Order No. 20 dt. 14/09/2017
The case of the complainant in brief is that the complainant obtained a mediclaim policy of the o.p. insurance company being mediclaim policy no. 30144269201 – 200 commencing from 30/10/2012 to 29/10/2013. The o.p. incorporated the communication address of the complainant at 13, Ashwini Dutta Road, Kolkata – 700029. After expiry of one year the complainant renewed his said policy for the term 2013 – 14 by making payment premium for the second term. The policy number was changed as 30144269201301. The said policy was valid till the month of October, 2014. During the month of October, 2014 the complainant felt pain in his left hip and accordingly contacted with renowned specialist doctor, viz. Dr. S. V. Baidya for arthritis and join replacement surgery in Mumbai. Dr. Vaidya advised the complainant to take admission in Breach Candy Hospital, Mumbai on 07/03/2014. After operation he was released on 13/03/2014. The complainant paid the entire medical bills to the tune of Rs. 5,96,105/- and submitted bills for medical reimbursement to the insurance company, o.p. 1. But the o.p. 1 repudiated the claim of the complainant on the flimsy ground of non-disclosure of complainant’s disease like pain in left hip since 2 years. At the same time also notified the complainant for termination of his medical policy after expiry of 30 days from the receipt hereof. On the basis of the said fact the complainant filed this case praying for reimbursement of medical bills of Rs. 5,96,105/- and compensation of Rs. 1,00,000/- for harassment and Rs. 50,000/- for litigation cost.
O.p.s contested the case by filing w/v and denied all the material allegations on the complaint. It was stated that the complainant has deliberately suppressed his illness at the time of issuance and/or renewal of the mediclaim policy under the respondents and tried to cover up such deliberate suppression and get the amount of claim from the insurance company. Such state of affairs does not make out any case for passing of any order as prayed for in the said complaint and as such the complaint is liable to be dismissed. The complainant falsely stated that he put his signature on some blank papers. Being a Chartered Accountant it is not believable that he will sign on a blank policy proposal form. The complainant manufactured the case that during the month of March, 2014 the complainant felt pain in his left hip and went for replacement of the hip as per the advice of the doctor. Dr. Baidya corrected the history incorporating the period of disease as one year instead of two years prior to clinical examination conducted by the said doctor, Dr. Vaidya who issued the certificate dt. 12/05/2014. Such contradictory statement is enough to raise eye brows on the issue of actual period of subsistence of actual disease. On the basis of the said fact the insurance company rightly asked the said doctor to swear on Affidavit before a Judicial Magistrate, First Class certifying the reason for rectification of earlier statements relating to the case history of the disease. The insurance company was within its right for requiring the doctor’s statement on Affidavit and as it is very necessary to establish the veracity of declaration made by the doctor in order to rule out fraud. That apart denial of the claim of the complainant / applicant on the ground of non-disclosure of disease of which the complainant was suffering from since the last 2 years as appearing from the previous certificate of concerned doctor, was absolutely as per the terms and conditions of the policy. In view of such perspective of the case as well as the denial made by the complainant that the court should not generally interfere with the terms and conditions of any contract / agreement between the parties and in the instant cae the prayer for extension of the said insurance policy beyond its expiry date on 29/10/2014 should not be entertained by this Forum in any manner whatsoever. On the basis of the said facts and circumstances of the case the o.p. insurance company prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided :-
- Whether the complainant had the insurance policy with the o.p. ?
- Was the policy valid while the complainant was treated by Dr. Vaidya ?
- Whether the complainant suppressed his disease at the time of applying for the policy /
- Whether the denial of the medical bills of the complainant tantamount to deficiency in service on the o.p. ?
- Whether the complainant will be entitled to get relief as prayed for ?
Decision with reasons :-
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. Lawyer for the complainant argued that the complainant being a Chartered Accountant during the year he was approached by an agent of the o.p. 1 insurance company applied for the policy. At the time of filling of the policy form did not go through the same. But he issued an A/C payee cheque in favour of the o.p. 1. Accordingly the policy was received by the complainant bearing no. 30144269201 – 200 commencing from 30/10/2012 to 29/10/2013. The o.p. incorporated the communication address of the complainant at 13, Ashwini Dutta Road, Kolkata – 700029. After expiry of one year the complainant renewed his said policy for the term 2013 – 14 by making payment premium for the second term. The policy number was changed as 30144269201301. The said policy was valid till the month of October, 2014. During the month of October, 2014 the complainant felt pain in his left hip and accordingly contacted with renowned specialist doctor, viz. Dr. S. V. Vaidya for arthritis and join replacement surgery in Mumbai. Dr. Vaidya advised the complainant to take admission in Breach Candy Hospital, Mumbai on 07/03/2014. After operation he was released on 13/03/2014. The complainant paid the entire medical bills to the tune of Rs. 5,96,105/- and submitted bills for medical reimbursement to the insurance company, o.p. 1. But the o.p. 1 repudiated the claim of the complainant on the flimsy ground of non-disclosure of complainant’s disease like pain in left hip since 2 years. At the same time also notified the complainant for termination of his medical policy after expiry of 30 days from the receipt hereof. On the basis of the said fact the complainant filed this case praying for reimbursement of medical bills of Rs. 5,96,105/- and compensation of Rs. 1,00,000/- for harassment and Rs. 50,000/- for litigation cost.
Ld. Lawyer for the o.p.s argued that the complainant has deliberately suppressed his illness at the time of issuance and/or renewal of the mediclaim policy under the respondents and tried to cover up such deliberate suppression and get the amount of claim from the insurance company. Such state of affairs does not make out any case for passing of any order as prayed for in the said complaint and as such the complaint is liable to be dismissed. The complainant falsely stated that he put his signature on some blank papers. Being a Chartered Accountant it is not believable that he will sign on a blank policy proposal form. The complainant manufactured the case that during the month of March, 2014 the complainant felt pain in his left hip and went for replacement of the hip as per the advice of the doctor. Dr. Vaidya corrected the history incorporating the period of disease as one year instead of two years prior to clinical examination conducted by the said doctor, Dr. Vaidya who issued the certificate dt. 12/05/2014. Such contradictory statement is enough to raise eye brows on the issue of actual period of subsistence of actual disease. On the basis of the said fact the insurance company rightly asked the said doctor to swear on Affidavit before a Judicial Magistrate, First Class certifying the reason for rectification of earlier statements relating to the case history of the disease. The insurance company was within its right for requiring the doctor’s statement on Affidavit and as it is very necessary to establish the veracity of declaration made by the doctor in order to rule out fraud. That apart denial of the claim of the complainant / applicant on the ground of non-disclosure of disease of which the complainant was suffering from since the last 2 years as appearing from the previous certificate of concerned doctor, was absolutely as per the terms and conditions of the policy. In view of such perspective of the case as well as the denial made by the complainant that the court should not generally interfere with the terms and conditions of any contract / agreement between the parties and in the instant cae the prayer for extension of the said insurance policy beyond its expiry date on 29/10/2014 should not be entertained by this Forum in any manner whatsoever. In view on the materials on record the Ld. Lawyer for the o.p.s prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that the complainant obtained the policy after paying the first premium and the policy number 30144269201 – 200 commencing from 30/10/2012 to 29/10/2013 was provided to the complainant. The complainant has alleged that after the expiry of one year he renewed the said policy. From the materials on record it appears that the complainant availed of the insurance policy of the o.p. 2 and the complainant was suggested the scheme “Family First Silver 5 lakhs + 15 lakhs”. The terms of the policy were also disclosed to the complainant. On being satisfied the complainant issued a cheque and accordingly the policy was issued in favour of the complainant and his family for a period of one year from 30/10/2012 to 29/10/2013. The complainant has stated that he signed on a blank application form. It is not believable that a chartered accountant would sign on the blank papers without going through those papers. It is found from the materials on record that the complainant after accepting the terms and conditions of the policy renewed his policy from 30/10/2013 to 29/10/2014. The complainant in the month of March, 2014 requested for availing cashless facility. The complainant himself filled up the pre-authorization request mentioning that he had been suffering from pain in his left hip for a period of 3 years, i.e. the complainant had been suffering since the year 2011 which he suppressed at the time of availing the policy in October, 2012. It is pertinent to mention here that the doctor Dr. S. V. Vaidya in the prescription issued on 06/03/2014 specifically mentioned that the complainant was suffering from pain in his left hip since the last two years which the o.p.s annexed with the evidence as exhibit F. Since the complainant realized that he suppressed the period of illness and availed of the policy the complainant somehow managed the doctor who treated him by producing another document whereby the said doctor disclosed that he mistakenly overheard the duration of pain as two years whereas the same was actually one year. It is hardly believable that the complainant without consulting any doctor in Kolkata rushed to Mumbai for surgery of his hip. The complainant was rightly advised by the insurance company that he should submit an Affidavit before the Judicial Magistrate, First Class from the said doctor to corroborate the said fact but it is curious enough the said doctor did not get courage to swear an Affidavit before the Judicial Magistrate, First Class to that effect. From the materials on record it is crystal clear that the complainant suppressed his disease and obtained the policy. It is relevant to mention here that the o.p. insurance company rightly rejected the claim of the complainant as well as for suppression of the material fact at the time of obtaining the policy, the policy was cancelled by the o.p. insurance company. Thereby we hold that the steps taken by the insurance company was done correctly and there was no deficiency in service or unfair trade practice on the part of the o.p.s. As such the claim made by the complainant cannot be entertained and he will not be entitled to get the relief as prayed for.
Thus all the points are disposed of accordingly.
Hence, it is ordered,
that the case no. 388 of 2014 is dismissed on contest against the o.p.s without cost. The interim order passed earlier is hereby vacated.
Supply certified copy of this order to the parties free of cost.
