Order No.  14  dt.  28/02/2017

          The case of the complainant in brief is that the complainant had the mediclaim policy bearing no.P/191121/01/2012/001152 and continued till the period from 23.9.11 to 22.9.12 which was again renewed and continued from 23.9.12 to 22.9.13 along with sum insured for Rs.2 lakhs. It was stated by the complainant that during the period of subsistence of the policy the mother of the complainant was admitted to hospital for breathing problem. The complainant paid the doctor’s fee of Rs.33,783.70. The complainant thereafter lodged a claim along with all the documents and o.p. insurance company repudiated the claim of the complainant with the observation that the nature of treatment could have been to the patient as an OPD only, accordingly the claim was repudiated. The claim of the complainant was closed on 25.6.12 stating that the purported and habitual reason that the insured person was patient of multi infarction dementia and it was not disclosed prior to the inception of the policy was the claim was repudiated. While the complainant was waiting for the reimbursement of the medical claim at that time again the insured person faced with a physical problem and insured was admitted in the Harikrista Nursing Home for the 3^rd time on 20.9.12 for the treatment of infection under the treatment of Dr. Prabir Mukherjee and the complainant had to pay Rs.1,60,356/-. The complainant claimed the amount regarding the illness of the insured and total claim was made Rs.2,15,093.70.

                Since the claim of the complainant was repudiated the complainant filed this case praying for direction upon the o.ps. for releasing the fund of Rs.2,15,093.70 along with compensation of Rs.1 lakh and litigation cost of Rs.20,000/-.

                The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that Barasat office of o.ps. issued the complainant Senior Citizen Red Carpet Insurance Policy covering Mrs. Ava Mitra, mother of the complainant for the sum insured of Rs.2 lakhs for the period from 23.9.11 to 22.9.12. In the said insurance policy it was clearly stated that the insurance under this policy subject to conditions, clause, warranty, exclusion, etc. attached and accordingly a contract of insurance was entered into between the complainant and o.ps. As per the terms of the said policy the settlement of the claim is subject to application co prey clause of 30% which shall be borne by the policy holder each and every claim. The history of examination record dt.21.9.12 revealed that the insured patient had a history of old CVA since Feb 2012. In the pre authorization request from the treating doctor certificate dt. 28.9.12 it was stated that the insured patient had past history of osteoarthritis for the last 30 years.

                The consultation reported dt.28.9.12 states that the insured patient was bed ridden for the last 30 years due to osteoarthritis during such illness she had developed several respiratory distress and gasping respiration with blood pressure pulse less condition and diagnosed as a septicemia / multi organ failure. The insured did not disclose her illness while filled in the policy form and for the first time from 30.9.11 the insured did not disclose the past medical history of the insured. In the proposal form which definitely can be termed non disclosure / misrepresentation of material facts on the part of insured. As per condition 7 of the policy if there is any misrepresentation / non disclosure of material facts whether by the insured person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim. Considering the above facts the claim of the insured was repudiated and the repudiation was communicated to the insured. In view of such fact it was stated by o.p. that there was no negligence and deficiency in service and the complainant will not be entitled to get any claim amount of Rs.2,15,093.70 and also for compensation and litigation cost.

                On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainant’s mother was insured with o.p. insurance company.
2. Whether the complainant claimed the amount for the treatment of his mother.
3. Whether there was any deficiency in service on the part of o.ps.
4. Whether the complainant will be entitled to get any 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’s mother was the policy holder and she became ill and after recovery from the illness the complainant submitted the bills of the medical reimbursement of the bills, but o.ps. repudiated the claim of the complainant without any reason for which the complainant had to file this case praying for reimbursement of the mediclaim to the tune of Rs.2,15,093.70. In support of the said contention ld. lawyer for the complainant filed some documents including the policy and also the medical papers to substantiate that the mother of the complainant was admitted to the nursing home where she underwent treatment and after recovery the claim was made. The o.ps. without any cogent reason whatsoever repudiated the claim thereby the complainant prayed for compensation as well as the amount claimed by him.

                Ld. lawyer for the o.ps. argued that the insured at the time of filling up the form never disclosed that she had any illness. Ld. lawyer for o.ps. brought to our notice the annexure-D of w/v which was the proposal form for the policy. In the proposal form the insured disclosed that she was not suffering from any illness. The document filed by o.ps. annexure-E it appears that the patient had Senior Citizen Red Carpet Insurance Policy and the period was from 23.9.11 to 22.9.12 and the treatment rendered to the patient was for septicemia / multi organ failure. The medical team of o.ps. observed from the discharge summary of the hospital that the insured patient is a known case of multi infarction dementia which is prior to inception of medical insurance policy. Hence it is  a pre existing disease and accordingly the claim was not made. since at the time of inception of the first policy the insured has not disclosed the above mentioned medical history / health details of the insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts. Ld. lawyer for o.ps. also brought to our notice that the doctor who treated the patient issued a certificate whereby it was stated that the patient was bed ridden for the last 30 years and for such suppression of material facts and for violation of the terms and conditions of the policy o.ps. emphasized that the repudiation made by o.ps. was in accordance with the terms and conditions of the policy, thereby o.ps. had not committed any deficiency in service and the complainant will not be entitled to get any relief as prayed for.

                Considering the submissions of the respective parties it is an admitted fact  that the mother of the complainant had Senior Citizen Red Carpet Insurance Policy at the relevant point of time and it is also an admitted fact that the complainant’s mother while admitted in the hospital the policy was valid. During the subsistence of the said policy the mother of the complainant became ill and phase by phase on different occasions the complainant was treated by different doctors including the hospitalization for which the complainant claimed the amount for realization of the amount spent by the complainant. On perusal of the evidence as well as the documents filed by both the parties it is an admitted fact that the mother of the complainant was admitted to the hospital but at the time of obtaining the insurance policy and filing up the form by the insured the insured had not disclosed that she was suffering from any illness which is crystal clear from the annexure-D of w/v filed by o.ps. It also appears from the documents filed by o.ps. that including the treatment rendered by the doctor to the insured wherefrom it is evident that the complainant was bed ridden for the last 30 years and the said certificate was issued on 28.9.12 i.e. at the time of making proposal for the insurance policy the mother of the complainant was bet ridden, the said fact was suppressed by the complainant. It is also found from the materials on record that the insured patient sought for reimbursement for hospitalization expenses for the treatment of septicemia / multi organ failure and as per pre authorization request form the treating doctor certificate dt.28.9.12 which forms part of the claim form states that the insured patient had past history of osteoarthritis for the last 30 years. Apart from the said fact the history and examination record dt.21.9.12 revealed that the insured patient had a history of old CVA since Feb 2012. The consultation report dt.28.9.12 also revealed that the patient was bed ridden for the last 30 years due to history of osteoarthritis. During such illness she had developed several respiratory distress and gasping respiration with blood pressure, pulse less condition and diagnosed as a septicemia / multi organ failure. Since there was non disclosure of material facts and pre existing disease violates he terms and conditions of the policy, thereby we hold that the insurance company rightly repudiated the claim of the complainant. Accordingly we hold that there was no deficiency in service on the part of o.ps. 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.514/2014 is dismissed on contest without cost against the o.ps.                

                Supply certified copy of this order to the parties free of cost.