Order No.  19  dt.  18/05/2017

       The case of the complainant in brief is that the complainant being the account holder of Indian Overseas Bank was provided with the facility of an insurance policy bearing no.1287750080349/02/000 for the period from 17.3.11 to 16.3.12 and the sum insured was Rs.1 lakh for health floater. Initially the said insurance was covered under United India Insurance Co. Ltd., subsequently the said health insurance policy was taken over by Universal Sompo General Insurance Co. Ltd. with the knowledge of Indian Overseas Bank. The complainant sustained a heart surgery and was admitted to Medica Super Speciality Hospital, Kolkata. Before admission the Universal Sompo General Insurance Co. Ltd. was informed. After recovery from the said heart surgery the complainant submitted medical reimbursement to E-Meditek Services Ltd. The branch office of E-Meditek refused to entertain the medical reimbursement and returned the same with remarks. The website of Universal Sompo General Insurance Co. Ltd. mentioned that he following condition is applicable; “Pre acceptance medical test to be carried out for persons above the age of 50 years”, but no such medical test was carried out either by the erstwhile insurance company or by Universal Sompo General Insurance Co. Ltd.

            It was further stated that there was lapse and deficiency in service on the part of insurance company and Indian Overseas Bank for which the complainant is not at all responsible. The complainant in the year 2003 had a heart operation and in the year 2006 the complainant took a health policy. As per guideline of IRDA in case of pre existing condition in health insurance policy view of IRDA is that a medical condition / disease that existed before obtaining health insurance policy and because the insurance companies do not cover such pre existing condition within 48 months of prior to the 1^st policy. It means pre existing condition can be considered for payment after completion of 48 months of continuous insurance cover. The o.p. insurance company refused to pay the insured amount on the ground of suppression of pre existing disease, since the complainant after the gap of 48 months from the date of taking over the health insurance policy in 2006 till submitting the claim by the complainant and the complainant paid the premium within the due date and therefore the point raised by TPA is not acceptable. In view of the said fact the complainant filed this case praying for direction upon the o.ps. to pay the insured sum of Rs.1 lakh along with compensation of Rs.86,000/- and Rs.7000/- for harassment.

            The o.p. nos.1 to 3 and 6 contested this case by filing w/v and denied all the material allegations of the complaint. It was stated by o.p. nos.1 and 2 that the complainant suppressed the material fact and as such, the claim of the insured was repudiated and the said fact was communicated to the complainant vide letter dt.1.11.13 on the ground that non disclosure / misrepresentation of material fact in the proposal form by the insured and the same is violation condition no.2 of the subject policy.  In condition no.2 it has been laid down that the policy shall be void and premium shall be forfeited by the insurance company in the event of misrepresentation / misdescription or non disclosure of any material fact.  Non disclosure shall include non intimation of any circumstances which may affect the insurance cover granted. The insured did not disclose about his previous ailment in the proposal form submitted to the insurance company. The claim was rightly and lawfully repudiated and as such, the complainant will not be entitled to get any claim whatsoever against the o.ps.

            It was stated by o.p. no.6 that the claim made by the complainant that the insurance policy with the erstwhile United India Insurance Co. Ltd. is being renewed till date by Sompo General Insurance Co. Ltd. The complainant has lodged claim with Universal Sompo General Insurance Co. Ltd. for reimbursement of expenses for his heart surgery. The complainant has no cause of action against the o.p. no.6 and o.p. no.6 is not a necessary party and as such, the complainant will not be entitled to get any relief from o.p. no.6.

            It was stated by o.p. no.3 that the complainant will not be entitled to get any relief from o.p. no.3.

            In spite of receipt of notices the o.p. nos.4 and 5 did not contest the case and as such, the case has proceeded ex parte against them.

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

1. Whether the complainant had the policy with the insurance policy.
2. Whether the complainant suppressed his illness at the time of applying for the policy.
3. Whether there was any deficiency in service on the part of o.ps.
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 complainant being the account holder of Indian Overseas Bank obtained a policy and paid premium to United India Insurance Co. Ltd. Subsequently with the taking up of the policy by the Universal Sompo General Insurance Co. the complainant paid premium to the said insurance company. Since in the year 2003 the complainant underwent her surgery and claimed the assured sum but the same was refused on the ground that suppression of pre existing disease the complainant will not be entitled to get any reimbursement of the medical expenses incurred by him for his  heart surgery. In order to nullify the contention of o.ps. ld. lawyer for the complainant emphasized that if the policy is continued and the claim of the insurance company for pre existing condition cannot be denied and as per the IRDA policy it has been laid down that pre existing condition can be considered for payment after completion of 48 months of continuous insurance cover. On that score ld. lawyer for the complainant emphasized that the complainant had the heart attack in the year 2003 and after the expiry of long period of 4 years and payment of the premium towards the policy and continued by the complainant, therefore the denial made by the insurance company suppression of pre existing disease the insured amount cannot be released in favour of the complainant cannot be accepted. in view of the said fact ld. lawyer for the complainant emphasized that o.ps. be directed to pay the sum assured as well as compensation.

            Ld. lawyer for the o.ps. argued that the complainant suppressed the material fact that he had the pre existing disease at the time of applying for the policy and for that reason the claim of the complainant was repudiated. Since the complainant did not disclose any disease, therefore medical test was not conducted by the insurance company. It is the incumbent duty of the complainant / the person who is applying for the policy to disclose the pre existing disease. If no disclosure is made how the insurance company will come to know that the complainant had any disease at all at the time of applying for the policy. In view of the said fact the insurance company rightly repudiated the claim of the complainant and there was no deficiency in service on the part of the insurance company.

            Considering the submissions of the respective parties it is an admitted fact that the complainant at the relevant point of time was the account holder of Indian Overseas Bank and by virtue of obtaining the account he was provided with the policy of the insurance company. At the time of applying the said policy he did not disclose the ailment he had and by suppressing the said fact he obtained the policy. As per Sec 45 of Insurance Act the contracts of insurance are contracts of Uberrima Fides and every material fact is required to be disclosed by the applicant for the said policy. In a contract of insurance there is requirement of good faith on part of insured. Any fact which  goes to root of contract of insurance and has a bearing of risk involved would be material. Had assured disclosed that he was suffering from heart ailment the insurance company would have asked for special medical reports which could have been placed before a medical referee and based upon report of medical referee, decision would have been taken whether to accept any proposal or not. False or inaccurate statement by assured was on a material aspect which influenced decision of insurer whether to accept proposal or not. In view of the facts and circumstances of the case since the insured suppressed the material fact, therefore the insurer was justified in repudiating the claim on account of false statement made by assured in proposal form. Therefore we do not find any illegality was committed by the insurance company in refusing to accept the claim of the complainant and therefore we hold that the complainant will not be entitled to get any claim whatsoever from o.ps.        

            Thus all the points are disposed of accordingly.

            Hence, ordered,

            That the CC No.747/2013 is dismissed on contest against the o.p. nos.1 2, 3 & 6 and dismissed ex parte against the o.p. nos.4 & 5 without cost.          

            Supply certified copy of this order to the parties free of cost.