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WEST BENGAL STATE CONSUMER DISPUTES
REDRESSAL COMMISSION, CALCUTTA
Hon’ble Mrs. Justice Jyotirmoyee Nag, President;
Prof. Sunil Kanti Kar, Member; Mrs. S. Dutta, Member
BIMAN KRISHNA BOSE—Appellant
versus
UNITED INDIA INSURANCE CO. LTD.—Respondent
S.C. Case No. 994/A of 1993—Decided on 5.4.1993
Counsel for the Parties :
For the Appellant : In person.
For the Respondent:Mr. Kamal Krishna Das, Advocate.
The non-disclosure of a temporary or causal illness like hypertension in the proposal form for a mediclaim policy is not a suppression of material fact.
Headnote:
INSURANCE - MEDICLAIM POLICY - SUPPRESSION OF MATERIAL FACT - NON-DISCLOSURE OF HYPERTENSION - INTERPRETATION OF CLAUSE 7 OF THE POLICY - CLAIM SETTLEMENT - DEFICIENCY IN SERVICE - UNFAIR TRADE PRACTICE - CONSUMER PROTECTION ACT, 1986 - SECTION 2(1)(g) AND SECTION 2(1)(r).
Fact of the Case:
The appellant had a mediclaim policy with the respondent for the treatment of various ailments. The appellant's wife was treated at Kothari Medical Center for hypertension and the appellant claimed the expenses incurred for the treatment from the respondent. The respondent denied the claim on the ground that the appellant had suppressed the material fact of hypertension in the proposal form.
Finding of the Court:
The court held that the non-disclosure of hypertension was not a suppression of material fact as it was not a permanent illness and the appellant was not required to disclose it in the proposal form. The court also held that the respondent was guilty of deficiency in service by not settling the claim within time despite repeated demands.
Issues: 1. Whether the appellant had suppressed the material fact of hypertension in the proposal form. 2. Whether the respondent was guilty of deficiency in service.
Ratio Decidendi: 1. The court held that the non-disclosure of hypertension was not a suppression of material fact as it was not a permanent illness and the appellant was not required to disclose it in the proposal form. 2. The court held that the respondent was guilty of deficiency in service by not settling the claim within time despite repeated demands.
Final Decision: The court allowed the appeal, set aside the judgment of the Consumer Disputes Forum, and directed the respondent to pay the claim amount of Rs. 8,243/- along with Rs. 500/- towards harassment, mental agony, and cost of the proceedings within 30 days.
Mrs. Justice Jyotirmoyee Nag, President—The complainant/appellant’s case is that he along with his wife opened a Mediclaim policy with the opposite party/respondent on 14.12.90 for benefit of their treatment of various ailments. The wife of the appellant had been treated in Kothari Medical Center. He incurred a expenses of Rs. 8,243/- for the said treatment of the appellant’s wife and he claimed the said sum of Rs. 8,243/- from the opposite party as per the Insurance Policy bearing No. 0532 dt. 14.12.1990. The Petitioner/appellant made a series of correspondences in this regard with the opposite parties in letter bearing No. 310/60C 17/00056/91 dated 2.3.1992 being annexed I to the petition of complaint the opposite party assured to consider the claim of the petitioner in a lenient way as a gesture of good wishes and to dispose of the matter but ultimately did nothing in the matter, hence the complaint was lodged before C.D.F. and the Complaint being dismissed this appeal has been preferred by the petitioner/appellant.
2. The crux of contention by the opposite party is that the petitioner/appellant suppressed the material fact in as he did not disclose the illness of hypertention in the proposal form at the time of opening the insurance policy. The opposite party also contended that subsequent E.N.T. treatment of appellant’s wife at residence does not entitle the appellant to receive the claim amount as claimed by the appellant and in support thereof the opposite party cited the provision of Clause 7 of the policy in his written objection filed in this regard.
JUDGMENT
3. It is admitted position that there was a mediclaim Insurance for treatment of the appellant and his wife for all sorts of ailments covered by that policy. The contention of the opposite party is that there is suppression of material facts in the proposal form as to ailment of hypertension suffered by the wife of the appellant while answering the questions No. 10 and 11 of the proposal form. Whereas the appellant has denied of any such clauses in the proposal form; but the fact remains that opposite party has not produced the proposal form or copy thereof before this commission for its examination and opinion.
4. Be that as it may we are of opinion that even there be any such clauses in the proposal form, the non-disclosure of hypertension is not suppression of material fact. Temporary or causal suffering from hypertension not being a permanent illness need not be required to be disclosed, no it was a fatal for a acceptance of the Insurance Policy when the acceptance of Policy has duly been accepted by the opposite party. Even if conceding but not admitting that at the time of making the claim the party concerned was suffering from hypertension, but that will not serve the purpose of the O.P., because the time of disclosure should be at the moment when the Insured person’s details were mentioned in the prescribed form in this regard. It might be, specifically when this has not been challenged, that such ailment started in a more later stage when he/she submitted that prescribed form before the O.P.
5. Moreover, the allegation as made by the O.P. — Insurance Company must be proved by it, but neither a scrap of paper nor any cogent evidence has been adduced by the Company to establish the allegation.
From scrutiny of the paper and the treatment chart shown to us it appears that treatment of the appellant’s wife mainly concentrated for pathological aspects and ENT treatment associated with hypertention. As such the appellant is entitled to the claim as per Clause 7 of the proposal form as reproduced in the written objection by the opposite party. After pathological examinations if treatment is continued at home as was done in the instant case how it stands in the way to receive the claim by the appellant as per provisions of Clause 7 of the proposal form for Insurance Policy. The appellant is entitled to all charges incurred by him at Nursing Home for diagnostic X
