SRI JIBAN KRUSHNA BEHERA, MEMBER (I/C)

            The complainant has filed this complaint petition, U/s-12 of the Consumer Protection Act, 1986 (here-in-after called as the “Act”) alleging deficiency-in-service against the Ops, who are the authorities of Life Insurance Corporation of India, but located in different places claiming compensation of R.1,00,000/-.

2.         The case of the complainant, in a nutshell, is that on 28.3.2011, he had purchased one policy, a health protection plus plan, bearing No.594343903 from the OP No.1 and he had paid two premium of Rs.15,000/- and obtained the policy bond which covers the complainant’s health care expenses as well as his wife. While the aforesaid polices were in force, on 19.10.2012, his wife namely Krushna Kumari Sahoo became ill and she was suffering from hypothyroidism and chronic psychiatric illness and admitted at Talcher hospital and then at Ashwini Hospital, Cuttack and cured after 10 days. Thereafter, the complainant submitted her hospitalisation claim with prescribed format with all medical documents. As per the terms and conditions of the policy bond, the insured and his spouse are entitled to get the benefit of the said policy. Both the spouse had been to the office of OP No.1 several times. At that time, the concerned authority assured them to settle the matter, but after four months the OP No.1 rejected the claim illegally. Being aggrieved, the complainant moved the OP No.2 for non-settlement of his claim, but no steps has been taken as yet.

            The cause of action for filing of the case arose on 28.2.2013, and on 17.12.2014, when the Ops refused the claim. Therefore, finding no other way out, the complainant was constrained to file the present case against the Ops with the prayer, as stated in the complaint petition. Hence, the case.

            To substantiate his case, the complainant relied upon the following documents, which are placed in the record-

1. Photocopy of Discharge summery of Ashwini Hospital.
2. Photocopy of Policy Bond.
3. Photocopy of First premium receipt.
4. Photocopy of Renewal premium receipt.
5. Photocopy of Letter relating to repudiation of claim dated 28.2.13.
6. Photocopy of Letter dated 10.3.13 of complainant in favour of OP No.2.
7. Photocopy of Medical papers of Apollo Hospitals.
8. Photocopy of Medical papers of Ashwini Hospital.

3.         All the Ops have made their appearance and filed their joint written version. In their written version, the Ops not only challenged the averments made in the complaint petition but also stated that the complainant has no cause of action to file the present case and the case is not maintainable. The Ops have stated, inter alia, that the complainant has suppressed the material fact with regard to the fact that his wife was suffering from hypothyroidism and chronic psychiatric at the time of submission of proposal form. The insurance policy is a contract between the parties which was executed on good faith. But the complainant has not intentionally supplied the information regarding suffering of his wife on the very day of proposal, thereby the complainant has violated the terms and conditions of the policy bond. The Ops have not at all committed any deficiency in service as because the claim paper received from the complainant was promptly processed and sent it for consideration to Administrator and after thorough scanning of all the medical documents, rejected the claim of the complainant on the ground that the spouse of the complainant was suffering from psychiatric problem since long and on 18.10.2012, she had consumed 10 tables of Lorazepam and carbamzepam and admitted at Central Hospital, Talcher and thereafter shifted to Ashwini Hospital, Cuttack. The ground for rejection of his claim was also intimated to the complainant vide letter dated 28.2.2013 with a request that in case he is not satisfied with the decision, he may send his representation within a month for consideration to the OP No.2, but till today no representation is received from him. Hence, it is prayed to dismissed the case.

            In order to substantiate its case, the Ops relied upon the following documents, which are placed in the record-

1. Photocopy of Policy bond.
2. Photocopy of Proposal form.
3. Photocopy of Discharge summary of Ashwini Hospital.
4. Photocopy of Discharge summary of Ashwini Hospital dated 27.11.12.
5. Photocopy of Out patient slip.
6. Photocopy of Certificate issued by Ashwini Hospital.
7. Photocopy of Intimation regarding rejection of claim dated 28.2.13.
8. Photocopy of Policy scheme.
9. Photocopy of statutory report.

4.         In view of the above averments of both the parties, the points for determination in this case are as follows:-

1. Whether the complainant is a consumer as per C.P Act?
2. Whether there is any cause of action to file this case?
3. Whether the present case is maintainable?
4. Whether there is any deficiency of service on the part of the Ops?
5. To what other relief(s), the complainant is entitled to?

F  I  N  D  I  N  G  S

5.         So far as the point No.(i) & (ii) are concerned, first of all, it is seen that the complainant had purchased Health Insurance policy from the OP No.1 for bearing No. 594343903 on 28.3.2011. It is not disputed that the wife of the complainant underwent treatment at Talcher and Cuttack. After discharge of his wife from Ashwini Hospital, the complainant claimed benefits in terms and conditions of the policy bond. But, without settlement of the claim of the complainant, the Ops have repudiated the claim on different grounds. In the present scenario, whether the complainant is entitled to the benefit or not is required to be discussed later on, but from the above discussion, it is held that the complainant is a consumer and he has cause of action to file the present case.

6.         In order to arrive at a definite conclusion, it is required to be decided as to whether the case is maintainable and whether there is any deficiency of service on the part of the Ops. It is an admitted fact that the complainant had purchased the policy in question from OP No.1 and had also deposited first premium of Rs.15,000/-. It is also an admitted fact that on 19.10.2012, the wife of the complainant became serious suffering from Hypothroidism and chronic Psychiatric and admitted at Talcher Hospital and then at Ashwini Hospital, Cuttack and soon after his discharge, the complainant has placed the claim for hospitalization expenses before the OP No.1, which was turned down subsequently.

7.         On the other hand, on perusal of the medical documents submitted by both the parties, it is found that once the wife of the complainant was admitted in the Ashwini Hospital, Cuttack on 19.10.2012 for suffering from Hypothyroidism, chronic Psychiatry illness and sedative over dose and after recovery she was discharged on 24.10.2012 as shown vide Annexure-C. In the discharge summary dated 27.11.2012 vide Annexure-D, it has been clearly mentioned that the wife of the complainant was consumed 10 tablets of Lorazepam and carbamzepam at about 5.00 a.m. on 18.10.2012 and admitted at Central Hospital, Talcher and then brought there for further management. Thus, it is clear that the wife of the complainant was attempted to commit suicide by taking over dose of drugs. Further, it is well ascertained from the medical papers that the wife of the complainant had psychiatric problem since long. Further, in the proposal form vide Annexure-B, the complainant has not disclosed the pre-existing disease or ailments intentionally prior to inception of the policy in question at the time of proposal. The complainant had supplied wrong and false information with regard to the personal history of his wife in the proposal Form knowing very well that these were false and incorrect. Thus, the complainant has intentionally and fraudulently concealed the true state of affairs regarding the health condition of his wife at the time of proposal for insurance. It is, therefore, held that the ailments from which the wife of the complainant was suffering is prior to the date of proposal for which the Ops did not accept the risk on the health of the spouse of the complainant. Had the complainant disclosed the true facts and information at the time of proposal for insurance, the risk under the policy in question would not have been accepted by the Ops and the policy in question would not have been issued in his favour or would have been issued on different terms and conditions. In all the contract of insurance, the proposer is bound to make full disclosure of all the material facts and nor merely those, which he thinks material, misrepresentation, non-disclosure or fraud in any document leading to acceptance of the risk automatically discharges the insurer from all liabilities under the contract. On the other hand, the complainant had also supplied a false declaration that the information supplied by him are all true, accurate and complete and correct in all respects and thus, the contract of insurance is null and void. That apart, the complainant has not stated the above facts in his complaint which otherwise held that the complainant has filed the present case by suppressing the material facts.

8.         From the above discussions made in the foregoing paragraphs, it is held that the Ops have not committed any deficiency in service in repudiating the claim of the complainant. Therefore, the case of the complainant is not maintainable. Consequently, the complainant is not entitled to any relief what-so-ever as claimed in her complaint.

            Hence, it is ordered: –

O  R  D  E  R

            The case of the complainant be and the same is dismissed on contest against the Ops. In the facts and circumstances, no order as to costs.                          

            Pronounced in the open court of this Commission, this the 29th day of July, 2024 under signature & seal of the Commission.