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Smart Summary

Factual and Procedural Background

The Complainant obtained an Indian Overseas Bank Health Care Plus medical insurance policy from Opposite Party No.1 through Opposite Party No.3, covering himself and his wife for ₹2,00,000. He stated that the proposal form disclosed their medical ailments, including hypertension and heart-related conditions. [1][2]

The Complainant’s wife underwent angioplasty on 19.02.2013, incurring expenses of ₹1,97,574. Opposite Party No.2 rejected the claim on the ground that her diabetes and hypertension pre-dated the policy and that the coronary condition was related to those pre-existing illnesses. [3]

The Complainant sought reimbursement of ₹1,97,574 and ₹1,00,000 as compensation for mental agony and harassment. Opposite Party No.3 contended that it was only an agent and was not a necessary party; Opposite Party No.1 denied disclosure of the relevant ailments and relied on the policy exclusions. [4][5][6][7]

The Complainant and Opposite Party No.1 led evidence. Opposite Parties Nos.2 and 3 did not appear and were proceeded against ex parte. [8][9][10]

Legal Issues Presented

  1. Whether the Complainant was entitled to recover ₹1,97,574 under the insurance policy. [11][12]
  2. Whether the Complainant was entitled to compensation. [11][12]

Arguments of the Parties

Complainant’s Arguments

  • The proposal form disclosed the ailments suffered by the Complainant and his wife, and the insurer could not rely on an erroneous policy entry stating that there was no pre-existing disease. [1][2][13]
  • The wife had no prior history of ischemic heart disease and experienced symptomatic chest pain and dyspnea only shortly before the angioplasty. [14][13]
  • Diabetes was not specifically mentioned in the proposal form, and the Complainant had answered affirmatively regarding circulatory disorders. [15]
  • The Complainant relied on decisions concerning lack of knowledge of an ailment and argued that a layperson could not be expected to know that the wife was suffering from diabetes. [16][17]
  • The Complainant also relied on decisions concerning related diseases, medical examination by an insurer, and the effect of exclusion clauses. [18][19][20]

Opposite Party No.1’s Arguments

  • The Complainant failed to disclose the wife’s pre-existing diabetes and hypertension, which rendered the policy void for misrepresentation or non-disclosure of material facts. [6]
  • The wife’s coronary condition was related to diabetes and hypertension and was excluded under the policy terms. [6][21]
  • Alternatively, the claim was barred because the wife suffered from the relevant condition within the policy’s exclusion period. [21]
  • The bills were alleged to be false or fabricated, and there was no deficiency in service. [6][7]

Table of Precedents Cited

PrecedentRule or Principle Cited ForApplication by the Court
Ashok M. Ahuja Vs. United India Insurance Co. Ltd. & Ors, 2015(3) ALL MR (JOURNAL) 50 A claim was not rejected for suppression where the complainant was unaware of the ailment. The Court held that the principle did not apply because the wife had been receiving treatment for diabetes since 2008 and the Complainant was aware of it. [16][17][22][18]
Girish M. Raval Vs. The Oriental Insurance Co. Ltd. & Ors., 2015(3) ALL MR (JOURNAL) 53 A claim was not rejected where the complainant lacked knowledge of the ailment. The Court distinguished the decision on the same basis of the Complainant’s knowledge of his wife’s diabetes. [16][17][22][18]
Gopal Tandon Vs. Universal Sompo Gneral Insruance Co. ltd., Complaint No. CC/21/2011 The decision was relied upon by the Complainant. The Court held that the Forum’s prior order had no binding force and therefore did not examine its facts. [18]
P.J. Chacko and Anr. Vs. Chairman, Life Insurance Corporation of India & Ors, AIR 2008(SC) 424 An insured who answered negatively about a material medical fact was estopped from arguing that disclosure would not have affected the policy decision. The Court relied on this principle in supporting repudiation based on non-disclosure of diabetes. [23]
National Insurance Co. Ltd. Vs. Girin R. Shah, Revision Petition No. 4019/2011 An exclusion clause was not applied where there was no evidence that the claimed condition was related to diabetes and the policy did not refer to related diseases. The Court distinguished the decision because the policy here referred to related diseases and the Complainant had admitted the wife’s ischemic heart disease. [24][19][20]
Life Insurance Corporation Vs. Neelam, Appeal No. A-362/2001 An insurer’s right to rely on concealment of a pre-existing disease could be waived where its own medical panel found the insured healthy. The Court held that the decision did not assist the Complainant. [20]

Court's Reasoning and Analysis

The Court admitted the proposal form into evidence because it came from proper custody, bore the Indian Overseas Bank’s endorsement, and was supported by an explanation for its delayed production. The Court considered that the insurer should have possessed the original because the policy was issued on the basis of the form. [25][26][27]

The proposal form recorded that the Complainant and his wife suffered from high blood pressure, heart disease including ischemic heart disease, and other circulatory disorders. Although diabetes was not expressly listed, the form required disclosure of additional medical facts relevant to the insurance. The Court held that the wife’s diabetes should have been disclosed there. [28][15][29]

The Court rejected the argument that diabetes constituted a circulatory disorder, describing diabetes as a metabolic disorder involving insulin and blood sugar levels. It also relied on the hospital certificate stating that the wife had suffered from diabetes and hypertension since 2008, concluding that the Complainant knew of the condition before submitting the proposal. [30][31][32]

Under the policy’s mis-description clause, non-disclosure of a material fact made the policy void and permitted forfeiture of the premium. The Court held that failure to disclose diabetes entitled the insurer to repudiate the claim. [33][34][23]

The Court further applied the policy’s exclusion for conditions for which symptoms, diagnosis, medical advice, or treatment occurred within 48 months before the first policy. The angioplasty occurred within 36 months of the first policy, and the Court found that the proposal form itself admitted pre-existing ischemic heart disease. The 36-month waiver did not assist the Complainant because the claim was made within that period. [35][36][37][38][39][40][24]

Although the amount of the hospital bills was not disputed, entitlement to payment depended on proving liability under the policy. Since the Complainant failed to establish such entitlement, the claim for reimbursement and compensation failed. [41][42][43]

Holding and Implications

Complaint dismissed. The Court answered both issues in the negative and dismissed the complaint with costs of ₹500. [11][12][41][42][43]

The Complainant was denied reimbursement of ₹1,97,574 and compensation. The decision was based on the findings of material non-disclosure and the policy’s pre-existing-condition exclusion; no broader implication or new precedent was stated. [34][23][24][43]

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    Rajaram N.Sawant v. M/s Universal Sompo General Insurance Co. Ltd & 2 OTHERS

    (Per Mr. Pradip V. Sawaiker, President)

    1. This Judgment and Order shall dispose of the Complaint filed by the Complainant under section 12 of the Consumer Protection Act, 1986 ( for short The CP Act).

    2. The Complainant had availed a medical insurance policy with Opposite Party No.1 through Opposite Party No.3 under the Indian Overseas Bank Health Care Plus (Floater) with an insurance cover for self and his wife Smt. Reshma Rajaram Sawant. The policy was for an amount of ` 2,00,000/-. At the time of availing of said policy, the Complainant had submitted a proposal form. In the said form the proposer had to disclose whether he was suffering from high blood pressure, heart disease including ischemic heart disease and other circulatory disorders. The Complainant had answered the said queries in the affirmative for himself as well as for his wife. The Complainant had also disclosed names, addresses and contact numbers of the doctors from whom he was taking treatment for said disease. The Complainant had thus disclosed all his ailments and had applied for said policy with all honesty.

    3. The Opposite Party No.1 issued policy bearing No. 2817/50529226/02/000 dated 21.03.2012 on said proposal. Although the Complainant had given details of all the diseases, he and his wife were suffering, in the policy the Opposite Party No.1 erroneously mentioned against pre-existing disease declared in the negative. An error if committed, is done by Opposite Party No.1.

    4. On or about 19.02.2013, Smt. Reshma R. Sawant, wife of the Complainant had undergone an angioplasty surgery in Nusi Wockhardt Hospital, Cuncolim. The expenses incurred by her for said surgery were ` 1,97,574/-. The Complainant submitted all the original bills to the office of Opposite Party No.2 within the prescribed time limit. The claim of the Opposite Party No.2 was registered under No. 100031307315. The Opposite ...3/- Party No.2 then raised a query with regard to the duration of diabetes and hypertension, for which wife of the Complainant was taking treatment. Doctor certified that she had no prior history of Ischemic heart disease. On or about 29.04.2013 the Opposite Party No.2 rejected the claim of the Complainant making following observations: As per the submitted documents you are having diabetes and hypertension since 5 years which falls prior to inception of policy and was not disclosed at time of insurance also the present condition of Angina and CAD (coronary artery disease) is complication of diabetes and hypertension, thus it is related to pre-existing condition. Hence the claim stands rejected.

    5. The Complainant had disclosed the medical history of heart ailment in the proposal form at the time of taking policy. Doctor had also certified that the Symptomatic chest pain and Dyspnea occurred since 13.01.2013 and there was no prior history of Ischemic heart disease. The rejection of the claim is, therefore, not based on any material. The Opposite Parties 1 & 2 have avoided payment of the expenses on frivolous ground. The Opposite Parties 1 and 2 have played fraud on the Complainant. The Complainant had issued a legal notice on the Opposite Parties. The Opposite Parties 1 and 2 however, did not settle a genuine claim of the Complainant.

    6. The Complainant had also submitted the original medical bills to Opposite Party No.2. The Opposite Party No.2 refused to return the said bills with malafide intention. With these allegations, the Complainant has approached this Forum for insurance claim of ` 1,97,574/- and compensation of ` 1,00,000/- for the mental agony and intentional harassment.

    7. In the written version, it is the case of the Opposite Party No.3 as under:

    8. There are no allegations made and no reliefs are sought against this Opposite Party. The Opposite Party No.3 was only an agent of Opposite Parties 1 and 2. The Opposite Party No.3 is, therefore, not a necessary party to the proceedings. ...4/-

    9. In the written version, the case of Opposite Party No.1 is as under:

    10. The Complainant had never intimated to this Party pre-existing illness. Under the terms and conditions of the policy, the ailment or injury or related condition for which insured had signs or symptoms and /or were diagnosed and/or received medical advise or treatment was taken within 48 months prior to the first policy, were expressly excluded. The records, of the wife of the Complainant show that she was suffering from diabetes mellitus type-II and hypertension since 2008. The first policy was issued in the year 2010. The ailment with respect to which the Complainant has submitted the claim, therefore, is excluded from insurance cover by virtue of clause 1 of the policy. The Complainant had not disclosed the pre-existing ailments to the Company. The policy issued is, therefore, void on account of mis-description or non-disclosure of material facts. The premium paid is liable to be forfeited. This Opposite Party had also earlier settled two claims of the Complainant through Opposite Party No.2. The present claim is, therefore, barred under the terms and conditions. The Complainant had never disclosed in the proposal form that he or his wife were suffering from high blood pressure, high heart disease including ischemic diseases or other circulatory dis-orders. This Opposite Party has also denied that the Complainant has disclosed names and addresses and contact numbers of the doctors from whom the wife of the Complainant had taken treatment. In case there was an error made by Opposite Party No.1, while issuing the policy, by endorsing that there was no pre-existing ailment suffered by the Complainant or his wife, the Complainant ought to have brought this fact to the notice of this Opposite Party. The Complainant however, deliberately suppressed the alleged error from this Opposite Party. A perusal of the bills indicates that the Complainant had hardly incurred any expenditure for treatment of his wife. The bills are false and fabricated and manufactured to suit the needs of the Complainant. There was no deficiency on the part of the Opposite Parties

    1 and 2.

    11. The claim made by the Complainant is frivolous and false. The complaint is, therefore, liable to be dismissed. ...5/-

    12. The Complainant has examined himself as CW-I. He has produced the medical insurance policy, the proposal form, medical bills, claim submitted to Opposite Parties 1 and 2, letters dated 01.04.2013, 15.04.2013 and 15.04.2013, legal notice dated 01.06.2013, letters dated 27.05.2013, 05.02.2013, 23.08.2013 and 29.04.2013.

    13. The Opposite Party No.1 has examined Mr. Piyush Shankar in support of their defence. He has produced the policy at Exhibit OP-1/A, claim at Exhibit OP-1/B and policy schedule at OP-1/C.

    14. Arguments have been heard. Ld. Adv. Ms. Y.R. Sawant argued on behalf of the Complainant. Ld. Adv. Shri A. Eremita argued on behalf of Opposite Party No.1. None appeared on behalf of Opposite Parties 2 and 3. Order to proceed ex-parte against them was made on 27.07.2017.

    15. Issues arises for our determination and findings on them are as under: ISSUES FINDINGS

    I. Whether the Complainant is entitled to the claim of `1,97,574/-. Negative

    II. Whether the Complainant is entitled to any compensation? Negative REASONING: ISSUE-I:

    16. It is the contention of the ld. Adv. Ms. Sawant for the Complainant that in the proposal form, the Complainant had disclosed all the ailments or diseases, he, as well as his wife were suffering; that wife of the Complainant had to be operated for angioplasty; that there is a certificate issued by the doctor to the effect that she had symptomatic chest pain and dyspnea since 13.01.2013 and prior to that she had no history of ischemic heart disease; that there is sufficient material on record to prove that she did not suffer from this ailment prior to issuance of the policy and therefore, the Opposite Parties could not have rejected the claim. ...6/-

    17. On the other hand, the contentions of ld. Adv. Shri Eremita for Opposite Party No.1 are that the Complainant had not disclosed in the proposal form that his wife Smt. Reshma R. Sawant was suffering from diabetes since prior to submitting his proposal for policy, that the Complainant had suppressed this material fact from the Opposite Party No.1, that the ailment for which the said Smt. Reshma was operated was related to disease of diabetes, and therefore, the Complainant is not entitled to the claim made on account of suppression of material fact. In the alternative, he submitted that Smt. Reshma had been suffering from ischemic heart disease within 36 months from the date she was operated and therefore, in view of exclusion clause, she is not entitled to the claim.

    18. The Complainant has produced a certified copy of the proposal form vide application at Exhibit 24. It is not disputed that this proposal form was submitted to the Indian Overseas Bank and the policy was issued in view of tie up arrangement between the Opposite Party No.1 and the Indian Overseas Bank.

    19. Ld. Adv. Shri Eremita for Opposite Party No.1 had vehemently objected to the production of said document, on the ground that the document is sought to be produced at a belated stage and there is every reason to doubt its genuiness.

    20. In the Exhibit at 24, the Complainant has averred that he could not produce the verified copy earlier, as it was received by him vide letter of Opposite Party dated 07.04.2017. Vide said letter dated 07.04.2017, the Branch Manager of Indian Overseas Bank has communicated to the Complainant that earlier they could not issue the said verified copy, as they could not trace the same and it was traced only around the time when the letter dated 07.04.2017 was addressed to the Complainant. The letter also mentions that the said document is a copy of application submitted to the Indian Overseas Bank for Health Care Plus Policy taken by the Complainant in March 2010. The document has come from a proper custody. Explanation ...7/- has been given by the Opposite Party No.3, Indian Overseas Bank for non- issuing the said verified copy earlier to the Complainant. In fact, original of this form should have been in possession of Opposite Party No.1 since the policy is issued by Opposite Party No.1 on the strength of this proposal form. Shri Eremita, ld. Adv. for Opposite Party No.1 has submitted that these are the documents of more than 5 years and that now they are not in possession of the same. The Opposite Party should have produced the document. The document is produced from proper custody and therefore, there is no reason to doubt its genuiness. There is no reason to dis-allow the application for production of said documents.

    21. There is an endorsement made by the Indian Overseas bank on said proposal form with its seal. There is also a signature within the seal with a date below it. The date that appears is 17.03.2010. This form obviously, therefore, was submitted to the bank on 17.03.2010. It is not disputed that Opposite Party No.1 had for the first time issued policy in the year 2010. The policy was, therefore, issued based on this document. The Complainant himself has relied on this document. On the first page at the bottom of this form there are columns in which the proposer is required to give the medical history. Under item no.3, the proposer was required to give medical history with regard to high blood pressure, heart disease, including ischemic heart disease and other circulatory disorders. Against this item, the proposer has confirmed that he as well as his wife were suffering from said ailments.

    22. Ms. Sawant, ld. Adv. for the Complainant submitted that there was no column in the proposal form requiring the proposer to mention about the disease of diabetes, that the Complainant had filled all the columns and, therefore, question of suppression of disease of diabetes does not arise. Alternatively, she submitted that the Complainant has answered in the affirmative about circulatory disorders which includes disease of diabetes.

    23. Both the submissions of ld. Advocates are not convincing. It is true that the form does not specifically mention about diabetes. However, against ...8/- item no. 4 under medical history, the proposer was required to give additional facts or matters medical or otherwise affecting or relevant to the proposed insurance. Against this column, the Complainant has mentioned that he has undergone angioplasty in December 2003. In case, his wife was suffering from diabetes, he had ought to have mentioned the same against this item.

    24. The submission that the other circulatory disorders include diabetes is also not convincing. The Diabetes cannot be said to be circulatory disorder. Diabetes is group of metabolic disorder in which there are high blood sugar levels over a prolonged period. Diabetes is due to either pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced. It could not be termed as circulatory disorder. It is disability of pancreas to produce enough insulin.

    25. The Complainant has also mentioned that both, he and his wife Smt. Reshma were suffering from high blood pressure, heart disease including ischemic heart disease and other circulatory disorders. In that back ground , it is also difficult to believe that doctor has never advised the Complainant or his wife to get the blood test done. The Complainant has produced a certificate dated 15.04.2013 issued by the Vrundavan Shalby Hospitals which reads as under: This is to inform you that Mrs. Reshma Sawant,, 59 years old , female is suffering from diabetes mellitus, type II and hypertension: 5 years (2008). She is regular patient of Vrundavan Shalby Hospital

    26. There is, therefore, a certificate issued by Doctor certifying that Smt. Reshma was taking treatment for diabetes since 2008. The Complainant was, therefore, well aware of the said disease since the year 2008. In that case, he ought to have disclosed of said disease in the proposal form. As contended by ld. Adv. Eremita for Opposite PartyNo.1 that the Complainant has suppressed this material fact from Opposite Party No.1. ...9/-

    27. In a review article in journal on diabetes professor Antonio Tuttolomondo and ors. of University of Palermo, Palermo, Italy have opined that among the patients with diabetes mellitus several factors contribute in varying degrees to the over all cerebrovascular risk including hyperglycemia, vascular risk factors such as hypertension dyslipidemia /and also genetic demographic, and life style factors and several studies have shown that people with diabetes have approximately twice the risk of ischemic stroke compared with those without diabetes. In that background, the contention of ld. Adv. Sawant that diabetes has no relation to ischemic disorders, cannot be sustained.

    28. Ms. Sawant, ld. Adv. for the Complainant has relied on the decisions in the cases of Mr. Ashok M. Ahuja Vs. United India Insurance Co. Ltd. & Ors , 2015(3) ALL MR (JOURNAL) 50 and Mr. Girish M. Raval Vs. The Oriental Insurance Co. Ltd. & Ors., 2015(3) ALL MR (JOURNAL) 53 and has contented that the Complainant or his wife, being a layman would not know that Ms. Reshma was suffering from diabetes and therefore, submission that the Complainant has deliberately suppressed her ailment does not hold water.

    29. In both the said decisions, in the case of Ashok M. Ahuja (supra) and Girish M. Raval(supra), the Honble State Commission found that the Complainant was not aware of the ailments and therefore, on the ground of suppression of the fact the claim was not rejected.

    30. The ratio laid down in the said decisions will not be applicable to the case at our hand. In the case at our hand, the wife of the Complainant had been taking treatment for disorders relating to her blood. As discussed hereinabove, the hospital where she was taking treatment has certified that she was suffering from diabetes mellitus since 2008 i.e. since 2 years prior to filling the proposal form. This therefore, cannot be a case where the proposer

    i.e. the Complainant and his wife were not aware of her diabetes. ...10/-

    31. Ms. Sawant, ld. advocate for the Complainant has also relied on an order of this Forum in Complaint No. CC/21/2011 of Mr. Gopal Tandon Vs. Universal Sompo Gneral Insruance Co. ltd., the said decision does not have any binding force on this Forum. We, therefore, need not go into facts of said case.

    32. The Complainant has produced the insurance policy issued by the Opposite Party No.1 based on which the claim is filed. The policy speaks of policy schedule which sets out the terms of contract with the Insurance Company. The Complainant has not produced this policy schedule. Shri Piyush Shankar, Power of Attorney of Opposite Party No.1 has produced the terms and conditions of Indian Overseas Bank Health Care Plus policy, which admittedly was issued in favour of the Complainant.

    33. Item no.2 under General Conditions of said terms and conditions reads as under: Mis-description: This policy shall be void and premium paid shall be forfeited by Us in the event of mis-representation, mis-description or non-disclosure of any material facts by you. Non-disclosure shall include non-intimation of any circumstances which may affect the insurance cover granted.

    34. It clearly stipulates that the policy shall be void in case of non- disclosure of any material fact by the proposer. It also clarifies non- intimation of any circumstances that may affect the insurance cover granted which includes non-disclosure. In the case at hand, the non-intimation of sufferance from diabetes would be covered by said clause. As submitted by Mr. A. Eremita, ld. adv. for Opposite Party No.1, the Opposite Party No.1 shall be entitled to repudiate the claim since the Complainant had not disclosed a material disease of diabetes in the proposal form.

    35. We are supported in our findings by the decision of the Honble Supreme Court in the case of P.J. Chacko and Anr. Vs. Chairman, Life Insurance Corporation of India & Ors, AIR 2008(SC) 424. In the said ...11/- decision the insured had undergone an operation for Adenoma. In the application form for obtaining policy he had answered in the negative to the question whether he had been operated. The Honble Supreme Court had held that the Claimant was estopped from pleading that even if such a fact was disclosed, it would not have made any material change.

    36. The terms and conditions also at page 7 clearly speak of what the policy excludes. Item No. 1 of said exclusion clause reads as under:

    1. Any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed and/or received medical advice/treatment, within 48 months prior to your first policy with us. This exclusion shall be waived if you have been continuously insured under this insurance cover (IOB Health Care Plus) or a similar medical insurance cover (offered by any other insurer under their earlier tie up arrangement with Indian Overseas Bank) for a continuous period of minimum 36 months and there had been no claim in during the 36 months period.

    37. It clearly stipulates that if the proposer had taken treatment for any disease or ailment or he had any signs or symptoms of an ailment within 48 months prior to the first policy issued by the Opposite Party No.1, the treatment taken for said ailment shall be excluded.

    38. The Complainant has made a claim for expenses incurred for angioplasty surgery. This surgery was conducted on 19.02.2013. As discussed hereinabove, the proposal form was submitted to Indian Overseas Bank on 17.03.2010. Obviously, policy was issued only after 17.03.2010. The Opposite Party No.1 had therefore, issued first policy after 17.03.2010. Smt. Reshma has made claim for the expenses incurred for angioplasty surgery performed on 19.02.2013 i.e. within 36 months or 3 years of issuance of first policy by Opposite Party No.1. As per the certificate issued by Vrundavan Shalby Hospitals, Smt. Reshma, had showed symptoms of chest pain and dyspnea since January 2013 and prior to that she did not have any history of ischemic heart disease. As per said certificate, therefore, for the ...12/- first time Smt. Reshma had symptoms of ischemic heart disease only on 06.01.2013. The Complainant made claim for the expenses incurred for angioplasty surgery based on said certificate and subsequent treatment taken therefore.

    39. As discussed hereinabove, in the proposal form the Complainant has admitted that he as well as Smt. Reshma suffered from heart disease including ischemic heart disease. The certificate issued by Vrundavan Shalby Hospitals that Smt. Reshma did not have history of ischemic heart disease prior to 13.01.2013 is falsified by the admission made by the Complainant in the proposal form submitted on 17.03.2010. The Complainant has clearly admitted in the proposal form that Smt. Reshma was suffering from not only high blood pressure and other circulatory disorders but also ischemic heart disease. As on the date of issuance of the policy, Smt. Reshma was, therefore, suffering from ischemic heart disease that is as on 17.03.2010. She was then treated by surgery for said disease on 19.02.2013

    i.e. within 3 years from the date of issuance of first policy by Opposite Party No.2. In view of exclusion clause no.1, the Complainant is not entitled to recover the expenses under the policy issued by the Opposite Party No.1. There is a proviso to said exclusion clause which stipulates that in case the insured does not make any claim for the ailment existing as on the date of issuance of first policy for a period of 36 months, then the insurer can waive the said condition. In the case at hand, the Complainant has made the claim within 36 months. The said waiver clause will also not help the Complainant.

    40. Ld. Adv. Ms. Sawant has also relied on the decision in the case of National Insurance Co. Ltd. Vs. Girin R. Shah in Revision Petition No. 4019/2011. In the said case the patient had abscess in the anus. There was no evidence to show that the abscess had occurred due to diabetes. In that background, the Honble National Commission has held that it was not a pre- existing disease. The Insurance Company had also sought to repudiate the claim in said case based on exclusion clause. The Honble National ...13/- Commission found that although the Insurance Company had mentioned D.M., H.T.,I.H.D disease in the exclusion clause of policy conditions, but had not mentioned about the related disease and, therefore, the exclusion clause was not attracted.

    41. In the case at our hand, the Insurance Company has also referred to related diseases. Secondly, as discussed hereinabove, the Complainant had already admitted in the proposal form that Smt. Reshma was suffering from ischemic heart disease, for the treatment of which claim has been made. It was, therefore, an existing disease. Consequently, it will be covered by the exclusion clause. The decision in the case of Girin R. Shah (supra) will not be applicable to the facts of this case.

    42. The Ld. Adv. Ms. Sawant has also relied on the desision, in Appeal No. A- 362/2001 Life Insurance Corporation Vs. Neelam. In the said case, the Insurance Company had got the insured medically examined by its own penal of doctors. The doctors had opined the insured enjoyed good health at the time of taking insurance policy. In that background, the Honble National Commission has held that the right of Insurance Company to excuse of concealment of pre-existing disease is waived off and it cannot be used to repudiate the claim. The ratio in said decision also will not help the Complainant.

    43. Looking at it, in any way, therefore, the Complainant cannot claim insurance on the strength of insurance policy issued by the Opposite Party No.1. Issue is accordingly decided in the negative. ISSUE-II:

    44. In the course of arguments, ld. Adv. Eremita did not dispute that the bills were issued by Apollo Victor Hospital. The bills are in the amount of Rs. 1,97,574/-. Had the Complainant proved that the Opposite Party No.1 was liable to settle the claim based on said policy, the Complainant would have been entitled to said amount with interest at the rate of 7% per annum. ...14/-

    45. For the reasons discussed under Issue-I above, the Complainant has failed to prove that he is entitled to reimbursement of medical expenses based on the policy issued to him by the Opposite Party. The Complainant, therefore, will not be entitled to recover the said amount from the Opposite Party No.1. Issue is, accordingly, decided in the negative.

    46. In the back drop of discussion hereinabove, we pass the following order: O R D E R The complaint is dismissed with cost of Rs. 500/- (Rupees five hundred only). ( Mr. Pradip V. Sawaiker) President (Ms. Cynthia A. Colaco) Member (Ms. Anjali A. Salkar) Member 11/9

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    Comments

    Rajaram N.Sawant v. M/s Universal Sompo General Insurance Co. Ltd & 2 OTHERS
    (Sep 6, 2017)