Sri Shyamal Gupta, Member

Feeling aggrieved with the dismissal of his complaint case, this Appeal is moved by the Complainant, Sri Pratap Chand Mitra.

Brief facts of the complaint case are that the Complainant took a mediclaim policy from the OPs, namely, ‘Senior Citizens Red Carpet Insurance Policy’ having sum insured for an amount of Rs. 2,00,000/- in the year 2011 and renewed the same from time to time.  During currency of the mediclaim policy, her mother, who happened to be a beneficiery of the said policy, developed some medical conditions for which she had to be admitted in the hospital.  However, all his claims were repudiated by the OP Insurer alleging non-disclosure of pre-existing disease. Therefore, the complaint case was filed.

The OPs defended their case by filing WV, wherein they stated that on going through the claim papers, it was found that the insured patient had past history of Osteoarthritis for the last 30 years and that she also had a history of old Cerebrovasculer accident (CVA) since February, 2012.  The consultation report dated 28-09-2012 revealed that the insured patient was bed-ridden for last 30 years due to history of Osteoarthritis and that during such illness she had developed severe respiratory distress and gasping respiration with blood pressure, pulse less condition and diagnosed as a Septicemia/multi organ failure. It was further stated therein that although the concerned ailment was not related with the past history as per the certificate of the treating doctor dated 28-09-2012, the most surprising part was that while proposing the policy for the first time from 23-09-2011, the Insured did not disclose the past medical history of the Insured in the proposal form and for such non-disclosure of material fact, the instant claims were not reimbursable and accordingly, the same were repudiated.

Decision with reasons

We have heard the arguments advanced by the Ld. Advocates of the parties and gone through the material on record, including the citations referred to in the matter carefully.

The instant medical policy commenced on 23-09-2011 and according to the Certificate dated 28-09-2012 issued by Dr. Subhendu Bikash Mishra, the relevant ailments giving rise to lodging of claims were not related to the past history of Osteoarthritis or other incidental medical conditions.  Therefore, we have no qualms holding that the pre-existing diseases had got no material bearing on the medical conditions of the patient for which claims were lodged.

Against such backdrop, the rationale behind repudiation of the claims of the Appellant is highly questionable.  It is true that, in the proposal form, existence of Osteoarthritis was not disclosed.  However, at the same time, it is also true that the concerned agent as well as the panel doctor, who examined the Appellant’s mother, acted most negligently.  Had they indeed been sincere, the actual medical condition of the beneficiary would never escape their attention.

Going by the afore-mentioned certificate issued by Dr. Mishra, the patient was bed ridden for the last 30 years.  It is not understood, despite this, on what basis the panel doctor of the Respondents gave a clean chit to facilitate issuance of the subject mediclaim policy.  The concerned authorized agent of the Appellants too was equally responsible and therefore, the Respondents cannot evade vicarious liability in the matter.

In this regard, it may not be out of the place to mention here that in terms of Sec. 19 of the Indian Contract Act, 1872, even if consent to an agreement is caused by coercion, fraud or misrepresentation, the contract is not voidable if the party to the said contract whose consent was so caused had the means of discovering the truth with ordinary diligence.  In this case, the Appellants had enough means to discover the inherent truth through ordinary diligence.  Thus, they cannot abdicate their liability in the matter.

Above all, as noted hereinabove, since the past medical conditions of the patient had no bearing on the ailments for which treatment was meted out to her, we feel that, the Respondents should have settled the said claims in accordance with the terms and conditions of the policy. The decision of Hon’ble National Commission in Royal Sundaram Alliance Insurance Co. Ltd. & Anr. v. Melanie Das, 2018 (1) CPR 720 (NC) is relevant in this respect.

In view of this, we cannot endorse the decision of the Ld. District Forum which has dismissed the complaint case.

Hence,

O R D E R E D

The Appeal stands allowed on contest against the Respondents with a cost of Rs. 15,000/-.  Respondents are directed to settle the instant claims in accordance with the terms and conditions of the policy within 40 days from this day and also pay compensation for a sum of Rs. 25,000/- to the Appellant, i.d., simple interest @ 9% p.a. over the total decretal amount shall be payable by them to the Appellant for the entire period of default.  The impugned is hereby stands set aside.