Shri B. Mukhopadhyay, President.   

This is an application u/s.12 of the C.P. Act, 1986.

            In the present consumer dispute complainant’s grievance is that practically he submitted a mediclaim after his bypass surgery to the extent of Rs.3,03,617/- for reimbursement by the OP and that claim was settled by the OP only by paying Rs.1,60,000/- out of total amount payable Rs.2,60,000/- and for which the complainant prayed for directing the OP to pay balance amount of medical bill of Rs.1,00,000/- including compensation etc.

            In the body of the compliant fact as alleged by the complainant is that he is a mediclaim policy holder under the OP being present policy no.030400/48/11/97/ 00000151 and some assured is Rs.3,25,000/- and valid period was for 09-04-2011 to 08-04-2011 and, in fact, complainant is a bona fide medical policy holder under the OP since 22-02-1995 without any break.

            During validity period of the present policy complainant was advised by the doctor after check up for coronary angiography and referred to Dr. Aftab Khan for further treatment and on 25-01-2012 Dr. Aftab Khan of Apollo Gleneagles Hospital further checked up and on examination he was hospitalized and there coronary angiography was done.  Thereafter, he was seriously ill at about 6.00 p.m. on 25-01-2012 and on that date complainant left for Chennai by flight for admission at Apollo Hospital, Chennai.  Where on 25-01-2012 he was under supervision of Dr. M.R. Girinath and J.K. Subramanya and as per their advice he was admitted in Apollo Hospital on 31-01-2012 for bypass surgery and was discharged on 07-02-1012 and, thereafter, this claim was submitted for a total amount of Rs.3,03,617/- but out of that partly it was allowed and balance part was rejected.  Hence, this complaint was filed.

            On the other hand, the OP by filing written statement submitted that, in fact, complainant did not go through the policy terms and further fact is that complainant at the time of submission of the application form for purchasing policy year to year preceding to opening this policy concealed the fact that he was suffering from diabetes and hypertension and for which he has violated the terms and condition of the policy.  Knowing fully well that he is a patient of high blood pressure and hypertension for which he suffered from different ailments including heart problem.

            It is further submitted that as per terms and condition of the insurance policy OP Company is under obligation to reimburse the claim of the complainant only 70% of sum assured, 10% of sum insured policy (towards pre and post hospitalization i.e. date of hospitalization on 24-01-2012) prior to four years from the date of claim in case of preexisting decease.

            It is further submitted that mediclaim policy of the complainant for the period of 09-04-2007 to 08-04-2008(four years back) being policy No.030400/48/07/20/ 00000104 was for sum insured Rs.2 lakh and accordingly a sum equal to 70% of Rs.2 lakhs i.e. Rs.1,40,000/- + 10% of sum insured Rs.2 lakhs i.e. Rs.20,000/- total Rs.1,60,000/- had been paid to the complainant and complainant accepted this sum as full and final settlement of the claim without any objection and fact remains that the discharge certificate as issued by the Chennai Hospital by the doctors supports that complainant had been suffering from high risk factors i.e. DM and HTN has a definite and direct bearing on the development of his present condition of CAD requiring the said surgical intervention.  So, it is clear that complainant suppressed the truth in each application form for purchasing mediclaim policy what is no doubt against terms and condition of the policy and he suppressed his actual disease in the application form but even then considering his policy since 1995 benefit was given thoughas per terms and condition of the policy no benefit can be awarded as there is no laches on the part of the OP and for which the same should be dismissed.

Decision with Reasons

On comparative study of the entire complaint and written version including the arguments of the Ld. Lawyers of both the parties and particularly relying upon the Clause 4.1 of the policy bond we are convinced to hold that the company shall not be liable to make any payment under the present policy in respect of any expenses whatsoever incurred by any insured in respect of any preexisting disease that conditions are in the policy, until 48 months of continuous coverage of such insured person elapsed since inception of her first policy with the company and relying upon that Clause we are confirmed that both the parties are guided by the terms and conditions of the policy and complainant has not challenged any part of that contract (terms and condition of the policy).

            Fact remains complainant was admitted to Chennai Apollo Hospital where he was treated and his bypass surgery was done and said discharge report issued by said hospital simply proves that the present complainant is 60 years old person having his history of hypertensive and diabetic since 7 years (preceding to 31-01-2012) and at the same time it was detected after evaluation that he was elsewhere by cardiac cath and coronary angiography which revealed cardiac left main with two vessels disease with mild to moderate LV dys-function (by echo) and he was advised CABG Surgery and his renal function was at border line and accordingly it is found that he was suffering from coronary artery disease with 7 years past history of hypertensive and diabetic and complainant has relied upon that discharge certificate and on the basis of that discharge certificate he submitted medical claim along with the bill. 

So, it is clear from the document of the complainant that complainant suppressed the fact of his seven years old preexisting disease in the declaration in the application form of purchase of mediclaim policy for last 7 years preceding to present purchase of the policy and also during purchasing this present policy and it is no doubt an overact on the part of the complainant as a consumer and for which he is not entitled to get any benefit because it is settled principle of law that the parties cannot go behind contract and at the same time the parties must have to give vital declaration about his health condition about his pre-existing disease like blood pressure, sugar and other diseases but that was not disclosed for last 7 years.  So, as per contract it is found that such a fellow who has suppressed his pre-existing disease for last 7 years at the time of yearly filing of the application form for purchasing the mediclaim and managed to purchase such policy, cannot get any benefit for treatment of preexisting diseases.  But it is settled principle of law that if any consumer at the time of purchase of the mediclaim policy or insurance policy does not give truthful declaration in respect of his health and if it is subsequently detected that such consumers have/had pre-existing disease but it was suppressed in that case the entire contract (the policy bond shall be treated as invalid) and it is also settled principle of law that Court or Forum while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substitute in the terms which were not intended by the parties and in this regard a ruling reported in AIR 2009 SC 2834 is relied.

            So, it is clear rather it is proved by the complainant himself by his own document of discharge issued by Apollo Hospital, Chennai that for last 7 years complainant had been suffering from high sugar and blood pressure.  But that was suppressed in all the applications form of the years starting from 2005-2011 and for that reason the complainant’s mediclaim policy should be treated as invalid one and for which the complainant cannot claim any further amount as mediclaim from the OP.  But what we have gathered from the entire cONDUCT as presented by the OP that OPs even after that without entering into technicalities regarding suppression of pre-existing disease gave complainant Rs.1,60,000/- as per Clause 4.1 of the policy bond and no doubt the OP not only discharged their liability morally but fact remains that they showed humanity to the complainant and in the present case OP not to have allowed any claim because this complainant suppressed his pre-existing disease like hyper tension and blood sugar since 2005 to 2011 at the time of purchasing fresh mediclaim policies. 

            In the light of the above observations we are convinced to hold that there was no laches on the part of the OPs and they have practically showed a moral approach by allowing Rs.1,60,000/- as per provision of 4.1 Clause of the bond though they had sword in their hand to cut the entire claim but that has not been done and that is the vital act on the part of the OP to be treated as human and moral approach and by showing it invariably OPs have given him a gift of Rs.1,60,000/- that OPs immoral activities on the part of the complainant at the time of open insurance policy is proved.  In the result, the complainant’s claim for further Rs.1 lakh as mediclaim is immoral, uncalled for, unwanted.

            In the light of the above findings we are inclined to hold that the present complaint is devoid of any merit.  So, this complaint fails.

Hence,

Ordered

That the complaint be and the same is dismissed on contest without any cost against the contesting OPs.