Arati Dutta Baruah v. United India Insurance Co. Ltd.
2000-03-25
D.DUTTA, J.N.SARMA
body2000
DigiLaw.ai
J.N. Sarma, Member— This appeal has been preferred by appellant Smti Arati Dutta Baruah against the judgment dated 30.12.96 of District Consumer Disputes Redressal Forum, Kamrup (for short District Forum) in CP Case No. 42/95. 2. The facts of the case are stated briefly as follows: The complainant (appellant herein) took a Medi-claim Policy jointly with her husband from Guwahati Branch of United India Insurance Co (respondent herein) for the period from 3.3.94 to 2.3.95. On an occasional visit to Madras when the complainant gotherself checked up at Apollo Hospital where it was detected that some kind of dismal pain in her gall bladder. On doctor's advice there she underwent surgical operation for immediate removal of gall bladder stones. Coming back to Guwahati the complainant lodged her claim with OP No. 2 for reimbursement of the cost of her medical treatment amounting to Rs. 19,063 only under the coverage of the aforesaid Medi-claim Policy. As claimed by her all the necessary documents like vouchers, X-ray plates etc were furnished as per requirement. The complainant issued a reminder dated 2.3.95 to the OPs. On the other hand, the opposite parties vide "their letter dated 13.3.95 asked for certain documents which she claims to have already been furnished. A copy of their earlier letter dated 21.11.94 asking for particular documents was also enclosed by the opposite parties with their letter to the complainant. The complainant denies receipt of the letter dated 21.11.94. As alleged by the complainant the opposite parties did not settle her claim in spite of several letters to them. Being aggrieved, the complainant filed the complaint in the District Forum for recovery of her claimed amount of Rs. 19,063 along with interest and compensation of Rs.5,000 only. 3. In their written version opposite party No.2.stated that the claim could not be settled as in spite of their letters dated 21.11.94 and 13.3.95 the complainant did not furnish the X-ray plate and the report of the USG to enable the panel of doctors of the insurance company to opine whether the gall bladder disease was pre-existing or not.
3. In their written version opposite party No.2.stated that the claim could not be settled as in spite of their letters dated 21.11.94 and 13.3.95 the complainant did not furnish the X-ray plate and the report of the USG to enable the panel of doctors of the insurance company to opine whether the gall bladder disease was pre-existing or not. The contention of the opposite parties is that the complainant wrote 'No' against the columns 13 and 14 of the proposal from whereas it appears from the discharge summary of the hospital produced by the complainant that she had history of gall bladder stone as also right heel pain for the past three months, that is prior to the commencement of the policy in question. The OP insurance company repudiated the claim as the proposal was bad for suppression or material facts and the policy was void ab initio. 4. The complainant filed affidavit in support other complaint. The opposite parties filed the copies of the complainant's policy, proposal form, the discharge summary issued by Apollo Hospital and other connected documents. Neither party examined any witness. 5. Upon hearing both the parties and on perusal of the evidence on record the learned District Forum held that there was no deficiency of service on the part of the OP insurance company for repudiating the claim and in view thereof dismissed the complainant The present appeal is against the impugned order dated 30.12.96 dismissing the complainant. 6. We have heard learned counsel Mrs M. Dutta Choudhury for the appellant. Although the learned counsel Shri S. Dutta for the respondent insurance company appeared before us later, he did not file any written argument. We have taken into consideration the decision of this Commission reported in 1998 (2) GLT (CP) 22 Oriental Insurance Co. Ltd vs. Sabia Rahman cited by the learned counsel for the appellant. 7. The decision in this case hinges on one point as to whether the disease was pre-existing. On perusal of the judgment of the District Forum and the evidence on record we find that this point has been dealt with rightly. There is no denying the fact that OP No. 2 (respondent herein) asked the complainant to submit the medical documents like preliminary investigation report. Reports and film of X-ray and USG done for detection of the disease of gall bladder stone.
There is no denying the fact that OP No. 2 (respondent herein) asked the complainant to submit the medical documents like preliminary investigation report. Reports and film of X-ray and USG done for detection of the disease of gall bladder stone. These documents were necessary to obtain opinion of the panel doctors about the nature of ailment, particularly as to whether the disease was pre-existing or not. The clause No.3.5 of the medi-claim policy reads as follows : “The insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim based and shall also give the company such additional information and assistance as the company may require in dealing with the claim.” We are not inclined to believe that the complainant did not receive the earlier letter dated 2.11.94. Even after receipt of the subsequent letter along with a complainants' contention that in spite of her producing the required documents she was unnecessarily harassed by the opposite parties by asking to produce the documents again, does not have force in it in view of the fact that she has not adduced evidence to show that she actually furnished the aforesaid documents in support of her claim. This conduct of the complainant establishes that the lapse was rather on her part and there was no deficiency of service on the part of the insurance company. The learned District Forum, therefore, rightly held that the insurance company can not be blamed for not settling the claim. There is violation of the clause 3.5 of the policy by the policy holder complainant. 8. It appears form the proposal from (Annexure II) that to the queries made in column Nos 13 and 14 she wrote the word 'No' that is she did not have the disease at that time. But the discharge summary (Annexure III) issued by the Apollo Hospital revealed that complainant herself told the doctor that she suffered from "Gaseous discomfort of abdomen on and off and she had right heel pain for the past 3 months duration ........” The policy was taken on 3.3.94 and she was admitted for treatment in the hospital on 22.5.94. that is after 2 months and 19 days. Apparently the complainant suffered from Gaseous disorder and right heel pain from before taking the policy. In other words, the disease was pre-existing.
that is after 2 months and 19 days. Apparently the complainant suffered from Gaseous disorder and right heel pain from before taking the policy. In other words, the disease was pre-existing. By writing the word 'No' in the proposal form against the queries on this point the complainant intentionally suppressed the material facts. In this connection the learned District Forum referred to the decision of National Commission in Revision Petition No. 233 of 1993 (United Insurance Co Ltd vs. Biman Krishna Bora) wherein it was held that non-disclosure or material facts at the time of taking Mediclaim Policy is fatal to the complainant's claim. We therefore, come to the conclusion that the District Forum rightly held that the £ disease was pre-existing and there was nondisclosure of material facts by the complainant. In view thereof, the insurance company rightly repudiated the claim and hence they are not liable for deficiency or service. The earlier decision of this Commission referred to by the learned counsel for the appellant does not help in anyway. 9. We do not find any merit in this appeal. The appeal is dismissed and judgment dated 30.12.96 of District Forum in CP Case No.42 of 1995 is upheld. There is no order as to costs.