IMPORTANT POINT
Purpose of medical insurance is to reimburse insured for treatment of any disease or ailment during period of insurance policy.

Ajit Bharihoke, Presiding Member—This revision is directed against the order of the Punjab State Consumer Disputes Redressal Commission in First Appeal No.1194 of 2008 whereby the State Commission concurred with the decision of the District Forum Ludhiana and dismissed the appeal resulting in dismissal of the complaint of the petitioner complainant.

2. Briefly stated facts relevant for the disposal of the revision petition are that the petitioner obtained a mediclaim policy from respondent no.1 insurance company effective for the period 19.09.2006 to 18.09.2007. During the subsistence of the insurance policy, the petitioner underwent surgery for knee implant replacement at Beach Candy Hospital Trust Mumbai. The cost of surgery implant was Rs.6,26,062/-. The petitioner filed an insurance claim but her claim was repudiated on the ground that petitioner obtained the insurance policy by concealment of material facts that she got one lateral total knee replacement (TKR) in the year 1990. As such, the insurance contract having been obtained on the basis of concealment was invalid.

3. The District Forum Ludhiana on consideration of the pleadings and evidence dismissed the consumer complaint vide order dated 04.09.2008.

4. Aggrieved by the order of the District Forum, the petitioner approached the State Commission in appeal and the State Commission dismissed the appeal on two counts, namely, that the insurance contract was invalid because the petitioner had obtained the insurance policy by concealing the material facts relating to her previous knee transplant and secondly on the ground that she was not entitled to any claim in view of exclusion clause 4.1 of the insurance policy.

5. Mr. J.S Bhola has assailed the impugned order on the ground that both the foras below have ignored the material factual aspects of the case. In support of this contention, learned counsel for the petitioner has drawn our attention to a letter addressed by doctor of Rapid Diagnostic Lab to the Senior Manager, United India Insurance Company informing that he has examined patient Reena Kansal 53 yrs. / F on 16.09.2003 regarding past history : knee replacement 13 years back both legs, now in left leg again. In the aforesaid letter, it is clear that the information regarding the past knee replacement surgery undergone by the petitioner was within the knowledge of the respondent insurance company at the time of issue of first insurance policy from 19.09.2003 to 18.09.2004. Therefore, it cannot be said that the respondent / insurance company was misled due to some incorrect information in the proposal form while issuing the mediclaim insurance policy.

6. It is further contended that the foras below have committed an error in declining the insurance claim to the complainant in view of clause 4.1 of the latest insurance policy valid from 19.09.2006 to 18.09.2007. It is contended that the foras below have failed to appreciate that from 2003 onwards, the petitioner was continuously renewing the mediclaim policy from year to year. Therefore, she would be governed by the terms and conditions of the first policy under which exclusion clause 4.1 was not there.

7. Sofaras the repudiation of the claim on the ground of concealment of material fact is concerned, it is undisputed that first mediclaim policy was obtained by the petitioner in September 2003 and, thereafter she continued to get the insurance policy renewed on year to year basis. On perusal of the copy of the proposal form submitted at the time of obtaining the insurance policy, it transpires that respondent answered in the affirmative to Question 12 (a) which reads as under:

“Are you a good health and free from physical and mental disease or infirmity or medical complaints? Yes.”

Further, the petitioner responded in the negative to question 12 (e ) which is reproduced as under:

“Any disease of the bones or joints including rheumatic disease? No.”

8. Admittedly, the petitioner has undergone knee transplant surge