Per Shri P.N. Kashalkar – Hon’ble Presiding Judicial Member:
This appeal is filed by Complainant whose complaint has been dismissed by the Consumer Disputes Redressal Forum, Pune, since he had not disclosed material facts.
Complainant was senior citizen. He had taken mediclaim policy from Opposite Party No.1 from 2005. In March, 2006, Complainant went to Mumbai. He felt breathlessness on 8th March, 2006, so he approached Doctor and on his advice he got admitted in I.C.U. at Breach Candy Hospital in Mumbai. Angiography was performed and immediately angioplasty was done on 09.03.2006. He was indoor patient till 17.03.2006. He spent `3,50,000/- towards operation, fees of doctors etc. He lodged claim on 03.04.2006 with the Opposite Party, but same was repudiated by the Opposite Party by letter dated 18.01.2007 alleging that this was a pre-existing disease.
In response to notice Insurance Company filed written statement and admitted that Complainant had taken mediclaim insurance policy for every year. But, main contention of the Opposite Party was that claim was repudiated on the terms and conditions of the policy and Complainant suppressed material facts. He was diagnosed as IHD patient in 1994. He suffered heart problem in 2006. It was preexisting disease and this was concealed by the Complainant in his application form and therefore, he was not entitled to any relief.
The Forum below on the basis of affidavits and documents held that Complainant had not disclosed material facts about his suffering heart attack in the year 1994 and having taken treatment from Dr.Jain of Deharadoon. The Forum below was of the view that for the pre-existing ailment he had preferred claim bearing no.48/38/95 in 1995 and this fact was suppressed by him in the policy purchased in 2005 and therefore, he was guilty of suppression of material facts and as such the Forum below was pleased to dismiss the complaint. Resultantly, Complainant himself has filed this appeal.
We heard submission of Advocate Mr.Ronak Shah for the Appellant and Advocate Mr.Sanjay Mhatre for the Respondent No.1 Insurance Company.
Everything is admitted by the Insurance Company. Only defence raised by the Insurance Company is that while purchasing policy the Complainant had not disclosed material facts about his pre-existing ailment or he having undergone treatment for heart ailment at Deharadoon for which he had preferred claim.
We asked Respondent No.1’s Counsel – Shri Sanjay Mhatre to produce before us the proposal form submitted by Khimji Keheraj Shah. In response to our direction Opponent Insurance Company filed some papers, the policy papers for the period 10.09.2005 to 09.09.2006, terms and conditions of mediclaim policy and proposal form, which is in the name of Mrs.Pramila Khimji Shah showing that she is wife and her date of birth is 25.11.1949 and average monthly income is `10,000/- per month and she was in the business and Dr.R.A. Shah is their family doctor. All other columns of this proposal form were left blank, not filled in by anybody, no date, month and year has been mentioned by the side of signature. Signature is of K.K. Shah. So, virtually this form is blank and on the basis of this form the Insurance Company, Respondent no.1 herein had issued mediclaim policy by collecting premium. If insurance company is collecting premiums and issuing policies on the basis of such blank forms simply after taking premium amount and signature on proposal form, less said the better. But, one thing is certain that it cannot be permitted to set up defence on the basis of virtually blank proposal form that Complainant/Appellant had not disclosed material fact when they acted upon the blank form to issue policy after accepting the premium. So, for making business and for earning profit insurance companies are resorting to such type of practices which are unfair trade practices and thereby are duping and harassing the poor consumers. Had they got filled in all the columns of this proposal form, we would have held agreeing with the finding recorded by Ld. District Forum, that there was non-disclosure of material fact (pre-existing disease), but, proposal form which is virtually blank is exposing the way and the manner in which (in lackadaisical) Respondent/insurance company is making business. This tendency is required to be curbed by allowing this appeal simply on the ground that the proposal form taken from the Appellant/Complainant in this instant case was blank and on the basis of blank proposal form they had issued policy after collecting premium. In this view of the matter they cannot be heard to say that the Appellant/org.Complainant had not disclosed pre-existing disease which he had suffered in 1994 when they had not bothered to get filled in proposal form. So, they are now estopped from taking any such defence in the circumstances obtainable. In the result we allow this appeal and pass the following order:
O R D E R
(i) Appeal is allowed.
(ii) Impugned order of dismissal passed by Consumer Disputes Redressal Forum, District Pune in Consumer Complaint No.122/2008 is set aside and complaint stands allowed.
(iii) Insurance Company is directed to honour mediclaim policy and to pay to the Complainant his dues as per said policy which comes to `2,51,500/-.
(iv) Insurance Company is also directed to pay `10,000/- as compensation for mental harassment and `5,000/- as costs of the proceeding.
(v) Copies of this order be furnished to the parties.
