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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Rekha Gupta, Presiding Member
Shashikant Awadooth Rotkar —Petitioner
versus
National Insurance Company
Limited and Ors. —Respondents
Revision Petition No.1184 of 2017
(Against the Order dated 21/03/2017 in Appeal No. 1218/2014 of the State Commission Maharastra)
Decided on 17.7.2017
Counsel for the Parties:
For the Petitioner:Mr. Anant Salway, Advocate
IMPORTANT POINT
It is responsibility of insured to give detailed information of all his ailments and operations conducted upon him.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance Regulatory and Development Authority (Protection of Policyholders’ Interests) Regulations, 2002—Regulation 2(1)(d)—Insurance—Mediclaim Policy—Angiography and Angioplasty—Claim not settled on ground of not submitting all documents—Complaint dismissed by State Commission in appeal—Petitioner had primarily suffered from Cervical Lamina Catania and taken treatment for the same—Any fact which goes to root of Contract of Insurance and has a bearing on risk involved would be material—Petitioner was well aware that he had suffered from Cervical Lamina Catania in year 2009 and taken treatment for the same but suppressed this information from respondents—State Commission correctly concluded that at the time of filling up proposal form it was his responsibility to give detailed information of all his ailments and operations conducted upon him—As petitioner suppressed information he was guilty of breach of condition and his claim was rightly repudiated—Revision petition dismissed. (Paras 10 to 15)
Result: Revision Petition dismissed.
Rekha Gupta, Presiding Member—The present revision petition has been filed against the judgment dated 21.03.2017 of the Maharashtra State Consumer Disputes Redressal Commission, Circuit Bench at Nagpur (‘the State Commission’) in First Appeal no. 218 of 2014.
2. The facts of the case as per the petitioner/ complainant are that the petitioner took a Medi-claim Insurance Policy (short MIP) from the respondent/ OP nos. 1 and 2 through respondent no. 3 – Mr Anurag Rathi. The petitioner filed the proposal form which was filled by respondent no. 3. During the operation of the MIP, in January 2011, the petitioner suffered chest pain. He was admitted to the hospital and was referred to Avanti Hospital at Nagpur. The petitioner remained admitted at Avanti Hospital Nagpur from 12.01.2011 to 17.01.2011 and underwent Angiography and Angioplasty on 13.01.2011 for which the petitioner paid an amount of Rs.1,77,430/-.
3. The petitioner and his brother submitted the claim of expenditure for compensation in the MIP with respondent no. 1 on 14.01.2011 and 01.12.2011. However, the respondent nos. 1 and 2 in spite of submitting the entire documents repudiated the medi-claim of the petitioner on 10.02.2012, on the ground of not submitting all the documents. The petitioner, therefore, gave notice on 09.03.2012 to OP nos. 1 and 2.
4. The petitioner thereafter filed a complaint with the information as above and then further submitted that the treatment taken by the petitioner in the year 2009 had no nexus with the heart attack suffered by him in the claim. The same was also informed to him by the doctor of Avanti Hospital Dr Mahurkar who treated the petitioner at Nagpur. The petitioner complained that the respondent without conducting a detailed enquiry repudiated the claim. Thereby caused deficiency in service and hence, the petitioner filed a complaint with a prayer to provide him the medi-claim of Rs.1,00,000/- with interest at the rate of 12% per annum and to provide him Rs.50,000/- as compensation for physical and mental harassment and cost of Rs.1000/- for litigation.
5. On notice, the respondent nos. 1 and 2 appeared and countered the complaint denying the allegations made. The respondent nos. 1 and 2 submitted that the petitioner did not disclose his ailment in the proposal form and the operation conducted upon him prior to taking the policy. He had suffered a Cervical Lamina Catania and was operated r in December 2009. He suppressed the information while filling up the proposal form. He also did not submit the original documents and bills of treatment taken by him regarding Heart ailment. Therefore, the claim filed in the MIP by the petitioner was repudiated. The OP nos. 1 and 2 claimed that there was no deficiency in service and submitted that the claim was repudiated as per the conditions of the policy. Hence, requested to dismiss the complaint.
6. The respondent no. 3 filed his written version and denied the contentions of the petitioner and stated that he was only an agent. The sanction of the claim or repudiation was to be done by respondent nos. 1 and 2. The proposal form was filled by the petitioner and it was his responsibility to give detailed information of his previous ailments and the operations conducted upon him. He did not inform about the operation which was conducted upon him in December 2009. Hence, he suppressed the information and therefore, the claim in MIP was repudiated. Thus, respondent no. 3 requested to dismiss the complaint.
7. The District Consumer Disputes Redressal Forum, Wardha (‘the District Forum’) vide its order dated 18.02.2013, while allowing the complaint gave the following order:
“1. The applicant nos. 1 and 2 are severally and jointly liable to pay the insurance amount of Rs.1.00 lakh and the interest @ 10 PCPA, since date of declined the claim, i.e., since 10.01.2012;
2. The non-applicant nos. 1 and 2 should pay Rs.5,000/- towards mental and physical agonies to the applicant and Rs.1,500/- to
