National Consumer Disputes Redressal
M/S New India Assurance Co. Ltd. vs Mr. Lalit M. Bhambani And Anr. on 7 August, 2001
ORDER
B.K. Taimni, Member
1. Appellant - New India Assurance Co. Ltd. has filed this Appeal against the order of the State Commission passed on 13.1.1994 in Complaint No. 169/92 deciding the Appellant to settle the claim under Medi-claim Policy with the Respondent/Complainant by paying Rs.59,588/- with interest @ 18% for 8.8.1990 along with cost of Rs.500/-.
2. Brief facts of the case are that the Respondent/Complainant had a Medi-claim Policy effective from 12.5.1989 for one year which was further renewed for one year from 12.5.1990 to 11.5.1991. In July 1990, Respondent/Complainant No.2 was admitted in the Hospital twice, once in July, 1990 and again in August, 1990 with heart problem and anglo-plasty, respectively for which, a total expenditure of Rs.59,588/- was incurred and upon filing a claim with the Appellant, who did not settle the claim on the ground that the Respondent/Complainant is guilty of not describing material facts and fraudulently suppressing the facts that the Respondent/Complainant was suffering from diabities and hypertension prior to the obtaining of Medi Claim Policy. Since the claim was not getting settled, Respondent/Complainant filed a complaint before the State Commission who after hearing both the parties and after perusal of material on record directed the Appellant company to give reliefs to the Respondent/Complainant already enumerated above.
3. The main grounds of appeal are that as per material on record obtained by the Appellant Company, Respondent/Complainant No.2 was suffering from diabities mellitius, hypertension and tuberoclosis which were not disclosed by him in the application form for obtaining Medi-claim Policy. Appellant Company produced certain unauthenticated record of Manavati Hospital, which was not relied upon by the State Commission. We also find ourselves unable to consider this unauthenticated material on record as any proof in support of contentions of the Appellant. Record procured from Hinduja Hospital also does not keep them much as it states patent diabitie since 1982, High Blood Pressure.
4. Key issue is not what ailments he had but key lies in the fact whether the Respondent/Complainant 2 gave any information which he ought to have given as per the proforma of the Appellant Company. Question No. 10 and 11 of the proposal form are the relevant ones.
Question No. 10 reads as under :-
"Details of knowledge of any positive existence or present of any ailment, sickness or injury which may require medical attention in immediate future Question No. 11 reads as under :-
Details of medical treatment/surgical operation during preceding 12 months.
- nature of treatment
- period of treatement
- Doctor
5. Answer given by the Respondent/Complainant was 'No' and 'Nil', respectively.
6. We do not find any material, evidence or proof on record rebutting the answers given by Respondent/Complainant. Answer to question no. 11 is clearly 'Nil'. Answer to question no.10 is quite correct as we see the qualifying clause is .....'... may require attention in immediate future! This is not borne by the instant case. Respondent/Complainant obtained the Policy on 12.5.1989 and claim relates to the period of July/August 1990. By no stretch, could this be stated that he required attention in immediate future , policy having been taken on 12.5.1989 i.e. when the proposal form was filled in. An occurrence after 15-16 months of the proposal form could not qualify as 'immediate'. Thus, on both grounds the Petitioner fails to satisfy us that the Respondent/Complainant gave any incorrect information as a per the proposal form.
7. It was also argued by the Learned Counsel for the Appellant company that as stated before the State Commission, the claim can be settled at Rs. 38,952/- which according to them is as per the terms of the Policy. We have gone through the Policy and find that there is nothing it to prevent the Appellant company to settle the claim at just amount of claim.
8. In the light of the above discussion, we do not find any merit in the appeal and is dismissed. No order as to costs.