M.C. MEHTA Vs. UNION OF INDIA

JUDGEMENT

(1.) Appellant is a general insurance company. It has filed this appeal against an order dated 29.8.2016, passed by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (in short 'the Forum' only), allowing a complaint bearing No.743 of 2015 filed by respondent No.1/complainant.

(2.) The complainant has filed above complaint against appellant/Opposite Party No.1 and Respondent No.2/Opposite Party No.2 alleging deficiency in providing service in repudiating his claim to reimburse the amount, spent by him upon his medical treatment. It was stated by him that he obtained a Group Health Insurance Policy from the appellant/Opposite Party No.1 in 2013, valid upto 1.12.2014. The total sum assured was Rs. 5.00 lakhs. On 16.8.2014, he became unconscious, was taken to the Fortis Hospital at Mohali. He was diagnosed as a patient of intra cerebral hemorrhage and intra ventricular hemorrhage. He underwent a major surgery. Request made for cashless treatment, as stipulated in the Insurance Policy, was declined by the appellant, on the ground that before issuance of above insurance policy, the complainant was suffering from hypertension and he had not disclosed that fact of pre-existing disease in his proposal form to get insurance policy issued. The complainant was discharged from Fortis Hospital on 22.9.2014. The hospital raised a bill for an amount of Rs. 10,00,631/-, which he paid from his own resources. When his claim for reimbursement upto an amount of Rs. 5.00 lacs was repudiated, he filed above consumer complaint in the Forum.

(3.) Upon notice, O.P No.2/respondent No.2 did not put in appearance and was proceeded against ex parte. Reply was filed by OP No.1/appellant stating that the complaint was liable to be dismissed being frivolous and vexatious. Deficiency in providing service was denied. It was stated that non-disclosure of the fact of pre-existing disease in the proposal form, before inception of the Policy, virtually amounts to fraud committed by the complainant in getting the policy issued. The complainant was suffering from hypertension for the last 4-5 years before he had fallen ill. Repudiation of claim for reimbursement was justified stating that non-disclosure of factum of pre-existing disease in the proposal form would amount to violation of terms and conditions of the policy. Under the above circumstances, a prayer was made for dismissal of the complaint.