Non-disclosure of material health facts by the insured justified the repudiation of the insurance claim under the principle of utmost good faith.

ORDER

1. Aggrieved against the repudiation of claim for sum of 4,76,715.02 U.S. Dollars (Rs.3,24,37,263/- in Indian currency), by the opposite party/lnsurance Company, in respect of medical treatment undertaken by the complainant under mediclaim policy at US, complaint has been preferred under Section 21 (a)(i) of the Consumer Protection Act, 1986

2. In brief, complainant had been obtaining health insurance policies from Oriental Insurance Company Ltd. (opposite parties) since 2000, and an 'Overseas Mediclaim Business and Health Policy’ was obtained on 14.12.2016 for travelling to USA from 18.12.2016 to midnight of 14.01.2017, by paying a premium of Rs.2494/-. During the currency of the policy on 07.01.2017 complainant developed cardiac palpitations and was rushed to Alexian Brothers Medical Ctr. in USA, wherein he was admitted and provided with necessary treatment. Complainant was discharged from the hospital on 23.01.2017 and returned back to India on 15.02.2017.

3. A claim for medical bills for sum of 4,76,715.02 US Dollars (equivalent to Rs.3,24,37,263/- in Indian currency), as on the date of filing the claim form, was submitted to the Opposite Party. However, the claim was repudiated by the Insurance Company vide letter dated 14.03.2017 on the ground that the complainant had past medical history of ‘hypertension’ and placement of ‘VP shunt’, and the overseas policy obtained^ by the complainant does not cover pre-existing disease and related complications. Communications were further addressed by the complainant on 05.06.2017, 24.06.2017 and 20.09.2017 to the opposite party for re-consideration but no positive response was received. Aggrieved against the rejection of claim by the Insurance Company, the present complaint has been preferred.

4. In the written version filed on behalf of the opposite party, it was submitted that the complainant played a fraud by withholding the true and correct facts of his medical condition at the time of obtaining the mediclaim policy in the proposal form. Further, the past ailments suffered by the complainant stand corroborated by admission record at Sriven Hospital, Hyderabad, Telangana dated 18.01.2013 and subsequent discharge on 21.01.2013, for treatment of Chronic Sinusitis with Bilateral Concha, Bilateral Hypertrophied Inferior Turbinates, DNS with Posterior Spur, Sino nasal Polypose, Allergic Rhinitis. Complainant, thereafter, is also stated to have been admitted in Sriven Hospital in the year 2014. The relevant portion of the discharge summary pertaining to diagnosis, clinical details, history of past illness and treatment details is further relied upon and it is also stated that complainant submitted Hospitalization Benefit Claim Policy form, for date of admission so recorded and the record of the same was relied.

5. The treatment history as recorded during treatment at Alexian Brothers ABS, USA was further relied by Insurance Company/opposite party to emphasize that the complainant had a history of ailments as under:-

"Patient is 60 years old male with a past medical history of VP shunt placement approximately 15 years ago, hypertension and hypothyroidism."

It is further averred that the ailments suffered by the complainant had direct nexus with the health of the complainant and the same had been suppressed by making declaration to the contrary in the proposal form, filled at the time of obtaining the Overseas Mediclaim Policy. It is pointed out that the answers with reference to Clause 13 in relation to suffering from any illness, admission in hospital and illness or disease s