PER SHRI. S.M. RATNAKAR – HON’BLE  PRESIDENT

1)        The Complainant by this complaint has prayed that the award for Rs.1,20,000/- be passed against the Opposite Party with interest @ 18% p.a. or at such rate as this Forum deems fit and proper.  The Complainant has further prayed Rs.5,000/- as compensation for mental torture and Rs.10,000/- towards the cost of this proceeding.

2)        According to the Complainant, he is a consumer who had hired the service by paying premium for Mediclaim Insurance Policy from the Opposite Party since 21/01/1999.  It is alleged that the Complainant was approached by agent of Opposite Party who was knowing the Complainant very well as well as the medical treatment he had taken prior to issuing mediclaim policy.  The said agent knowing this facts persuaded the Complainant in the year 1999 to take the aforesaid policy for the Complainant himself and his wife.  According to the Complainant, he was asked to give signature on the form know as proposal form.  The said agent noted down all information on separate paper and informed the Complainant that after discussing the proposal with the Divisional Manager, we will contact the Complainant to collect the premium, if the Manager agrees to give the policy.  It is submitted that the said agent contacted the Complainant and asked to give the premium amount which shows that after knowing about the health condition of the Complainant the Opposite Party agreed to give mediclaim policy and issued the same for the year1999-2000 without any remark, endorsement and objection and any exclusion.  It is alleged that the Opposite Party only gave part of the policy i.e. schedule part of the policy without furnishing the other part known as terms and conditions.  It is the case of the Complainant that the said policy then renewed for the year 2000-01 and 2001-02.  The copy of the policy for the year 2001-02 is marked as Exh.‘A’.  It is submitted that the policy was for Rs.1,00,000/- and accumulated bonus for two years was 20% on the said sum insured amount.  The Complainant has alleged that therefore, he entitled to get claim Rs.1,20,000/-.

3)        It is the case of the Complainant that in the month of March, 2002, he felt numbness in his right hand for two times.  He therefore, got diagnosed and was required to undergo operation for Carotid Aritery Stenosis Bilaterally. The Complainant therefore, admitted in the hospital and operation was performed on 09/03/2002.  The copies of medical papers are at Exh.‘B’.  The Complainant submitted the said papers with the bills of Rs.1,66,599/- to the Opposite Party.  The copies are the same at Exh.‘C’.  It is alleged that the Opposite Party by letter dtd.03/09/2002 repudiated the claim.  The copy of the said letter is at Exh.‘D’.  It is alleged that the Opposite Party repudiated the claim on the basis of the proposal form dtd.21/09/1999 stating that the information required as per proposal form was not disclosed and treatment for the disease which was taken by the Complainant was pre-existing disease.  The Complainant explained the facts by letter dtd.25/11/2002 to the Opposite Party and informed that the authorized agent of Opposite Party Mr. Narendra Kapadia was knowing all the facts of the medical treatment taken by the Complainant.  It is alleged that the Complainant was not aware what  details  were  submitted  by  the said agent the Complainant had therefore, called the copies of 1) proposal form 2) copy of entire policy including terms and conditions 3) copy of medical opinion if obtained by Opposite Party 4) all original medical papers and bills.  The copy of said letter is at Exh.‘E’.  It is submitted that the Opposite Party by letter dtd.16/01/2003 gave reply to the Complainant the copy of which is marked as Exh.‘F’.  It is alleged that the Opposite Party in the said reply did not denied that alleged exclusion is not stated in the policy.  The Complainant has pointed out that in view of the aforesaid copies of the letters issued by the Opposite Party, the Opposite Party had wrongly repudiated the claim which amounts to deficiency of service.  It is alleged that some of the employee made addition and alteration in the hospital record submitted by the Complainant by altering the figure of year “5 stated in the hospital record to “2”.  It is submitted that the acts on the Opposite Party denying the claim lodged by the Opposite Party are nothing but unfair trade practice against the Complainant.  The Complainant has therefore, prayed to grant the reliefs as mentioned in para 1 of this order.

4)        The Opposite Party contested the claim by filing written statement. It is contended that it is immaterial whether the Complainant had approached by the agent of the Opposite Party or several members of the family were insured by the said agent.  It is contended that on receipt of the proposal form dtd.21/11/1999 the following endorsement was made “ECG abnormal, Blood sugar normal, to exclude heart and circulated disease including hyper tension.”  It is contended that the original policy was subject to the exclusion by virtue of the endorsement in the acceptance advise. It is alleged that in the case summary Bhailal Amin General Hospital it was originally typed that the Complainant had a known case of hyper tension since 8 years, however, the figure 8 had been altered indulging to figure 2 without anyone signature to authenticate the correction.  It is submitted that the said alteration indicates that an attempts to show that as on 03/04/2002 hyper tension had been existing for 2 years only i.e. it commenced after the proposal form dtd.21/12/1999 and that was not a pre-existing disease.  The object of making this alteration was to avoid that the claim being hit by exclusion clause no.4.1.  It is submitted that the alteration in the hospital documents attracts exclusion clause no.5.7 of the policy.  It is denied that the Complainant is entitled to get Rs.1,20,000/-.  It is submitted that the Complainant lodged fraudulent claim to the Opposite Party.  The Complainant is not entitled to the reliefs claimed in the complaint and the Opposite Party has rightly repudiated the claim.  The Opposite Party has therefore, prayed to dismiss the complaint with cost.

5)        The Complainant has not filed separate affidavit of evidence.  The Opposite Party has also not filed separate affidavit of evidence.  Both the parties filed written arguments.  We heard the oral arguments of Ld.Advocate Shri. Harshad Trivedi for the Complainant and Smt. Krishna Sharma, Ld.Advocate for the Opposite Party.  We have perused the documents filed in the Complainant by both the parties.

6)        While considering the claim made in the complaint it is necessary to be taken into consideration that the Opposite Party by its letter dtd.03/09/2009 has specifically contended that in the proposal form submitted by the Complainant the Complainant had suppressed material facts as regards the diseases which he had suffered. The answers regarding the blood pressure mentioned in the proposal form was suggesting that the Complainant had not suffered hyper tension prior to 13/12/1999. The Complainant answered to question no.5 inquiring if he had ever suffered from any complication for other disease had only mentioned Angiography, but he had suppressed that he underwent Coronary Angiography on 30/08/1995 at Khamball Hill Hospital. Furthermore, from the original hospital case papers placed on record by the Opposite Party as regards the treatment for which the Complainant had submitted the claim to the Opposite Party i.e. case summary of Bhailal Amin General Hospital for the period 03/04/2002 to 10/04/2002 in the clinical history it is mentioned that the Complainant was known case of hyper tension (K/C/O) since ‘8’ years and the same had been altered in ink to the figure “2” without any once signature to authenticate the  correction. The Opposite Party by its letter dtd.03/09/2002 has rightly considered that the claim lodged by the Complainant was liable to be rejected after detail investigation of the medical papers and the clauses mentioned in the terms and conditions of the policy issued by the Opposite Party to the Complainant.  The submissions made by Shri. Harshad Trivedi for allowing the claim in our view, in view of policy condition no.4.1 and the policy condition no.5.7 cannot be accepted as legal and proper.  The Opposite Party has rightly repudiated the claim in view of suppression of the pre-existing diseases by the Complainant.  The Complainant failed to prove that the Opposite Party is guilty of deficiency of service and adopted unfair trade practice while rejecting the claim. We therefore, hold that the complaint is liable to be dismissed as the Complainant is not entitle to the claim made in this complaint. In the result the following order is passed –

O R D E R

                      i.      Complaint No.52/2003 is dismissed with no order as to costs.

                      ii.     Certified copies of this order be furnished to the parties.