Samaresh Kr. Mitra, Member.

The case of the complainant is that she purchased one mediclaim policy from the National Insurance Company Ltd. being policy No. P/191120/01/2018/001680 on 16.05.2007 with a sum assured of Rs.1,00,000/- and subsequently it wasport to the opposite party insurance Company on 20.5.2017 with a sum insured of Rs.300,000/-. The petitioner was treated for Multiple Symptomatic Uterine Fibroids and she was admitted and operated in Rabindranath Tagore International Institute. Prior to admission to Rabindranath Tagore International Institute for her operation as per advise of the petitioner the hospital authority sent a preauthorization request for cash less treatment to the opposite which was denied it is written by the opposite party in the denial of preauthorization for cashless treatment that Uterine Fibroid Embolisation is not payable as per policy terms and conditions hence this claim is denied. It was reported by the opposite party staffs that the disease of the petitioner has come within the schedule No.4(17) in the inclusion list and the petitioner is not entitled to get any claim. After getting such information the complainant informed the treating doctor Dr.Shuvro Roy Choudhury who on his turn issued a certificate that, “this is not a shan or cosmetic or fertility enhancing procedure this was deemed to be necessary by too eminent gynaecologist of this city. Therefore it surprises me, that ill informed professionals can decide about disability of procedure for reimbursement, I sincerely hope that, a) this lady gets her due amount back. b). you remove this procedure from your exclusion list as otherwise I will have to move via our national organization against such ill adverse protocols”. The discharge summary report of treating doctors of Rabindranath Tagore International Institute it is stated that she was admitted for multiple Symptomatic uterine fibroids, for uterine fibroid Embolisation. Patient presented with menorrhagia for 3 months.Before that periods was regular patients had a history of myomectomy in 2010 for large fibroid. It was an open myomectomy patient also complaints of heaviness and frequency of micturition.The complainants submitted her various medical bills, prescription and money receipts amounting to Rs.181,245/- in total before the opposite party on 18.09.2017 alongwith the letter of Dr. Shubro H. Roy Choudhury but the opposite party repudiated the claim of the complainant vide letter dated 11.11.2017 stating that at the time of porting the policy you have not disclosed the above mentioned medical history /health details of the insured person in the proposal formand other documents submitted to us which amounts to misrepresentation/ nondisclosure of material facts. As per the condition No.6 of the policy issued to you, if there is any misrepresentation/ nondisclosure 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. So they unable to settle the claim of the complainant. According to this complaint the opposite parties repudiated the medical expenses bills of the petitioner in respect of ovary related surgery. The repudiation letter itself is self contradictory with their schedule No.3 in which it is stated that, i). any disease contacted by the insured person during the first 30 days from the commencement date of the policy. This waiting period shall not apply in case of the insured person having been covered under any health insurance policy with any of the Indian General Insurance Companies/ health insurance companies for a continuous period of preceding 12 months without a break. ii). A waiting period of 24 consecutive months of continuouscoverage from the inspection of this policy will apply to the following specified ailments/ illness/ disease., a) Treatment of cataract and diseases of theanterior and posterior chamber of the eye- b). All treatments (conservative, interventional, laparoscopic and open) related to hepato –pancreato-biliary diseases including gall blader and pancreatic calculi. All types of management for Kidneys and genitourinary tract calculi. c). all treatment conservative, interventional, laparoscopic and open d) related to all diseases of cervix, uterus, Fallopian Tubes, Ovaries ( other than due to Cancer) Uterine Bleeding Pelvic Inflammatory diseases and benign diseases of the breast. 3). Pre existing diseases as defined in the policy until 48 consecutive months of continuous coverage have elapsed, since inception of the first policy with any Indian General / Health Insurer.The waiting period above are subject to portability regulations. ). It is relevant to mention here petitioner approached to the opposite party through her Hospital for cash less treatment which was denied due to their policy terms and conditions, Uterine Fibroid Embolisation is not Payable as per policy terms and Conditions. Hence this claim is denied. He also assailed that after discharge from the hospital the petitioner submitted her claim on 18.9.2017 alongwith the certificate issued by the attending doctor Dr. Subro H Roy Choudhury. That after getting the certificate issued by the attending doctor the opposite party changed their repudiation grounds that the petitioner has suppressed her medical history at the time of the porting the policy. The motive of the opposite party is clear that anyhow the claim of the complainant is to be repudiated. So the complainant filed the instant complaint before this Forum praying direction upon the opposite party no.1&2 to pay Rs.145,260/- & Rs.35,935/- in total Rs.181,245/- that expensed during her treatment including interest 18% per annum and compensation of Rs.50,000/- for harassment and a sum of Rs.10,000/- as litigation cost.

Opposite party No.1 & 2 filed written version denying the allegations leveled against them and averred that the instant complaint is frivolous, vexatious and devoid of merit.So, it is liable to be dismissed with cost. They further averred that complainant has not approached this Hon’ble Forum with clean hands. The complainant has suppressed various material facts in the present complaint. The answering respondent submits that insured was issued family health optima insurance policy covering Mrs.Priyanka Mukhopadhyay Basu- self, Mr. Sourav Mukhopadhyay-spouse for a floater, sum assured of Rs.3,00,000/- vide policy No.P/191120/01/2018/001680 valid for the period 31.5.2017 till 30.5.2018 based on the declarations made by the proposer herself,in the proposal Form being No.AA0005138159 and Portability Form dated 29.5.2017. It is also stated that insured patient Mrs. Priyanka Mukhopadhyay Basu had mediclaim insurance cover earlier for a sum insured of Rs.1,00,000/- with the National Insurance Company Ltd. and switched over to the answering respondent company under portability vide policy Nos.

1. 153600/48/13/8500001626 from 31.5.2013 to 30.5.2014
2. 153600/48/14/8500001557 from 31.5.2014 to 30.5.2015
3. 153600/48/15/8500001128 from 31.5.2015 to 30.5.2016
4. 153600/48/16/8500001441 from 31.5.2016 to 30.5.2017.

In the proposal form it is clearly enquired that the proposer should fill in the respective column for each of the person proposed to be covered under coloumn-4(h).  Have you ever suffered or suffering from any of the following-any gynaecological disorder such as DUB, Fibroid Uterus, Ovarian Cyst or have you undergone caesarian/hysterectomy-if yes since when-‘No’.  So, it is suppression of material facts while making the contract of insurance according to Supreme Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. (2009) 8 SCC 316.  According to answering opposite party portability means the right accorded to an individual to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions will be transferred from one insurer to another insurer.  Even though the complainant ensured has ported his policy from the National Insurance Company he has not stated medical history/health details in the proposal form and portability form and the answering respondent issued the policy based on the declarations made in the proposal and portability form.  It is the allegation of the complainant that she was admitted in the R.N. Tagore International Institute of Cardiac Sciences from 29.8.2017 and discharged on 31.8.2017. As per the discharge summary the complainant was diagnosed with multiple symptomatic uterine fibroid and for uterine fibroid embolisation and accordingly a pre-authorization was raised and sent by the said hospital for availing cashless facility, which was recorded as claim intimation No.CLI/2018/191120/0266042.  The preauthorization Form along with medical reports i.e. MRI Pelvis dated 21.8.2017 and the letter of treating doctor dated 25.7.2017 from the treating hospital shared by the said hospital during cashless processing with the answering respondent revealed that the insured has previous history of MYOMECTOMY in 2010 for large fibroid and also the insured was diagnosed for uterine fibroid embolisation which is not payable under exclusion No.12 of the policy terms.  Hence, the cashless authorization was denied and same was communicated to the treating hospital as well as the insured vide letter dated 26.8.2017.  Thereafter the complainant submitted claim for reimbursement of medical expenses of Rs.1,45,260/-.  As per condition No.6 of the policy, if there is any misrepresentation/non-disclosure of material facts whether by the insurance person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim. It is also evident that the insured patient is a known case of MYOMECTOMY prior to the inception of the medical insurance policy and the same was not disclosed in the proposal form at the time of taking the policy which amounts to non-disclosure of material fact.  The answering respondent was legally constrained to repudiate the claim and the same was communicated to the insured vide letter dated 10.11.2017. 

The opposite party referred a lot of case decisions of Hon’ble Supreme Court and Hon’ble National Commission, New Delhi to support his claim in respect of suppression of material fact, utmost good faith.

Both sides filed interrogatories followed by reply, evidence on affidavit and written notes of argument which are taken into consideration while passing final order.

ISSUES/POINTS   FOR   CONSIDERATION

1). Whether the Complainant Mrs Priyanka Mukhopadhyay Basu is a ‘Consumer’ of the opposite party?

2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

3).Whether the O.Ps carried on unfair trade practice/rendered any deficiency in service towards the Complainant?

4).Whether the complainant proved his case against the opposite party, as alleged and whether the opposite party is liable for compensation to her?

DECISION WITH REASONS

 In the light of discussions here in above we find that the issues/points should be decided based on the above perspectives.

(1).Whether the Complainant Mrs Priyanka Mukhopadhyay Basu is a ‘Consumer’ of the opposite party?

From the materials on record it is transparent that the Complainant is a “Consumer” as provided by the spirit of section 2(1)(d)(ii) of the Consumer Protection Act,1986.The complainant herein being the customer of the opposite party insurance company i.e. opposite party No.1&2 so being consumer she is entitled to get service from the opposite party Insurance Company.

• 2).Whether this Forum has territorial/pecuniary jurisdiction to entertain and try the case?

Both the complainant and opposite parties are residents/carrying on business within the district of Hooghly. The complainant prayed for a direction upon the opposite parties to pay mediclaim of Rs.1,81,245/- to the complainant, compensation against the opposite party of Rs.50,000/- for mental agony and harassment and litigation cost amounting to Rs.10,000/- ad valorem which is within Rs.20,00,000/- limit of this Forum. So, this Forum has territorial/pecuniary jurisdiction to entertain and try the case.

(3).Whether the opposite party carried on Unfair Trade Practice/rendered any deficiency in service towards the Complainant?

The opposite party being the largest Insurance Company associated with the insurance of a lot of people of throughout the whole nation since a long back with self generated assets i.e. goodwill of the business. So, the credibility of the opposite party Insurance Company is unquestionable and that is why the complainant insured her life before the said company without any doubt.It is well settled proposition of law that a contract of insurance is based on the principles of utmost good faith-uberrimae fidei applicable to both the parties. The rule of nondisclosure of material facts vitiating a policy still holds the field. The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts, the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge. The insurer may not even have the means to find out facts which would materially affect the risk. The law, therefore, enjoins on the insured an absolute duty to disclose correctly all material facts which is within his/her personal knowledge or which he ought to have known had he made reasonable inquiries. A contract of insurance, therefore, can be repudiated for non disclosure of material facts.

The case of the complainant is that she purchased one mediclaim policy from the National Insurance Company Ltd. being policy No. P/191120/01/2018/001680 on 16.05.2007 with a sum assured of Rs.1,00,000/- and subsequently it was port to the opposite party insurance Company on 20.5.2017 with a sum insured of Rs.300,000/-. The petitioner was treated for Multiple Symptomatic Uterine Fibroids and she was admitted and operated in Rabindranath Tagore International Institute. Prior to admission to Rabindranath Tagore International Institute for her operation as per advise of the petitioner the hospital authority sent a preauthorization request for cash less treatment to the opposite party which was denied it is written by the opposite party in the denial of preauthorization for cashless treatment that Uterine Fibroid Embolisation is not payable as per policy terms and conditions hence this claim is denied. It was reported by the opposite party staffs that the disease of the petitioner has come within the schedule No.4 (17) in the inclusion list and the petitioner is not entitled to get any claim. After getting such information the complainant informed the treating doctor Dr. Shuvro Roy Choudhury who issued a certificate that, The discharge summary report of treating doctors of Rabindranath Tagore International Institute it is stated that she was admitted for multiple Symptomatic uterine fibroids, for uterine fibroid Embolisation. Patient presented with menorrhagia for 3 months.Before that periods was regular patients had a history of myomectomy in 2010 for large fibroid. It was an open myomectomy patient also complaints of heaviness and frequency of micturition. The complainants submitted her various medical bills, prescription and money receipts amounting to Rs.181,245/- in total before the opposite party on 18.09.2017 alongwith the letter of Dr. Shubro H. Roy Choudhury but the opposite party repudiated the claim of the complainant vide letter dated 11.11.2017 stating that at the time of porting the policy you have not disclosed the above mentioned medical history /health details of the insured person in the proposal formand other documents submitted to us which amounts to misrepresentation/ nondisclosure of material facts. As per the condition No.6 of the policy issued to you, if there is any misrepresentation/ nondisclosure 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. So they unable to settle the claim of the complainant. According to this complainant the opposite parties repudiated the medical expenses bills of the petitioner in respect of ovary related surgery. The repudiation letter itself is self contradictory with their schedule No.3 in which it is stated that, i). any disease contacted by the insured person during the first 30 days from the commencement date of the policy. This waiting period shall not apply in case of the insured person having been covered under any health insurance policy with any of the Indian General Insurance Companies/ health insurance companies for a continuous period of preceding 12 months without a break. ii). A waiting period of 24 consecutive months of continuous coverage from the inspection of this policy will apply to the following specified ailments/ illness/ disease, a) Treatment of cataract and diseases of theanterior and posterior chamber of the eye- b). All treatments (conservative, interventional, laparoscopic and open) related to hepato –pancreato- biliary diseases including gall bladder and pancreatic calculi. All types of management for Kidneys and genitourinary tract calculi. C). all treatment conservative, interventional, laparoscopic and open ) related to all diseases of cervix, uterus, Fallopian Tubes, Ovaries ( other than due to Cancer) Uterine Bleeding Pelvic Inflammatory diseases and Benign diseases of the breast. iii). Pre existing diseases as defined in the policy until 48 consecutive months of continuous coverage have elapsed, since inception of the first policy with any Indian General / Health Insurer.The waiting period i,ii, iii above are subject to portability regulations. ii). It is relevant to mention here petitioner approached to the opposite party through her Hospital for cash less treatment which was denied due to their policy terms and conditions, “ Uterine Fibroid Embolisation is not Payable as per policy terms and Conditions. Hence this claim is denied. He also assailed that after discharge from the hospital the petitioner submitted her claim on 18.9.2017 alongwith the certificate issued by the attending doctor Dr. Subro H Roy Choudhury. That after getting the certificate issued by the attending doctor the opposite partychanged their repudiation grounds that the petitioner has suppressed her medical history at the time of the porting the policy. The motive of the opposite party is clear that anyhow the claim of the complainant is to be repudiated. So the complainant filed the instant complaint before this Forum praying direction upon the opposite party no.1&2 to pay Rs.145260/- & Rs.35,935/- in total Rs.181,245/- that expensed during her treatment including interest @ 18% per annum and compensation of Rs.50000/- for harassment and a sum of Rs.10000/- as litigation cost.

Opposite party No.1 & 2 filed written notes of argument and averred that complainant suppressed various material facts in the present complaint. The answering respondent submits that insurance was issued family health optima insurance policy covering Mrs. Priyanka Mukhopadhyay Basu- self, Mr. Sourav Mukhopadhyay-spouse for a floater, sum assured of Rs.3,00,000/- vide policy No.P/191120/01/2018/001680 valid for the period 31.5.2017 till 30.5.2018 based on the declarations made by the proposer herself, in the proposal Form being No.AA0005138159 and Portability Form dated 29.5.2017. It is also stated that insured patient Mrs. Priyanka Mukhopadhyay Basu had mediclaim insurance cover earlier for a sum insured of Rs.1,00,000/- with the National Insurance Company Ltd. and switched over to the answering respondent company under portability vide policy Nos.:-

1. 153600/48/13/8500001626 from 31.5.2013 to 30.5.2014
2. 153600/48/14/8500001557 from 31.5.2014 to 30.5.2015
3. 153600/48/15/8500001128 from 31.5.2015 to 30.5.2016
4. 153600/48/16/8500001441 from 31.5.2016 to 30.5.2017

In the proposal form it is clearly enquired that the proposer should fill in the respective column for each of the person proposed to be covered under coloumn-4(h).  Have you ever suffered or suffering from any of the following-any gynecological disorder such as DUB, Fibroid Uterus, Ovarian Cyst or have you undergone caesarian/hysterectomy-if yes since when-‘No’.  So, it is suppression of material facts while making the contract of insurance according to Supreme Court in Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. (2009) 8 SCC 316.  According to answering opposite party portability means the right accorded to an individual to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions will be transferred from one insurer to another insurer.  Even though the complainant insured has ported her policy from the National Insurance Company to the opposite party company she has not stated medical history/health details in the proposal form and portability Form and the answering respondent issued the policy based on the declarations made in the proposal and portability Form.  It is the allegation of the complainant that she was admitted in the R.N. Tagore International Institute of Cardiac Sciences from 29.8.2017 and discharged on 31.8.2017 and she was diagnosed with multiple symptomatic uterine fibroid and for Uterine Fibroid Embolisation and accordingly a pre-authorization was raised and sent by the said hospital for availing of cashless facility, which was recorded as claim intimation No.CLI/2018/191120/0266042. The preauthorization form along with medical reports i.e. MRI Pelvis dated 21.8.2017 and the letter of treating doctor dated 25.7.2017 from the treating hospital shared by the said hospital during cashless processing with the answering respondent revealed that the insured has previous history of MYOMECTOMY in 2010 for large fibroid and also the insured was diagnosed for Uterine Fibroid Embolisation which is not payable under exclusion No.12 of the policy terms.  Hence, the cashless authorization was denied and same was communicated to the treating hospital as well as the insured vide letter dated 26.8.2017.  Thereafter the complainant submitted claim for reimbursement of medical expenses of Rs.1,45,260/- .  As per condition No.6 of the policy, if there is any misrepresentation/non-disclosure of material facts whether by the insurance person or any other person acting on his behalf the company is not liable to make any payment in respect of any claim.  It is also evident that the insured patient is a known case of MYOMECTOMY prior to the inception of the medical insurance policy and the same was not disclosed in the proposal form at the time of taking the policy which amounts to non-disclosure of material fact. The answering respondent was legally constrained to repudiate the claim and the same was communicated to the insured vide letter dated 10.11.2017. 

The opposite party referred a lot of case decisions of Hon’ble Supreme Court and Hon’ble National Commission, New Delhi to support his claim in respect of suppression of material fact, utmost good faith. In Sony Cherian Vs. Oriental Insurance Company Ltd. 1999 (6) SCC 451, the Apex Court hold as follows;

The insurance policy between the insurer and the insured represent a contract between the parties.  Since the insurer undertakes to compensate the loss suffered by the insured on account of risk covered by the insurance policy.  The terms of the agreement have to be strictly construed to determine the extent of liability of insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein. 

     On the face of the case record it is clear that the claim of the complainant was repudiated by the opposite party on the ground that she was suffering from pre existing disease and the life assured suppressed her suffering in the policy Form during the period of porting so it is breach of terms and condition on the part of the complainant. The prescription dated 25/7/2017 of Dr. Shuvro H Roy Choudhury reveals that the life assured has history of Myomectomy -2010. But the patient at that point of time has been suffering from Menorrhagia for three months. The discharge summary speaks that patient presented with menorrhagia for 3 months. Before that period was regular. Patient had a history of myomectomy in 2010 for large fibroid. It was an open myomectomy. Patient also complaints of heaviness and frequency of micturition. Patient trying for a family. She was treated before the doctor at NH Rabindranath Tagore International Institute of Cardiac Sciences from 29.8.2017 to 31.08.2017 and expensed a lot for which she prayed cashless benefit through the hospital and her request turned down by the opposite party and subsequently when she filed the claim in respect of expense incurred during her treatment her claim was repudiated on exclusion clause and lastly for suppression of pre existing disease.

 The letter dated 26.08.2017 of the opposite party in respect of denial of pre authorization for cashless treatment speaks that on scrutiny of details furnished by the complainant they are unable to authorize cashless for the treatment of the insured patient under the policy issued covering the said person for the reason that uterine fibroid Embolisation is not payable as per policy terms and conditions .Hence the claim is denied. In the same letter it is stated that the opposite party supplied a claim Form which may be duly completed and submitted to them along with medical documents. On receipt of duly completed claim form and other documents the claim will be processed as per the terms and conditions of the policy issued to her. The discharge summary of the NH Rabindranath Tagore International Institute of Cardiac Sciences clearly speaks that diagnosis done for Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism.

By collecting the Xerox copies of prescriptions regarding the treatment of the life assured the opposite party investigated the claim of the complainant and firstly repudiated her claim on the grounds that the treatment done within the period after getting admission before the NH Rabindranath Tagore International Institute of Cardiac Sciences at EM Bypass, Mukundapur, Kolkata-700099 falls under Exclusion clause under 4(17) of the policy conditions. The treating doctor wrote a letter to the opposite party regarding the illegal repudiation and requested to consider the claim with a threat to put the matter before the doctors association as a result the opposite party tried their best to repudiate the Claim of the complainant by taking the plea that the complainant has been suffering from Myomectomy since 2010 and repudiated claim on the pretext that she suppressed her suffering in the proposal Form during the period of porting of the policy from other company. And banking upon the prescriptions the opposite party repudiated the claim of the complainant on flimsy ground that the deceased life assured prior to taking the insurance policy was suffering from disease and he suppressed those disease while taking the policy from the opposite party. It appears from the prescription sheet as well as discharge summary the complainant received treatment of  Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism, now it is a matter of discussion that the suffering from  Myomectomy in the year 2010 leads to Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism in the year 2017.

  After perusing the documents and going through the averments of the both sides that insured was not suffering from any chronic disease and there was no contributory cause of suffering occurred suddenly. Moreover, nobody knows when she/he will suffer from any kind of sudden pain or disease requiring treatment/operation. In the instant case the opposite party could not file any previous prescription of any doctor prior to taking out insurance policy that the life assured borne any symptoms or sickness relating to her disease.

  We do not find suppression of any material fact by the insured in the proposal form and opposite party has committed deficiency in repudiating claim on flimsy grounds.

     During the period of argument the advocate on behalf of the opposite party assailed that the policy holder undergo treatment in Myomectomy-2010 but suppressed such treatment during the period of porting which tantamount to suppression of material fact as the insurance policy is a contract. It does not mean that the earlier suffering leads to Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism in the year 2017. Merely because one is having heart problem may be without his knowledge, it cannot be said that ultimately he will die due to Myocardial Infarction. There is no material in the record to show that in any proposal Form, it was concealed or mentioned by the life assured that she was suffering from Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism. There is no material to show that there was any earlier treatment in respect of any disease which leads to such treatment during the period of hospitalization. In absence of any treatment paper, no court/Forum can hold that there was some earlier pre-existing disease which was concealed by the complainant while making proposal for the insurance cover. Thus the defense which has taken by the opposite party Company was having no legs to stand so it is rightly discarded by this Forum.

  It was pleaded on behalf of the complainant that if an insured is not aware of an ailment he may be suffering, nondisclosure thereof does not tantamount to suppression of material fact.

  No documents in respect of treatment of the complainant before the acceptance of Proposal Form are in the case record which corroborates that the complainant has been suffering from any disease which leads to her Uterine Fibroid Embolisation. The opposite party failed to produce such document to deny the claim of the complaint that during the acceptance of proposal Form life assured supplied the correct information regarding her health.

    So the life assured was unaware of her disease whether she was suffering from multiple symptomatic uterine fibroids and her illness at the material point of time for Uterine Fibroid Embolisation i.e. taking the insurance policy does not arise. She was not aware whether she will suffer from Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism in the future and she/ her nominee have to make claim before the Insurance Company for which the Insurance Company by repudiating her/complainants claim destructed the myth of utmost on good faith.

     Upon consideration of the evidence adduced by the parties, this Forum observed that the Insurance Company had failed to bring on record any proof in support of their plea that the complainant was suffering from any pre-existing disease at the time of obtaining the policy, there was no evidence to prove that the deceased was ever admitted for any treatment in a hospital for the alleged pre-existing disease at the time of obtaining the policy, there was no evidence to prove that the deceased was ever admitted for any treatment in a hospital for the alleged pre-existing disease and that the medical evidence relied upon by the Insurance Company was neither supported by any corroborative evidence nor did it prove that the said treatment had any nexus with the cause of Multiple Symptomatic Uterine Fibroids for Uterine Fibroid Embolism. Every person may suffer from normal diseases like acidity, fever, common cold and indigestion which does not lead to heart problem or cancer. This should not be the intention of the organization who has been established for the purposes of benefit of the public.  This Forum thus came to the conclusion that there was no suppression of any material fact by the life assured and therefore, in repudiating the claim of the complainant, there was deficiency of service on the part of the Insurance Company, causing great hardship, financial loss and mental agony to the complainant.We also carefully went through the judgment /citation submitted by the agent of the parties, i). Life Insurance Corpn. of India -vs- Smt Satwant Kaur Sandhu RP No.3138/2006 decided on 13^th Jan.2011.ii). Satwant Kaur Sandhu Vs. New India Assurance Company Limited reported in (2009) 8 Supreme Court Cases 316.iii).  Sony Cherian V. Oriental Insurance co. Ltd 1999 9M) SCC 451.

    So we are in a considered opinion to allow the complaint as policy holder was not suffering from any disease when she signed the policy proposal of this opposite party Insurance Company and opposite party could not prove the same. We direct the opposite party Insurance Company i.e. the opposite party to pay the claim amounting to Rs.181245/- against the policy being no. P/1921120/01/2018/001680 which is not disputed a sum of Rs.20000/- as compensation for mental pain, agony and harassment and another Rs.10,000/- for litigation cost.  

  4). Whether the complainant proved her case against the opposite party, as alleged and whether the opposite party is liable for compensation to her?   

 The discussion made herein before, we have no hesitation to come in a conclusion that the Complainant has abled to prove her case and the Opposite Party No.1&2 are liable to pay compensation for mental pain and agony of the complainant.

ORDER

Hence, it is ordered that the complaint case being No.16 of 2018 be and the same is allowed on contest against the opposite party with a litigation cost of Rs.10,000/-.

 The Opposite Party is directed to pay a sum of Rs.181,245/- that expensed during the treatment to this complainant.

The opposite party is further directed to pay a sum of Rs.20,000/- as compensation for harassment, causing mental pain and agony of this complainant. 

All the payments are to be made within 45 days from the date of this order.

At the event of failure to comply with the order  the Opposite Party  shall pay cost @ Rs.100/- for each day’s delay, if caused, on expiry of the aforesaid 45 days by depositing the accrued amount, if any, in the  Consumer Legal Aid Account.

  Let a plain copy of this Order be supplied free of cost to the parties/their Ld. Advocates/Agents on record by hand under proper acknowledgement/ sent by ordinary Post for information & necessary action.