medical reimbursement to the tune of Rs.2 lakhs and the complainant received a letter disallowing the claim of the complainant for reimbursement of the hospital expenses. Subsequently the complainant received another letter from o.p. by cancelling the policy relating to the complainant’s spouse form 2.1.15 for non disclosure of material fact. On the basis of the said fact the complainant filed this case praying for direction upon the o.p. for allowing the claim of the complainant of Rs.2 lakhs towards the sum assured and compensation.
Ld. lawyer for the o.p. argued that o.p. issued a Senior Citizen Red Carpet Insurance Policy covering the complainant and his spouse Smt. Shila Bajoria for the sum insured of Rs.2 lakhs for the period from 3.7.14 to 2.7.15. The said policy was renewed from earlier policy of National Insurance Co. Ltd. As per terms of the said policy settlement of the claim is inter alia subject to application co pay clause of 30% which shall be borne by the policy holder in each and every claim. The rights and liabilities of the parties are strictly circumscribed by the contract of insurance and only such contractual rights can be enforced which has been settled by Hon’ble National Commission in various judgments. The insured was admitted to Belle Vue Clinic on 14.8.14 for the treatment of dilated cardiomyopathy, systolic dysfunction, diabetic neuropathy and chronic liver disease. The complainant submitted surgical pathological report and various discharge summaries pertaining to the treatment underwent during the period 2008, 2010 and 2012 i.e. prior to the inception of the policy. Because of the disease suffered by the complainant prior to the said policy and the medical history was very much existed much earlier to submitting proposal and the complainant did not disclose the abovementioned medical history which tantamounts to misrepresentation / non disclosure of material fact. Since the terms and condition no.7 of the policy was violated and thereby the claim of the complainant was not entertained. The o.p. after scrutinizing the medical reports of the spouse of the complainant cancelled the policy and premium was returned to the complainant on pro rata basis. There was no deficiency in service on the part of o.p. and accordingly o.p. prayed for dismissal of the case.
Considering the submissions of the respective parties that the complainant availed of the policy and the same was ported to o.p. insurance company. The complainant after undergoing treatment of his spouse submitted a medical bill and since the sum assured was Rs.2 lakhs, the complainant claimed the said amount. The o.p. after registering the claim of the complainant made enquiry in respect of the illness sustained by the insured wherefrom it is evident that the insured was admitted to Belle Vue Clinic on 14.8.14 and the complainant submitted the medical reports of the patient in the hospital as per surgical pathology report dt.30.5.08 the patient was diagnosed for carcinoma endometreum 2. From the discharge summery of the complainant it reveals that post operative 2 years back. The patient also developed radiation procitities 4. As per discharge summary dt.30.8.12 of Apollo Gleaneagles Hospital the diagnosis was cirrhosis of liver. From those ailments there was medical history existed very much earlier before submitting the proposal to o.p. for the policy effected from 3.7.14. It is also an admitted fact that the complainant did not disclose the abovementioned medical history of the insured person in the proposal form which amounts to misrepresentation / non disclosure of materials fact. As per condition no.7 of the policy the claim of the complainant was repudiated and the same was communicated to the complainant vided letter dt.17.1.14. On perusal of the materials on record we do not find any fault on the part of o.p. and o.p. as per the terms and conditions of the policy rightly rejected the claim of the complainant. In view of the facts and circumstances as stated above, we hold that the case filed by the complainant has got no meri8t and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No.167/2015 is dismissed on contest with cost against the o.p.
Supply certified copy of this order to the parties free of cost.
