IMPORTANT POINT
Suppression of material fact must be conscious and intentional.

D. Appa Rao, President—This is an appeal preferred by the Insurance Company directing to pay the amount covered under the medi-claim policy together with interest at 7.5 per annum and costs.

2. The case of the complainant in brief is that he took a medi-claim policy covering the period from 1.7.2004 to 30.6.2005 which was renewed from 1.7.2005 to 30.6.2006. While so, when he fell sick, he was examined in the Hospital at Vijayawada, where he was referred to a hospital at Hyderabad. After conducting tests it was ultimately diagnosed as SOL right cerebellum glaucoma by Apollo hospital at Hyderabad. The Neurologist opined that it necessitates an immediate surgery and accordingly surgery was conducted on 21.8.2004 and was discharged on 28.8.2004. The said fact was informed to the Insurance Company seeking settlement of the claim. However, they did not respond, and on the contrary, they have renewed the policy. Later due to recoil of cerebella astocytoma, he was again admitted 22.7.2005 and surgery was conducted. When he made claim for the amounts, the Insurance Company repudiated the claim through letters dated 29.9.2005 and 11.11.2005. Assailing the said repudiation, the complainant filed the complaint claiming Rs.95,400 towards medical expenses for the first surgery and Rs.1,03,270 towards medical expenses for the second surgery, besides compensation of Rs. 5,00,000 towards mental agony and costs.

3. The Insurance Company resisted the case. While denying each and every allegation made in the complaint, it alleged that when the complainant was hospitalized and diagnosed, it was revealed that he was having SOL right cerebellum glaucoma by Apollo Hospital, Hyderabad. The complainant suppressed the disease which was pre-existing. In fact in the column of history there was a mention that “one month with a history of headache and vomiting and it was gradual in onset and progressive in nature and known case of Nephrotic syndrome—on regular wysolone.” The Insurance Company after getting medical opinion from a team of doctors repudiated the claim on the ground that the disease was pre-existing. The complainant was not entitled to claim more than Rs.1,00,000 towards medical expenses and the same be restricted as per the policy conditions.

4. The complainant in proof of his case filed his affidavit evidence and got the documents marked as Exs. A-1 to A-29, while the Insurance Company filed affidavit evidence of its officer and got the documents marked as Exs. B-1 to B-9.

5. The District Forum after considering the evidence placed on record opined that there was no proof that the complainant was suffering from any pre-existing disease at the time when the policy was taken and therefore, directed the Insurance Company to pay Rs.95,400 towards medical expenses for the first surgery and Rs.1,03,270 towards medical expenses for the second surgery together with interest at 7.5% per annum and costs of Rs.2,000.

6. Aggrieved by the said order, the Insurance Company preferred the appeal contending that the District Forum did not appreciate either the facts or law in its correct perspective. It ought to have seen that the deceased was having a problem of headache and vomiting for one month prior to the policy and the policy being obtained on 1.7.2004 the ailment was suppressed. He had taken the policy without mentioning the said ailment. The record discloses that he was not entitled to the amount, and therefore, prayed that the complaint be dismissed by allowing the appeal.

7. The point for consideration is whether the order of the District Forum is vitiated by misappreciation of fact or law in this regard?

8. It is an undisputed fact that the deceased complainant had taken a medi-claim policy for Rs.1,00,000 covering the period from 1.7.2004 to 30.6.2005, evidenced under Ex. A2 policy. It is not in dispute that the complainant underwent Carebellar Astocytoma on 21.8.2004 in Apollo Hospital, Hyderabad viz. removal of tumour. He incurred an expenditu