Order No.  14  dt.  20/11/2018

            The case of the complainants in brief is that the complainants availed mediclaim facility from o.p. nos.1 and 2 insurance company. The insurance company after taking all lawful procedures got satisfaction and assured the complainants to become a policy holder of an amount total coverage Rs.1,50,000/- and the complainants paid the premium amount of Rs.7,130/- and accordingly, a policy was issued. The complainant no. 2 is dependent mother of complainant no.1 and she became seriously ill and was admitted to Lansdowne Nursing Home and availed the medical treatment under Dr. Samarjit Naskar and she was discharged on 02/01/2017. During the treatment of the said patient since she had the difficulty in passage of urine along with stool and respiratory trouble she was admitted in the said hospital and the doctor who treated the said patient asked for some investigations. The report has been filed being Annexure-3 of complaint petition wherefrom it is crystal clear that blood pressure and pulse bit of the complainant no.2 was normal and there was no sign of cardiac disturbances. During the treatment between 19/12/2016 to 02/01/2017 it will be crystal clear that the complainant no. 2 never suffered any cardiac problem instead of suffering any cirrhosis  of lever and chololethiasis. During the said treatment the complainants had to bear the expenses of Rs.2,13,538.77. The complainant no.1 requested the o.ps. to reimburse the claim for the treatment of the complainant no.2 and prayed for reimbursement of the medical expenses, but the claim of the complainant was repudiated by mentioning therein that the insured patient was suffering from long standing heart disease prior to inception of medical insurance policy and was also suffering from multiple pre-existing diseases at the time of inception of the policy on and from 06/10/2016 to 05/10/2017. It was further stated that the complainant no.1 did not disclose medical history / health details of insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts and as per Rules insurance company is not liable to make any payment in respect of any claim made by the complainant no.1. On the basis of the said fact the complainants filed this case praying for direction upon the o.ps. to revive the said policy and to pay the claim amount of Rs.2,13,538.77 as well as compensation and litigation cost.

                The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that o.p. no.2 issued a policy “Mediclassic Individual – Revised” in favour of the complainant no.2 for the policy period 06/10/2016 to 05/10/2017. The claim was reported in the 1^st year of the policy. It was further stated that the complainant no.2 was admitted in the said nursing home from 19/12/2016 for the treatment of cirrhosis of lever and chololethiasis and raised pre authorization request for cashless treatment. On perusal of the documents submitted by the treating nursing home it was observed that the insured had history of dilated cavities with global hypokinesia, severe left ventricle systolic dysfunction which clearly confirms that the insured patient was suffering from long standing heart disease present prior to inception of medical insurance policy. At the time of inception of the policy the insured had not disclosed the above mentioned medical history / health details of the insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts. As per policy condition no.7, if there is any misrepresentation / non disclosure 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. Accordingly, the cashless authorization was denied on the ground of non disclosure of past history of heart disease. On the basis of the said fact the claim of the complainants was repudiated and also cancelled the policy in terms and condition no. 13 of the policy and returned the insurance premium of Rs.7130/-. On the basis of the said fact it was categorically stated that o.ps. did not commit any deficiency in service or which the complainants will be entitled to get any relief as prayed for.

                On the basis of the pleadings of parties the following points are to be decided:

1. Whether the complainants had the policy at the relevant point of time?
2. Whether there was suppression of material facts at the time of obtaining the policy?
3. Whether the repudiation of the claim of the complainants tantamounts to deficiency in service?
4. Whether the complainant will be entitled to get the 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 complainants availed mediclaim facility from o.p. nos.1 and 2 insurance company. The insurance company after taking all lawful procedures got satisfaction and assured the complainants to become a policy holder of an amount total coverage Rs.1,50,000/- and the complainants paid the premium amount of Rs.7,130/- and accordingly, a policy was issued. The complainant no. 2 is dependent mother of complainant no.1 and she became seriously ill and was admitted to Lansdowne Nursing Home and availed the medical treatment under Dr. Samarjit Naskar and she was discharged on 02/01/2017. During the treatment of the said patient since she had the difficulty in passage of urine along with stool and respiratory trouble she was admitted in the said hospital and the doctor who treated the said patient asked for some investigations. The report has been filed being Annexure-3 of complaint petition wherefrom it is crystal clear that blood pressure and pulse bit of the complainant no.2 was normal and there was no sign of cardiac disturbances. During the treatment between 19/12/2016 to 02/01/2017 it will be crystal clear that the complainant no. 2 never suffered any cardiac problem instead of suffering any cirrhosis  of lever and chololethiasis. During the said treatment the complainants had to bear the expenses of Rs.2,13,538.77. The complainant no.1 requested the o.ps. to reimburse the claim for the treatment of the complainant no.2 and prayed for reimbursement of the medical expenses, but the claim of the complainant was repudiated by mentioning therein that the insured patient was suffering from long standing heart disease prior to inception of medical insurance policy and was also suffering from multiple pre-existing diseases at the time of inception of the policy on and from 06/10/2016 to 05/10/2017. It was further stated that the complainant no.1 did not disclose medical history / health details of insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts and as per Rules insurance company is not liable to make any payment in respect of any claim made by the complainant no.1. On the basis of the said fact the complainants filed this case praying for direction upon the o.ps. to revive the said policy and to pay the claim amount of Rs.2,13,538.77 as well as compensation and litigation cost.

                Ld. lawyer for the o.ps. argued that o.p. no.2 issued a policy “Mediclassic Individual – Revised” in favour of the complainant no.2 for the policy period 06/10/2016 to 05/10/2017. The claim was reported in the 1^st year of the policy. It was further stated that the complainant no.2 was admitted in the said nursing home from 19/12/2016 for the treatment of cirrhosis of lever and chololethiasis and raised pre authorization request for cashless treatment. On perusal of the documents submitted by the treating nursing home it was observed that the insured had history of dilated cavities with global hypokinesia, severe left ventricle systolic dysfunction which clearly confirms that the insured patient was suffering from long standing heart disease present prior to inception of medical insurance policy. At the time of inception of the policy the insured had not disclosed the above mentioned medical history / health details of the insured person in the proposal form which amounts to misrepresentation / non disclosure of material facts. As per policy condition no.7, if there is any misrepresentation / non disclosure 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. Accordingly, the cashless authorization was denied on the ground of non disclosure of past history of heart disease. On the basis of the said fact the claim of the complainants was repudiated and also cancelled the policy in terms and condition no. 13 of the policy and returned the insurance premium of Rs.7,130/-. On the basis of the said fact it was categorically stated that o.ps. did not commit any deficiency in service or which the complainants will be entitled to get any relief as prayed for.

                Considering the submissions of the respective parties it is an admitted fact that the complainants had the policy at the relevant point of time and during the subsistence of the said policy the complainant no.2 became ill and she was admitted to the Lansdowne Nursing home. The complainant no.2 was examined by doctor Sarnav Kundu and the complaint noted was difficulty in passage of urine along with stool since 5-6 days and respiratory distress. The complainants filed Annexure-3 being the report of doctor who examined the patient initially. In the said report it was categorically stated that the blood pressure and pulse bit of the complainant no.2 was normal and there is no sign of any cardiac disturbances. The complainant filed the documents wherefrom it is found that the complainant no.2 never suffered any cardiac problem instead of suffering in cirrhosis of lever and chololethiasis. The complainant no.1 had to bear the expenses of Rs.2,13,538.77 for the treatment of the complainant no.2. After discharge from the hospital the complainant no.1 submitted the bills for reimbursement and the same was repudiated by insurance company stating inter alia that since the patient was suffering from heart disease prior to opening of the policy and on suppression of material facts and as per Clause -7 of the policy condition the claim of the complainants was repudiated. It is also found from the materials on record that insurance company not only repudiated the claim of the complainant but also refunded the policy premium of Rs.7,130/- and cancelled the said policy.

                On perusal of the documents we find that the patient was all along treated for cirrhosis of lever and chololethiasis and insurance company could not produce any evidence to show that the patient was ever treated for heart ailment. The o.ps. wanted to rely upon the report of the nursing home, but in the report itself it was not mentioned that the patient had heart ailment at the relevant point of time.  The o.ps. failed to prove that the patient was suffering from heart ailment. In this context we would like to rely upon the decision of Hon’ble Supreme Court in Civil Appeal No.8254 of 2015 in the case of Subha Prakash Motegaonkar and others – Vs.- LICI decided on 05/10/2015. In this case where the deceased died due to ischemic heart disease and myocardial infarction. There was a concealment of lumber spondelities with PID with sciatica and therefore, the insurance company repudiated the claim. Hon’ble Supreme Court held that it was not the case of insurance company that the deceased was suffering from life threatening disease which could or did cause death of the insured. The Court observed as below:-

                “We are of the opinion that  the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischemic heart disease and myocardial infarction had nothing to do with his lumber spondelities with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified” [Vol III (2018) CPJ 471 (NC)].

                On the basis of the said judgment, we hold that the insurance company for the purpose of evading the payment of reimbursement bills of the complainant no.2 has deliberately taken this plea that the complainant no.2 was suffering from heart ailment and on the basis of the said fact repudiated the claim illegally. Accordingly, we hold that the insurance company committed the deficiency in service and cancelled the policy without any cogent ground whatsoever. In view of the facts and circumstance of the case we hold that the complainants will be entitled to get the medical reimbursement bill from insurance company. Thus all the points are disposed of accordingly.

                Hence, ordered,

                That the CC No.382/2017 is allowed on contest with cost against the o.ps. The o.ps. are jointly and / or severally directed to revive the policy no.P/191111/01/2017/006413 and to pay the claim amount of Rs.2,13,538.77 (Rupees Two Lakhs Thirteen Thousand Five Hundred Thirty Eight and Seventy Seven Paisa) only to the complainants along with compensation of Rs.20,000/- (Rupees Twenty Thousand) only for harassment and mental agony and litigation cost of Rs.10,000/- (Rupees Ten Thousand) only within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.