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DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Barkat Ali Zaidi, President & Mr. V.K. Gupta, Member (Judicial)
Narayan Chimandas Bhambhani —Complainant
versus
Oriental Insurance Co. Ltd.
& Ors. —Opposite Parties
Complaint Case No. 2009/85
Decided on 02.07.2012
For the Complainant:Mr. A.K. Walia and Mr. R.N. Keswani, Advocates.
For the Opposite Parries:Mr. Kapil Chawla, Advocate.
IMPORTANT POINT
Once Insurance Company has accepted proposal it cannot go behind the same even if proposal is in violation of criteria mentioned in insurance policy.
Headnote:Consumer Protection Act, 1986—Section 17—Insurance—Overseas Travel Insurance Policy—Treatment for Transient Ischemic Attack—OPs declined to pay amount on the ground that complainant had medical history of coronary heart disease, hypertension and diabetes, which was not disclosed by complainant at the time of taking policy—OP made insurance of complainant despite full information given by complainant—Complainant gave information to Insurance Company which is mentioned in medical request and Self Declaration Form, forming part of Insurance Agreement—Since despite all this information Insurance Company accepted proposal for insurance of complainant, OP Insurance Company cannot now be allowed to resile and cannot avoid agreement of insurance, because it is estopped from challenging validity of insurance—Claim decreed for Rs.16,79,277—Complaint allowed. (Paras 5 to 7)
Barkat Ali Zaidi, President—The facts of the case are that since the complainant along with his wife was going to USA, he on 7.6.2008 obtained an Overseas Travel Insurance policy from OP No.1 and paid a premium of
Rs. 35,358. It is the case of the complainant that while taking the policy the complainant had filled up the “Self Declaration Form” disclosing his existing ailments at the time of taking the policy. The complainant was also medically examined by the doctors of the OP who certified the medical condition of the complainant. The complainant and his wife travelled to USA by flight on 9.6.2008, where the complainant suffered “Transient Ischemic Attack” and was hospitalized in Bayshore Community Hospital, New Jersey, where he remained till 5.8.2008. The hospital raised bill for a sum of $32,927.35 US, which was forwarded by the hospital to the OPs. The OPs declined to pay the amount on the ground that the complainant had a medical history of coronary heart disease, hypertension and diabetes, which was not disclosed by the complainant at the time of taking the policy. The complainant has therefore come to this Commission with the prayer that the OPs be directed to pay Rs. 22,86,877 on following account:
(i) Bill of Bayshore Community Hospital : Rs. 16,79,277
(ii) Other expenses for post hospitalization treatment, convalescence and prophylaxis : Rs. 16,79,277
(iii) Expenses incurred on safe transit Air travel : Rs. 1,20,000
(iv) Mental harassment and agony : Rs. 1,00,000
2. OP No. 1 Oriental Insurance Co. Ltd., filed the written statement saying that in terms of condition No. 10(b) and 10( c) the complainant is not entitled to the claim on the ground that the complainant had a medical history of coronary heart disease, hypertension and diabetes, which was not disclosed by the complainant at the time of taking the policy.
3. We have heard Mr. A.K. Walia and Mr. R.N. Keswani, Counsel for the complainant and Mr. Kapil Chawla, Counsel for the OPs.
4. The Insurance Company seeks to avoid payment on the ground mentioned in Section 10(b)(c) of the conditions of the policy which are as hereunder:
10(b): Pre-Existing Exclusion—This policy is not designed to provide an indemnity in respect of medical services, the need for which arises out of a pre-existing condition as defined below in General Condition 10(c).
10(c): Pre-Existing Condition—Any sickness for which the insured person has sought medical advice or has taken medical treatment in the preceding 12 months prior to the commencement of travel.
5. These statements in the policy will be of no avail to the OP Insurance Company because the OP made the insurance of the complainant despite full information given by the complainant. The complainant gave the following information to the Insurance Company which is mentioned in the medical request and Self Declaration Form, forming part of the Insurance Agreement.
Name of Date of First Name of
illnessl which treatment attending
diseasel first comple- medical
injury & treatment ted/is con- practitioner/
treatment taken tinuing surgeon with
received his address
& Tel. Nos.
Ischemic 1987, By- Continuing Dr. S.C.
Heart Pass Manchanda,
Disease, surgery P-721, New
Hyperten- 2003 Rajender
sion Nagar,
N. Delhi,
9873695460
6. Since despite all this information the Insurance Company accepted the proposal for insurance of the complainant, the OP Insurance Company cannot now be allowed to resile and cannot avoid the agreement of insurance, because it is estopped from challenging the validity of insurance. Once the Insurance Company has accepted the proposal it cannot go behind the same even if the proposal is in violation at the criteria mentioned in the insurance policy, because if according to the condition/principle mentioned in the insurance policy the complainant was not entitled to obtain the insurance, the Insurance Company should have refused the insurance. Once they accepted the insurance d
