State Consumer Disputes Redressal Commission
Max Bupa Health Ins. Co. Ltd.Thgough ... vs Mahipal Chaudhary S/O H.M.Chaudhay on 10 October, 2017
Daily Order BEFORE THE CONSUMER DISPUTES REDRESSAL COMMISSION,RAJASTHAN,JAIPUR BENCH NO.1 FIRST APPEAL NO: 302/2017 Max Bupa Health Insurance Co. Ltd. City Mall, C-21, Unit Number 209, 210 and 211, Bhagwan Das Road, C-Scheme, Jaipur through Br.Manager & ors. Vs. Mahipal Chaudhary s/o H.M.Chaudhary r/o Plot No. 22 Lane No. 1 Gopalbari, Ajmer Road, Jaipur. Date of Order 10.10.2017 Before: Hon'ble Mrs. Justice Nisha Gupta- President Mr.Prateek Kasliwal counsel for the appellant Mr. Atulya Paliwal counsel for the respondent BY THE STATE COMMISSION ( PER HON'BLE MRS. JUSTICE NISHA GUPTA,PRESIDENT):2
This appeal has been filed against the order passed by the learned DCF Jaipur 2nd dated 4.1.2017 whereby the claim has been allowed.
The contention of the appellant is that wife of the complainant was suffering from Parkinson. Fact has been suppressed hence, the claim should have been dismissed.
Heard the counsel for the parties and perused the impugned judgment as well as original record of the case. A written reply to the appeal was filed on behalf of the complainant.
It is not in dispute that the proposal form was submitted on behalf of the complainant respondent in which questions as regard to health of insured were answered in negative and it has also been stated that she had not experienced any health problem or medical condition within last three months for which she has not seen the doctor meaning thereby that even she has not been experienced any health problem within three months of purchase of the policy but Discharge Summary of Jaslok Hospital Ex. P 3 which has been relied by the 3 complainant respondent himself reveals that she started having tremors in left upper limb in 2006 alongwith slowness of movements. She was not able to perform fine movements like climbing, wearing clothes etc. it progressed to involve right upper limb over next three months. She developed similar complaints in both the lower limbs after 3-4 years. She has also developed some difficulty in speech since 4 years and complaint of imbalance while walking since 1 ½ years. She has developed hallucinations since last 6 months. She has fluctuating On-OFF periods.
This clinical summary clearly shows that insured having experienced health problem since 2006 but these facts have not been disclosed at the time of purchase of the policy.
The other contention of the respondent is that at the time of purchase of the policy she was medically examined. Be that may be the case, the discharge summary clearly shows that her general examination was normal and medical examination at the time of purchase of the policy cannot absolve the insured of his liability to furnish correct 4 information as the medical check up by the doctor of the insurance company is a routine check up broadly on the basis of reply given by the insured and it is the duty of the insured to furnish correct information and reliance could be placed on the judgment passed by the National Commission in Revision Petition No. 1585/2011 LIC of India Vs. Kusum Patro where the National Commission has held as under:
" Failure of the Medical Officer to record nothing except' No' in reply to any of these questions can only show his complete and gross incompetence (including perhaps collusion ) in examining the life-to-be assured but that cannot absolve the latter of his responsibility to furnish correct information regarding the status of his health which he alone was aware of and should have disclosed in keeping with the principle of 'utmost good faith' which forms the bedrock a contract of insurance."
Hence going through medical examination could not absolve the insured from the responsibility of giving correct information. The respondent has relied upon 1 (2000) CPJ 1 (SC) Modern Insultors Ltd. Vs. Oriental Insurance Co. where exclusion clause was not disclosed to the insured which is not 5 the case here as the insured was taking the policy since 2009.
The other contention of the appellant is that free look period of 15 days was allowed and reliance has been placed on III (2015) CPJ 551 (NC) ICICI Prudential Life Insurance Vs. Preeti Prasad but here in the present case the insurance was purchased under the portability scheme and it was valid since July 2012 whereas she was admitted for surgery on 7.4.2014.
Further reliance has been placed on (1987) 2 SCR 752 Skandia Insurance Co. Vs. Kokilaben Chandravadan where rules of construction are being explained that whole instrument should have been looked into and not only one part of it. There is no dispute about this preposition.
Further reliance has been placed on II (2016) CPJ 467 (NC) National Insurance Co. Vs. Harcharan Singh where on the date of death no policy was subsisting which is not the case here. Further reliance has been placed on IV (2015) CPJ 407 (NC) Padmavathy Venkatesh Vs. Oriental Insurance Co. where the insurance company has failed to establish that policy 6 was obtained by concealing any previous ailment. Reliance has also been placed on III (2011) CPJ 198 (NC) New India Assurance Co. Vs. Murari Lal Bhusri where the respondent was not aware of any pre-existing disease which is not the case here.
Per contra in the complaint itself the contention of the respondent was that Rajshree was suffering from advance stage of Parkinson. Reliance has also been placed on IV (2010) CPJ 229 (NC) Oriental Insurance Co. Vs. Vikram Sabharwal where no record of treatment was furnished. Here in the present case discharge summary of Jaslok Hospital submitted by the respondent clearly states that Rajshree was suffering from health problem since 2006. This may also be noted that as per claim form the hospitalization was planned meaning thereby that the insured was knowing well that she is suffering from Parkinson.
Hence, in view of the above that material facts have been suppressed as regard to the health condition. The insured was suffering from pre-existing disease at the time of purchase 7 of the policy, the insurance company cannot be held deficient and the claim should have been rejected.
In view of the above, the appeal is allowed and the order of the Forum below dated 4.1.2017 is set aside.
(Nisha Gupta) President nm