IMPORTANT POINT
Duty of utmost good faith in disclosing material facts lies with insured when he seeks insurance cover.

Anupam Dasgupta, Presiding Member—This revision petition challenges the order dated 10.11.2006 of the Andhra Pradesh State Consumer Disputes Redressal Commission, Hyderabad (in short, ‘the State Commission’). By this order, the State Commission allowed the appeal of the complainant and directed the opposite party (OP – Insurance Company) to pay to the complainant, within six weeks, Rs.1,20,051/- with interest @ 9% per annum from the date of the complaint till the date of realisation towards reimbursement of expenditure incurred by him on his treatment in the Care Hospital and Rs.1,000/- towards cost. The State Commission also directed that failure to comply would attract further interest @ 9% per annum on the awarded amount.

2. The respondent was the complainant before the District Consumer Disputes Redressal Forum I, Hyderabad (in short, ‘the District Forum’). In his complaint he alleged that the OP (petitioner before us) was guilty of deficiency in service in repudiating his claim for reimbursement of the expenditure of Rs.1,20,051/- on his medical treatment at the Care Hospital, Hyderabad during 06.11.2000 to 20.11.2000 for Coronary Artery Disease (CAD). The case set out by the complainant was that he had purchased the mediclaim policy for Rs.2 lakh each for himself and his wife for the period 28.09.2000 to 27.09.2001. Though he (45 years of age) was hale and hearty when he obtained the insurance, he suddenly developed chest pain on 06.11.2000 and was taken to the Care Hospital. After the requisite tests, including Coronary Angiogram, he was diagnosed with Coronary Artery Disease (CAD - 2-vessel disease). Accordingly, a Coronary Artery By-pass Graft (CABG) surgery was performed on him on 13.11.2000. After his discharge from the hospital on 20.11.2000, the complainant submitted a claim to the OP. However, the OP repudiated the claim without sufficient ground. Hence, alleging deficiency in service on the part of the OP, the complainant prayed for a total award of Rs.1,68,901/- on various counts.

3. The allegations in the complaint were strongly resisted by the OP. It was submitted that the complainant was suffering from CAD for long. As he was running a Chemist and Druggist Shop, he was fully aware of his medical condition. On 06.10.2000, the complainant went to the clinic of one Mr. Kedarnath, Cardiologist who advised him to get admitted to the Care Hospital with the observation, “Rest Angina Post Prandial with ECG changes”. However, the complainant did not get himself admitted soon thereafter because he was aware that it would affect his claim for reimbursement of expenditure on the treatment under the mediclaim insurance policy taken by him if the treatment started within 30 days of taking the policy. Therefore, he delayed his admission to the Care Hospital till 06.11.2000 by when the policy had run for a little over a month. As per clause 4.1 of the insurance policy, all pre-existing diseases/injuries at the time of inception of the insurance cover were excluded from the purview of the policy. Further, under clause 4.2 of the policy, any disease for which treatment was taken during the first 30 days of the commencement of the policy was also excluded. The claim was validly repudiated because the complainant/insured was suffering from CAD even before he applied for the mediclaim policy. In his proposal for the insurance, he suppressed this information while filling in the “Details of The Insured” in the prescribed form.

4. After considering the pleadings, evidence and documents brought on record by the parties, the District Forum dismissed the complaint by its order dated 13.07.2004, holding that the complainant did not disclose the history of his pre-existing disease at the time of submitting the proposal for the mediclaim insurance policy and also deliberately delayed his admission to the Care Hospital to 06.01.2001, though he had consulted Dr. Kedarnath, Cardiologist on 06.10.2000 and was advised to get admitted to th