IMPORTANT POINT
Non-disclosure of past medical history makes the NMG mediclaim policy void.

JUDGMENT :

DHANANJAYA Y. CHANDRACHUD, J.

1. Leave granted.

2. The District Consumer Disputes Redressal Forum, Ambala [“District Forum”] allowed a consumer complaint instituted by the respondent on the basis of a mediclaim policy. The District Forum directed the appellant to pay a sum of Rs 2,21,990, together with interest at the rate of 9% per annum from 29 October 2009, which is the date on which the claim was repudiated. Compensation of Rs 10,000 was awarded towards mental harassment and Rs 10,000 towards litigation expenses. Failing payment within the stipulated period, the amount awarded was directed to carry interest at 12% per annum. This order of the District Forum was affirmed in appeal by the State Consumer Disputes Redressal Commission [“SCDRC”]. The National Consumer Disputes Redressal Commission [“NCDRC”] dismissed a revision filed by the appellant. This has given rise to the present appeal.

3. The respondent obtained a Mediclaim policy from the appellant. On 7 June 2008, he had submitted a proposal form for a Health Plus policy. The policy was issued on 25 June 2008 under the category of ‘Non-Medical General[“NMG”]' for a sum of Rs 1,60,000. The proposal form required a disclosure of health details and medical information. Among them was whether the proposer had suffered from “cardiovascular disease e.g.: Palpitations, heart attack, stroke, chest pain”. The proposal form contained a response in the negative to the above query.

4. The Third Party Administrator received a hospital claim form on 7 August 2009, submitted by the respondent, which was certified by a doctor at Fortis Hospital, Mohali on 4 August 2009, during which period he had undergone a Mitral Valve Replacement [“MVR”] surgery. The claim was repudiated by the appellant on 29 October 2009 on the ground that the respondent was suffering from a preexisting illness.

5. The expression “pre-existing condition” is defined in the exclusions under the policy in the following terms:

“ii. “Pre-existing condition” - any medical condition or any related condition (e.g. illnesses, symptoms, treatments, surgery, pains) that have arisen at some point prior to the commencement of this coverage, irrespective of whether any medical treatment or advice was sought. Any such condition or related condition about which the Principal Insured or insured dependent know, knew or could reasonably have been assumed to have known, will be deemed to be pre-existing. The following conditions will also be deemed to be “pre-existing”:

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ii. Any Sickness, illness, complication or ailment arising out of or connected to the preexisting illness.”

6. The District Forum held in favour of the respondent. The NCDRC, while affirming the SCDRC, held that though the treating doctor had recorded, under the column of 'past history', that this was a known case of rheumatic heart disease since childhood, the doctor had not been examined in order to prove how the information had been recorded in his report. According to the NCDRC, the notes of the doctor did not indicate that it had been recorded on the basis of the information furnished by the patient. In this view of the matter, the decision of the District Forum, as affirmed by the SCDRC, has not been interfered with.

7. Learned counsel appearing on behalf of the appellant submitted that the Health-plus policy falls in the NMG category where the insured is not subjected to a medical examination before the issuance of the policy. Hence, it is a solemn obligation of the proposer to truthfully fill out the details required by the insurer in the proposal form on the basis of which the insurer takes a decision in regard to the issuance of the policy. Hence, it was urged that the onus was on the insured to provide material particulars of his health since no medical examination was mandated. In the present case, it has been submitted that, ex facie, there was a breach on the part of the insured in suppressing information pertaining to the fact that he had been suf