Sri Shyamal Gupta, Member

Aggrieved by and dissatisfied with the Order dated 22-05-2015 passed by the Ld. District Forum, Kolkata, Unit-I (North) in C.C. No. 103/2013 whereof the complaint has been dismissed, this Appeal is filed by the Complainant of complaint case.

To encapsulate the facts of the complaint case, Complainant staked an insurance claim for a sum of Rs. 78,063/- with the OPs pertaining to the treatment of his mother.  However, the OPs reimbursed only a sum of Rs. 48,114/- to him.  When he sought for due clarification, the OPs cited policy condition which was never made known to him beforehandHowHo

.  Since the OPs did not relent on their stand, feeling dejected, Complainant filed the complaint.

OPs contested the case by filing WV whereby they denied all the material allegations of the complaint.  Counter case of the OPs is that, they did send policy documents to the Complainant wherein detail terms and conditions of the policy were mentioned.  Therefore, the Complainant cannot feign ignorance of policy terms and conditions at this stage.

Decision with reasons

Heard the Ld. Advocates of both sides and gone through the documents on record.

The dispute, as it appears, primarily revolves over the fact as to whether or not details terms and conditions of the policy were made known to the Appellant by the Respondents.

On one hand, it is the case of the Appellant that he was only shown the brochure in respect of the subject policy wherein there was no mention of any exclusion clause, including the ‘co-pay’ clause. 

On the other, it is the case of the Respondents that the Appellant was duly apprised of the pros and cons of the concerned policy at the time of opting for the said policy and further the disputed document that contained ‘co-pay’ clause was sent to the Appellant together with policy schedule. 

The moot point for consideration is whether the Appellant was indeed taken into confidence by the Respondents about the grey areas of the policy, namely, exclusion clause or not. 

From the copy of policy brochure of ‘Senior Citizens red Carpet Health Insurance’ it appears that the same maintained a studded silence about the silver lining of said policy. That said, it is also a fact that policy documents containing detail terms and conditions of the concerned policy was sent to the Appellant every time the policy was renewed and such fact gets clear from the stipulation in the policy schedule to the effect “The insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached’.  Since the Appellant himself attached the policy schedule, it is naïve to believe that he read between the lines of said schedule.  In such a scenario, had he did not find any attachment together with the policy schedule, he would certainly write to the Insurance Company.

Also, it transpires from the copy of letter dated 31-07-2012 of the Appellant that he took strong exception of the fact that 30% co-payee clause was not mentioned in the policy bond boldly.  Such contention of the Appellant makes it abundantly clear that he did receive policy terms & conditions together with the policy schedule.

Thus, it can reasonably be accepted that the Respondents did send policy bond containing terms & conditions of the policy.  Even if it is assumed for the sake of argument that the concerned agent did not point out the limitation of the subject mediclaim policy to the Appellant; however, that does not anyway lessen Appellant’s own shortcoming.  As a policyholder, in his own interest, he ought to go through every intricate detail of the policy wordings on receipt of the policy bond to properly evaluate its efficacy vis-à-vis his requirement.  Had he remained vigilant, the co-payee clause would certainly not escape his attention and in that case, he could opt out of the policy or switch over to any other Insurer of his choice, in case of his dissatisfaction with such terms & conditions.

That apart, in terms of Sec. 19 of the Contract Act, 1872, a contract would not be voidable if the consent was caused by misrepresentation or by silence, fraudulent within the meaning of Sec. 17, if the party whose consent was so caused had the means of discovering the truth with ordinary diligence. In this case, as stated hereinabove, had the Appellant gone through the policy documents diligently, it was not at all a difficult task for him to discern the grey areas of the policy. 

Therefore, we find no infirmity with the impugned order.  Consequent thereof, the Appeal fails.

Hence,

O R D E R E D

That the Appeal stands dismissed on contest against the Respondents but without any costs.  The impugned order is hereby affirmed.