BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.261 of 2015

Date of Instt. 15.06.2015

Date of Decision : 18.07.2016

Kanta Devi wife of Jagat Ram Sharma R/o House No.322, Preet Nagar, Sodal Road, Jalandhar.

..........Complainant

Versus

1.Star Health and Allied Insurance Co.Ltd KRM Centre VI Floor, Harrington Road, Chetpat, Chennai-600031 through authorized signatory.

2.Branch Manager, Star Health & Allied Insurance Co.Ltd., Vijay Towers, Next to State Bank of India, Civil Lines, Jalandhar.

.........Opposite parties

Complaint Under the Consumer Protection Act.

Before: S. Bhupinder Singh (President)

Sh.Parminder Sharma (Member)

Present: Sh.DK Sharma Adv., counsel for the complainant.

Sh.AK Arora Adv., counsel for the opposite parties.

Order

Bhupinder Singh (President)

1. The complainant has filed the present complaint under the Consumer Protection Act against the opposite parties (hereinafter called as OPs) on the averments that husband of the complainant has taken Health Optima Insurance Policy from the Ops bearing policy No.P/161125/01/2011/000654 for himself and his wife i.e. complainant Kanta Devi for the first time for the period from 10.1.2011 to 9.1.2012 and thereafter he continuously was getting the same renewed every year alongwith increased premium and the last policy was for the period from 10.1.2014 to 9.1.2015 i.e. policy No.P/161/125/01/2013/001198. During this period, complainant/ insured became ill and was admitted in Dayanand Medical College & Hospital, Ludhiana on 1.8.2014 where she was diagnosed to be suffering from “Idiopathic Thrombocytopenic, purpura-relapse and hypertipidema” and was medically treated and discharged on 5.8.2014. The husband of the complainant filed claim for the reimbursement of medical expenses to the tune of Rs.50,000/- incurred on the medical treatment, clinical and laboratory tests, etc of the complainant. However, Ops repudiated the claim of the complainant vide their letter dated 21.11.2014 on the ground that from the discharge summary of the complainant for the period of hospitalization from 14.10.2010 to 24.10.2010 in Dayanand Medical College & Hospital, Ludhiana, the insured remained admitted and medically treated at Dayanand Medical College & Hospital, Ludhiana for the same disease, for the aforesaid period but at the time of inception of first policy from 10.1.2011 to 9.1.2012, neither the complainant nor her husband disclosed these facts i.e. medical history/health details of the insured/complainant in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per clause 7 of the policy, the OP insurance company is not liable to make any payment in respect of any claim. Complainant submitted that the complainant was medically checked up by the empanelled doctor by the OP at the time of inception of the policy in the year 2011 and at that time no such disease was detected by the doctors. Complainant was not suffering from any disease at the time of getting policy. So, it is not necessary for the complainant or her husband/proposer of the policy to disclose about the medical treatment, the complainant has suffered in the year 2010 much prior to the inception of the policy and filling in of the proposal form for the policy. The OP was not justified in repudiating the claim of the complainant on the ground of non-disclosure of any medical treatment suffered by the complainant/insured much prior to the inception of the policy. On such averments, the complainant has prayed for directing the OPs to reimburse the claim amount of Rs.50,000/- alongwith interest. She has also claimed compensation and litigation expenses.

2. Upon notice, OPs appeared through counsel and filed a written reply pleading that the complainant herself submitted discharge summary for the period of hospitalization from 14.10.2010 to 24.10.2010 issued by Dayanand Medical College & Hospital, Ludhiana which fully proves that the complainant was diagnosed to have ITP (Idiopathic Thrombocytopenic Purpura) for which she was medically treated at Dayanand Medical College & Hospital, Ludhiana and she remained admitted for the treatment of this disease in that hospital from 14.10.2010 to 24.10.2014 and all these facts were not disclosed by complainant or her husband/proposer of the policy in the proposal form as well as to the doctor who medically checked the complainant at the time of inception of the policy in question in the year 2011. Thereby, the complainant is guilty of misrepresentation and concealment of facts and she has taken the policy from the OP by concealment of facts/suppressing the material facts. As such, the OP was justified in repudiating the claim of the complainant.

3. In support of his complaint, learned counsel for the complainant has tendered into evidence affidavits Ex.CW1/A and Ex.CW2/B alongwith copies of documents Ex.C1 to Ex.C5 and closed evidence.

4. On the other hand, learned counsel for opposite parteis has tendered affidavit Ex.OPA alongwith copies of documents Ex.OP1 to Ex.OP11 and closed evidence.

5. We have heard the Ld. counsel for the parties, minutely gone through the record and have appreciated the evidence produced on record by both the parties with the valuable assistance of Ld. counsels for the parties.

6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that husband of the complainant has taken Health Optima Insurance Policy from the Ops bearing policy No.P/161125/01/2011/000654 for himself and his wife i.e. complainant Kanta Devi for the first time for the period from 10.1.2011 to 9.1.2012 and thereafter he continuously getting the same renewed every year alongwith increased premium and the last policy was for the period from 10.1.2014 to 9.1.2015 i.e. policy No.P/161/125/01/2013/001198. During this period, complainant/insured became ill and was admitted in Dayanand Medical College & Hospital, Ludhiana on 1.8.2014 where she was diagnosed suffering from “Idiopathic Thrombocytopenic, purpura (hereinafter called ITP), relapse and hypertipidema” and was medically treated and discharged on 5.8.2014. The husband of the complainant filed claim for the reimbursement of medical expenses to the tune of Rs.50,000/- incurred on the medical treatment, clinical and laboratory tests, etc of the complainant. However, Ops repudiated the claim of the complainant vide their letter dated 21.11.2014 Ex.C5 on the ground that from the discharge summary of the complainant for the period of hospitalization from 14.10.2010 to 24.10.2010 in Dayanand Medical College & Hospital, Ludhiana, it is clear that the insured remained admitted and medically treated at Dayanand Medical College & Hospital, Ludhiana for the same disease, for the aforesaid period but at the time of inception of first policy from 10.1.2011 to 9.1.2012, neither the complainant nor her husband disclosed these facts i.e. medical history/health details of the insured/complainant in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per clause 7 of the policy, the OP insurance company is not liable to make any payment in respect of any claim. Learned counsel for the complainant submitted that the complainant was medically checked up by the empanelled doctor by the OP at the time of inception of the policy in the year 2011 and at that time no such disease was detected by the doctors. Complainant was not suffering any disease at the time of getting policy. So, it is not necessary for the complainant or her husband/proposer of the policy to disclose about the medical treatment, the complainant has suffered in the year 2010 much prior to the inception of the policy and filling in of the proposal form for the policy. The OP was not justified in repudiating the claim of the complainant on the ground of non-disclosure of any medical treatment suffered by the complainant/insured much prior to the inception of the policy. The OP has, therefore, wrongly repudiated the claim of the complainant, all this amounts to deficiency of service on the part of the OPs qua the complainant.

7. Whereas the case of the OPs is that the complainant herself submitted discharge summary for the period of hospitalization from 14.10.2010 to 24.10.2010 issued by Dayanand Medical College & Hospital, Ludhiana which fully proves that the complainant was diagnosed to have ITP (Idiopathic Thrombocytopenic Purpura) for which she was medically treated at Dayanand Medical College & Hospital, Ludhiana and she remained admitted for the treatment of this disease in that hospital from 14.10.2010 to 24.10.2014 and all these facts were not disclosed by complainant or her husband/proposer of the policy in the proposal form as well as to the doctor who medically checked the complainant at the time of inception of the policy in question in the year 2011. Thereby, the complainant is guilty of misrepresentation and concealment of facts and she has taken the policy from the OP by concealment of facts/suppressing the material facts. As such, the OP was justified in repudiating the claim of the complainant. Learned counsel for the Ops submitted that there is no deficiency in service on the part of the OPs qua the complainant.

8. From the entire above discussion, we have come to the conclusion that complainant has taken Health Optima Insurance Policy from the Ops bearing policy No.P/161125/01/2011/000654 for the period from 10.1.2011 to 9.1.2012 for the first time and thereafter complainant has been continuously getting the same policy renewed every year without any break with increased premium and the last relevant policy was for the period from 10.1.2014 to 9.1.2015 i.e. policy No.P/161/125/01/2013/001198. During this period, complainant/ insured became ill and was admitted in Dayanand Medical College & Hospital, Ludhiana on 1.8.2014 where she was diagnosed suffering from “Idiopathic Thrombocytopenic, purpura-relapse and hypertipidema” and was medically treated and discharged on 5.8.2014. Complainant filed claim for the reimbursement of medical expenses to the tune of Rs.50,000/- incurred on her medical treatment, clinical and laboratory tests, etc. The OP investigated and verified the matter. Complainant herself has filed discharge summary of the complainant which proves that complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period from 14.10.2010 to 24.10.2010. Ex.OP10 which fully proves that the complainant/insured remained admitted and was medically treated at Dayanand Medical College & Hospital, Ludhiana for the same disease i.e. ITP from 14.10.2010 to 24.10.2010 i.e. prior to the inception of the first policy for the period from 10.1.2011 to 9.1.2012. At that time, neither complainant nor her husband/proposer for the policy, disclosed these facts i.e. medical history/details of the complainant/insured in the proposal form as well as before the doctor who medically checked up the complainant. The complainant did not deny this discharge summary Ex.OP10. Therefore, it stands fully proved on record that before taking first policy from the OP i.e. policy from 10.1.2011 to 9.1.2012, the complainant or her husband i.e. proposer of the policy while filling in proposal form did not disclose these facts that the complainant earlier remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period from 14.10.2010 to 24.10.2010 where she was diagnosed the same disease i.e. ITP and was medically treated as is evident from discharge summary Ex.OP10. Complainant did not disclose these facts to the OP i.e. insurance company at the time of filling in the proposal form and has concealed all these facts. Not only this, complainant was medically examined by the doctor of the OP before issuing the policy. There also, the complainant did not disclose these facts to the doctor who medically checked-up the complainant in general/in routine that earlier she was diagnosed disease of ITP at Dayanand Medical College & Hospital, Ludhiana and she remained admitted there for the aforesaid period in 2010. So, the complainant has got this policy from the OP by concealment of facts. It has been held by Hon'ble Supreme Court of India in case “Satwant Kaur Sandhu Vs. New India Assurance Company Limited” 2013(3) CPR 664 that “at the time of taking policy the insured was suffering from Diabetic Nephropathy/ Chronic Renal Failure, deceased did not disclose the fact of ailment while taking the policy which was within his knowledge and he was required to disclose it under the terms of the policy. It was held that the facts suppressed a material fact and the insurance company was justified in repudiating the claim. Material fact means any fact which would influence the judgment of prudent insurer in fixing insurer the premium or determining whether to accept the risk or not”. The contract of insurance is of utmost faith and the insured or any person on her behalf is duty bound to disclose the true status of the health of the insured. The husband of the complainant/proposer on behalf of complainant, while filling in the proposal form, did not disclose that the complainant earlier suffered from disease ITP and remained admitted in Dayanand Medical College & Hospital, Ludhiana in the year 2010 as per discharge summary Ex.OP10. Not only this, the doctor who medically checked-up the complainant before this policy, has specifically asked the questions regarding any hospitalization of the complainant or the medical treatment she has suffered prior to taking of the policy but the complainant replied in the negative. All this shows that the complainant has obtained the policy from the OP by concealment and suppression of facts. Thereby, she has committed breach of utmost faith and the OP was justified in repudiating the claim of the complainant. The same view has been taken by the Hon'ble National Commission in case 'Subhash B.Jatani Vs. National Insurance Co.Ltd., 2015(1)' CPR 807 as well as by the Hon'ble Punjab State Commission in case 'Sangeeta Kaushik & others Vs. Life Insurance Corporation of India and others 2010(1)' CLT 481. The OP was also justified in further refusing the complainant to issue policy to the complainant for the year 2015-16.

9. In view of the above discussion, we are of the opinion that there is no deficiency of service on the part of the OP qua the complainant. Consequently, we hold that complaint is without merit and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Bhupinder Singh

18.07.2016 Member President