No. 4/01.07.2011.

HON’BLE JUSTICE SRI PRABIR KUMAR SAMANTA, PRESIDENT.

Both sides are present through their Ld. Advocates.  This appeal is by the Insurer against the judgement and order dated 11.11.2010 passed by the District Forum at Darjeeling in complaint case being CC Case No. 9/D/2010 that was filed by challenging repudiation of the medical insurance claim raised by the Complainant.  By the aforesaid impugned order the claim case has been allowed on contest with a direction upon the insurer to settle the claim of the Complainant at Rs.1,42,578.60 and pay to the Complainant the said amount along with interest @ 9% per annum with effect from the date of repudiation of the claim till realization with further direction for payment of compensation of Rs.25,000/- and litigation cost of Rs.7,000/- against the insurance cover of the Complainant for Rs.1,00,000/- only. 

Evidently the aforesaid medical insurance was obtained by the Complainant w.e.f. 11.07.2009 issued by the O.P. – Insurer for the period from 11.07.2009 till 10.07.2010.  It has been stated by the Complainant himself that he fell ill in the month of July 2009 and was rushed to Bangalore for his treatment as he preferred to get himself treated at the recognized hospital of the O.P. namely Wockhardt Hospital and Heart Institute at Bangalore where he was hospitalized on 17.07.2009.  The Complainant accordingly incurred expenses for an amount of Rs.1,42,578.60 for his medical treatment at the said hospital at Bangalore for which a claim was raised by the Complainant with the O.P. – Insurer.  The said claim has been repudiated by the O.P. – Insurer on the ground that the Complainant was suffering from hypertension since last 6 to 7 years which is the cause for his ailment.

In the proceeding before the Forum below the Complainant in support of his case has filed the Discharge Certificate issued by the said hospital at Bangalore which has been made Annexure ‘B’ to the memo of appeal.  The said Discharge Summary in an unambiguous manner has disclosed that the Appellant before being fell ill in the month of July had an Inferior Wall Myocardial Infarction (Thrombolysed) on 28.06.2009 with systemic hypertension and he was treated for such acute Inferior Wall Myocardial Infarction at elsewhere before being admitted in the aforesaid Wockhardt Hospital at Bangalore.  This very document, which has been relied upon by the Complainant himself to substantiate his claim for disbursement of the expenses incurred for his medical treatment has clearly revealed that the Complainant had such Inferior Wall Myocardial Infarction recently before taking of the Insurance Policy from the O.P. – Insurer without disclosing the fact of such recent Inferior Wall Myocardial Infarction of the Complainant.  It has been consistently held in claim cases arising out of repudiation of the medical insurance claim that where insured has suffered heart problem from which he was suffering from before taking of the Policy and has not disclosed his suffering at the time of taking of the Insurance Policy, it is a case of material suppression of facts which would justify repudiation of the claim.  It has nowhere been established by the Complainant that before inception of the above Insurance Policy the factum of suffering of the Complainant of such Inferior Wall Myocardial Infarction was made known to the Insurer.  The District Forum below has thus failed to notice from the aforesaid Discharge Summary issued by the hospital itself in which the Complainant was treated that there was clear material suppression of facts by the Complainant at the time of taking of the Insurance cover. 

For the reasons as aforesaid we are of the view that the Forum below has failed to consider the material evidence on record and as such the impugned judgement cannot, therefore, be sustained.  The same is accordingly set aside.  The complaint is accordingly dismissed as the Complainant has obtained the aforesaid medical insurance Policy from the O.P. – Insurer with malafide motive of chance exploitation upon suppression of material facts.  The appeal is thus allowed.  There will, however, be no order as to costs.