ROYAL SUNDARAM ALLIANCE Vs. LYNDA O LEPCHA

JUDGEMENT

(1.) The petitioners are aggrieved by the award dated 25th July, 2006 of Insurance Ombudsman awarding a sum of Rs.1,95,149/- to respondent No.1 for the treatment of her son, Master Jordan, at Apollo Hospital. The amount has been awarded by respondent No.2 on a complaint of respondent No.1 that her claim with the petitioners was rejected on 10th December, 2004 on the ground that there has been suppression of congenital heart conditions necessitating heart surgery immediately after the birth which was not disclosed in the proposal form. Declining any amount on the claim of the respondent no.1 was also confirmed by the petitioners by their letter dated 24th March, 2005.

(2.) The son of the respondent No.1 was born in August 2004 after cesarean prematurely at 32 weeks, however, he survived after intense medical care. During the treatment in hospital, it transpired that her son, Jordan, had PDA (Patent Ductus Artriosus) which is a condition medically known as congenital heart defect where a blood passage in the heart for circulation, before the baby is born, remains open instead of closing shortly after birth. According to the petitioner, in some cases, this condition closes automatically, however, in case of her son, despite medication he had to be operated surgically for this. According to the respondent No.1, as told to her, this condition was a defect and is not a disease as she has been advised that it will not reoccur.

(3.) According to the petitioners, the respondent No.1 was aware of various types of congenital anomalies on the inception of policy but she had not disclosed the facts in the application form and specifically under the column Medical History of her son's disease where she had written 'No' and consequently the petitioners had repudiated her claim on condition E of the policy, which contemplates that the policy shall be void and all premium paid thereon shall be forfeited to the company, in the event of mis-representation, mis-description or non-disclosure of any material fact.