State Consumer Disputes Redressal Commission
Star Health & Allied Insurance Co Ltd vs Amol Narhari Kulkarni on 14 September, 2017
1 F.A.No.: 264/2017
Date of filing :09.12.2016
Date of order :14.09.2017
MAHARASHTRA STATE CONSUMER DISPUTE REDRESSAL
COMMISSION,MUMBAI, CIRCUIT BENCH AT AURANGABAD.
FIRST APPEAL NO. :264 OF 2017
IN CONSUMER COMPLAINT NO.:137 OF 2016
DISTRICT CONSUMER FORUM :AURANGABAD.
1. Star Health and Allied Insurance Co.Ltd.,
Through its Manager,
Office at New Tank Street, Valluvar Kottam,
High Road, Nungabakkam,
Chennai.
2. Star Health and Allied Insurance Co.Ltd.,
Through its Manager,
Branch office at II floor, Block 6 & 7,
Suyash Complex, Baba Harda Nagar,
Kalda Corner,
Aurangabad. ...APPELLANTS
VERSUS
Amol Narhari Kakade,
R/o 16, 'Nathshri' , Anupama Housing Society,
Shreya Nagar,
Aurangabad. ...RESPONDENT.
CORAM : Smt.Uma S.Bora, Hon`ble Presiding Member.
Shri.K.B.Gawali, Hon`ble Member.
Present : Adv.Shri.Shrikant Kulkarni for appellants, Adv.Shri.U.N.Shete for respondent.
O R A L O R D E R (Delivered on 14th of September 2017) Per Mrs.Uma S.Bora, Hon`ble Presiding Member.
1. Star Health and Allied Insurance company Ltd.Chennai and Star Health and Allied Insurance company, Aurangabad challenges in this appeal the judgment and order passed by Dist.Consumer Forum Aurangabad on 13.10.2016 allowing complaint case No.137/2016.
2 F.A.No.: 264/20172. Facts giving rise to this appeals are that , complainant Amol Kakde resident of Aurangabad had obtained the medical insurance policy called as Family Health Optima Policy bearing No. P/151115/01/2015/001847. This was the policy for the entire family of the complainant and period of insurance policy was from 17.9.2014 to 16.9.2015.
3. On 30.8.2015 complainant had headache which become severe till the end of day and therefore he approached to doctor who advised MRI. After getting report of MRI it was revealed that complainant is suffering from "Pituitary Macroadenoma With Hemorrhage". Therefore to get treatment for that he went to Mumbai in Hinduja Hospital on 1.9.2015. After conducting various medical tests doctor came to conclusion that complainant was required to undergo surgery for "Pituitary Mass Lesion". Complainant therefore underwent to that surgery. He claimed reimbursement of the expenses of hospital as he was having medical policy with the appellant. But on 5.9.2015 his claim was repudiated by the appellants on the ground that complainant suppressed the pre-existing disease while obtaining the policy. Therefore complainant approached the Forum by claiming the sum assured Rs.5 lakhs with 18% interest from 2.9.2015, Rs.1,50,000/- for mental agony and Rs.25,000/- for cost of proceeding.
4. Appellants appeared before the Forum and resisted the complaint mainly on the ground that complainant suppressed the material particular about his health while obtaining the policy. On perusal of discharge card from hospital where the surgery of the complainant was conducted it was revealed that complainant was suffering from hyper tension since last 10 years. But while filing the proposal form said fact was not disclosed by the complainant. Therefore his claim was rightly repudiated.
5. After hearing both the parties Dist.Consumer Forum allowed the complaint and directed appellant to pay Rs.5 lakhs with 12% interest from 7.9.2015 within 30 days from the date of order and to pay Rs.50,000/- for 3 F.A.No.: 264/2017 mental agony and Rs.50,000/- to be deposited in the consumer welfare fund of Dist.Consumer Forum Aurangabad.
Hence present appeal.
6. Adv.Shri.Shrikant Kulkarni appeared for appellants and Adv.Umesh Shete appeared for respondent. It is submitted by Adv.Kulkarni that complainant had obtained the medical policy but while filing proposal form fact about suffering from hyper tension was suppressed. It is an admitted fact that wife of complainant is medical practitioner. Therefore she must have been well aware about the fact that complainant was suffering from hyper tension. But by suppressing said fact policy was obtained. After getting claim from the complainant investigation was carried out and it was revealed that as per discharge card of the Hinduja Hospital complainant was suffering from hyper tension since last 10 years. Therefore claim of the complainant was rightly repudiated as complainant had committed breach of terms and conditions of the policy.
7. It is further submitted by Adv.Kulkarni that the contract of insurance is based on utmost good faith. Therefore parties to contract are under obligation to supply true and correct information before taking policy. But in the present case it is crystal clear that complainant suppressed the fact that he was suffering from hyper tension. Complainant did not approach the higher authority of insurance company but directly filed consumer complaint. If complainant would have been approached to officer of insurance company insurance amount would have been disbursed to him. Appellant insurance company is not liable for deficiency in service. Therefore order passed by Dist.Consumer Forum directing insurance company to deposit Rs.50,000/- in the consumer welfare fund is to be set aside.
8. Adv.Umesh Shete appearing for complainant submitted that complainant was never suffered from any ailment before surgery undergone 4 F.A.No.: 264/2017 at Mumbai. He was only the problem of headache that was also for one day. As it became severe he approached to doctor. Doctor advised him for surgery and accordingly surgery was conducted. Therefore complainant first time came to know that he was suffering from "Pituitary Macroadenoma With Hemorrhage". Even after the receipt of claim insurance company investigated the matter and in the said investigation also it was clearly mentioned that " we have checked extensively for any past history. However, vicinity check did not reveal any past history". It is therefore submitted by Adv.Shete that as there were no symptoms or any problem to the health of complainant it was never noticed that he was suffering from hyper tension. Dist.Consumer Forum rightly appreciated all the facts and evidence while allowing complaint. Hence appeal be dismissed. Adv.Shete further submitted that order of Dist.Consumer Forum directing appellant to deposit Rs.50,000/- can be quashed and set aside.
9. We thus heard both the counsel and perused the record. It is an admitted fact that complainant had obtained mediclaim policy. It is seen from the record that he had suffered from headache for one day only. But as it become severe he approached to Hinduja Hospital where surgery was conducted. It is the contention of appellant insurance company that as per history recorded at Hinduja Hospital complainant was suffering from hyper tension since last 10 years. But no affidavit of persons who had recorded said history is produced on record by the insurance company. It is seen that many time healthy persons are unaware of such silent ailment like hyper tension and diabetes which come to their knowledge first time if any emergent situation occurred.
10. It is the contention of insurance company that complainant deliberately suppressed the information about his health. In that respect we are relying on Section 45 of Insurance Act as per that section three ingredients are necessary that complainant himself was knowing about his ailment, complainant himself deliberately suppressed said fact and it was material to disclose. In our view complainant was not aware about his 5 F.A.No.: 264/2017 ailment. In our view therefore there is no suppression as alleged. Dist.Consumer Forum rightly appreciated the facts and evidence while allowing complaint. Hence no interference is required.
11. In our view the order passed by Dist.Consumer Forum to deposit Rs.50,000/- in the Consumer Welfare Fund is unwarranted as we are not feeling that appellant is liable for any deficiency in service. Hence the following order.
O R D E R
1. Appeal is partly allowed and order of Dist.Consumer Forum is modified.
2. Clause No.3 of the operative part of order of Dist.Consumer Forum is hereby quashed and set aside.
3. Rest of order is maintained as it is.
4. No order as to cost.
5. Copies of the judgment be supplied to both the parties.
Sd/- Sd/- K.B.Gawali, Uma S.Bora, Member Presiding Member Mane