Per Shri P.N. Kashalkar – Hon’ble Presiding Judicial Member:

(1)                This appeal is filed by the original Complainant whose complaint was dismissed by the District Consumer Disputes Redressal Forum, Thane vide its order dated 29.10.1999.  Complainant who is Appellant herein had filed consumer complaint against The New India Assurance Co. Ltd., alleging deficiency in service on the part of the Insurance Company by not honoring insurance cover.  He had taken insurance cover called Hospitalization and Domiciliary Hospitalisation Benefit Policy (Mediclaim Individual).  Complainant had undergone some treatment at Dr.Balabhai Nanavati Hospital, Vile Parle, Mumbai during the period from 25.06.19941 to 19.07.1991 and incurred expenses of `65,045/- towards hospitalization, medicines and other expenses and he was required to remain on leave for one month after he was discharged from the hospital.  Besides the Complainant was required to take tonic and he had also to incur other expenses for purchase of medicines of `15,000/- and hence, he raised a claim of `80,000/- under the said Insurance Policy towards Mediclaim. However, the claim of the Complainant was repudiated by the Opponent Insurance Company on the ground of suppression of material facts relating to prior illness before obtaining the mediclaim policy.  He had given all the answers in the negative in the proposal form when he was required to give information about the past history and past illness of the Complainant.  After receiving repudiation letter the Complainant had filed consumer complaint alleging deficiency in service on their part.

(2)                Opponent was duly served with the notice.  It filed written version on 10.12.1993.  According to Opponent, Proposal form was signed by the Complainant on 05.02.1991 and while answering question nos.10 and 11 in the proposal form he gave answers in the negative.  When he was asked whether he had knowledge of any ailment, sickness or injury which required medical attention and details of medical treatment during last 12 months.  His answer was simply in the negative.  However, according to Opponent after making enquiry it was found that Complainant was admitted in the hospital from 25.06.1991 to 29.07.1991 for surgical operation of ruptured sinus of valsalva and 5 mm VSD done under C.A.  Opponent also found that the Complainant had suppressed at the time of signing the proposal, ailments of pyrexia of unknown origin, intermitted fever and volvular heart disease.  Dr.Kirti M. Mistry treated the Complainant for a period of 4 months.  He had to undergo echocardiography and other investigations as per his certificate given in Annexure-2 to the defence version.  It was also found that Dr.Ravindra V. Gandhi treated the Complainant from 10^th January, 1991 to 23^rd March, 1991 for pyrexia of unknown origin as per Certificate of Dr.R.V. Gandhi, as per annexure-3 to the defence version.  So also certificate issued by Balabhai Nanavati Hospital dated 16.04.1993 also certified that the history of Complainant’s illness showed a period of 9 months prior to admission on 25.06.1994.  Thus according to Opponent the Complainant had positive knowledge of ailment during the time of signing the proposal and he had falsely answered question nos.10 and 11 in the negative.  Hence, Opponent pleaded that it was justified in repudiating the claim of the Complainant.

(3)                Considering the affidavits and documents placed on record District Forum clearly held that Complainant was guilty of suppression  of material facts and though he had filed affidavit of Dr.Misty, it was of no use.   In his affidavit Dr.Ravindra Gandhi mentioned that “I hereby affirm and reiterate that Complainant was taking treatment from me for Pyrexia of unknown origin for the period 20.1.91 to 23.03.91”.  The District Forum noted that evidence of Dr.Ravindra Gandhi corroborates the earlier certificate issued by Dr.Kirti Mistry about ailment of 4 months prior to 24.04.1991.   Dr.Ravindra Gandhi treated the Complainant from 20.01.1991 and then referred Complainant’s case to Dr.Kirti Mistry and therefore, the District Forum held that it was the duty of the Complainant to examine Dr.Ravindra Gandhi, rather than to give evidence of Harish Mohanty, Medical Administrator in Nanawati Hospital.  Whereas the proposal form was filled in on 5^th February, 1991.  In the circumstances, the District Forum was pleased to dismiss the complaint.  Being aggrieved by the said dismissal the original Complainant has filed this appeal.

(4)                This appeal was lying unattended since 1999 and since then no steps were taken by the Appellant even to serve notice to other side or to even seek first order by taking circulation.  It was lying in the cupboard of this Commission and as per policy of this Commission this appeal was placed before us on 12^th July, 2011.  On that day this matter was shown on the notice board of this Commission and it was also published on the internet board.  Despite this fact both the parties were absent. Hence, we directed office to issue notice to both the parties returnable on 30^th August, 2011.  On 30.08.2011 it was found that the office had not sent notice  and therefore, we directed office to issue notice by ordinary post to both the parties returnable on 16.11.2011.  Accordingly on 02.11.2011 office has sent notice to both the parties informing today’s date.  But today both the parties are absent, so we have decided to dispose of this appeal on merit.

(5)                As we have already seen that it was a case of Mediclaim Insurance which has been rejected by the Insurance Company.  Insurance Company’s stand was that the appellant had suppressed material facts regarding his pre-existing ailments.  Appellant had given false answers of question nos.10 and 11 in the proposal form which was signed on 05.02.1991.  Before that the Complainant/Appellant had already taken treatment from Dr.Ravindra Gandhi for his ailment of pyrexia of unknown origin.  He had then referred the patient to Dr.Mistry.  He had also taken treatment from Dr.Mistry as he was also suffering from valvular heart disease and he was advised to undergo echocardiography and other investigations as suggested by Dr.Kirti Mistry.  This fact was suppressed by the Complainant and therefore, when mediclaim was lodged with the Opponent Insurance Company, the Insurance Company after thorough investigation came to the conclusion that Complainant was guilty of having suppressed material facts which he was bound to disclose at the time of filling up the proposal form and on this count it appears that Insurance Company/Respondent herein rightly repudiated the claim of the Appellant/Complainant and being not satisfied with the repudiation of the claim the Complainant had filed the consumer complaint and the District Forum after going through the affidavits and supporting documents was pleased to dismiss the complaint due to the reason of suppression of material facts which he was bound to disclose while answering question nos.10 and 11 of the proposal form.   We agree with the findings given by the District Forum.  We are finding that there is no merit in the appeal filed by the Appellant/original Complainant.  We find no any legal infirmity in the order passed by the District Forum.  We are finding no substance in the appeal filed by the District Forum.  Hence, we pass the following order:

O  R  D  E  R

    (i)               Appeal stands dismissed.

  (ii)               No order as to costs.

(iii)               Inform the parties accordingly. 

Pronounced on 16^th November, 2011.