RATANCHAND J SHAH Vs. ORIENTAL INSURANCE CO LTD

JUDGEMENT

(1.) THIS appeal under Section 15 of the Consumer Protection Act, 1986 is directed against order dated 16.10.2006 rendered in Complaint No. 383 of 2005 by the learned Ahmedabad City Consumer Disputes Redressal Forum, dismissing the complaint with no order as to costs.

(2.) FACTS leading to the filing of the present appeal shortly stated are that complainant had earlier obtained mediclaim policy from National Insurance Company Limited. Thereafter, since 1999, the mediclaim policy of the complainant has been renewed from time -to -time; that during the validity period of the insurance policy under policy No. 300101/48/98/8502636 issued by the National Insurance Company Limited, on 14.4.1999 the complainant was admitted as indoor patient for heart ailment; that the policy renewed by National Insurance Company was valid up to 18.4.1999; that from 19.4.1999 the policy was renewed with opponent Oriental Insurance Company Limited; that the proposal form was filled in and cheque for the premium amount was given on 10.4.1999 to the opponent Insurance Company for further renewal also narrating the fact that earlier the mediclaim policy was taken from National Insurance Company Limited; that for the hospitalisation on 14.4.1999 complainant lodged claim with National Insurance Company Limited as the same was before the expiry of the mediclaim policy on 18.4.1999; that thereafter the mediclaim policy has been renewed by the opponent Insurance Company from time -to -time; that the renewed mediclaim policy issued by the Oriental Insurance Company was with 30% cumulative bonus and some insured was Rs. 75,000; that on 28.10.2002 the complainant was admitted to Krishna Heart Institute for angiography and incurred medical expenses to the tune of Rs. 17,722; that the complainant was admitted on 7.2.2003 for by -pass surgery at Krishna Heart Institute and spent Rs. 1,43,301. The claim was intimated to the opponent Insurance Company. The opponent Insurance Company vide letter dated 18.7.2005 repudiated the claim. Hence the complaint. The opponent Insurance Company filed reply and resisted the complaint contending that the complainant has deliberately with fraudulent intention and ulterior motive did not disclose/suppressed material facts at the time of making proposal for risk coverage and has stated falsehood in order to obtain risk cover from the opponent Insurance Company; that the complainant had filled up and submitted the proposal form to the present opponent for revised mediclaim insurance policy which was received by the opponent Insurance Company on 16.4.1999 at 4.30 p.m. and thereafter proposal for risk coverage was accepted by the opponent; that on the basis of the facts stated the complainant's mediclaim policy was issued by the opponent which was to come into effect from 19.4.1999; that on 14.4.1999 the policy issued by the opponent was not effective and that is why the complainant had preferred the claim with National Insurance Company Limited; that the complainant had replied the questions put in the questionnaire in the negative; that in the proposal form/questionnaire it is nowhere stated that the complainant had history of heart disease or that CBGA was undergone by the complainant in the year 1988. Therefore, the opponent issued the mediclaim policy in the year 1999 -2000; that if the opponent had knowledge of medical history of the complainant, then the opponent would not have issued the policy at the normal premium rate and/or would not have granted 20% cumulative bonus. Thus, the claim of the complainant was rejected on the ground of suppression of material facts. The learned Forum considering the pleadings and material on record, dismissed the complaint with no order as to costs. It is this order which is assailed in the present appeal.

(3.) IT is submitted by Mr. S.J. Mehta, learned Advocate for the appellant -original complainant that the proposal form was filled in on 10.4.1999; that the complainant was admitted to Krishna Heart Institute for angiography on 14.4.1999 as he suffered chest pain; that the complainant had to undergo by -pass surgery at Krishna Heart Institute; that the renewed mediclaim policy has been issued by the opponent w.e.f., 19.4.1999 for a period of one year; that the opponent has wrongly repudiated the claim put forth by the complainant; that on 10.4.1999 when the complainant filled in the proposal and paid the premium for renewal of the mediclaim policy with cumulative bonus, the complainant had no idea that on 14.4.1999 he would develop chest pain requiring hospitalisation for angioplasty and then for by -pass surgery; that on 10.4.1999 the complainant could not have disclosed about chest pain and the angiography treatment; that though the claim is of Rs. 1,49,701, the same is restricted to Rs. 70,000 plus 30% cumulative bonus in view of the sum assured; that the angiography treatment on 14.4.1999 is subsequent to filling up of proposal form on 10.4.1999; that this is a case of renewed policy and no proposal form was required to be filled. As against this, it is submitted by Mr. H.L. Parmar, learned Advocate for the respondent that the complainant underwent by -pass surgery in the year 1988; that the questions put in the questionnaire required the complainant to disclose that he underwent by -pass surgery in the year 1988; that on 10.4.1999 the complainant in answers to the questionnaire should have disclosed that he underwent by -pass surgery in the year 1988; that the answers to all the questions in the questionnaire are in the negative; that on 10.4.1999 the complainant ought to have disclosed about the by -pass surgery in the year 1988 and this is the suppression of material fact which influenced the decision of renewal of the mediclaim policy by the opponent; that the complainant for the reasons best known to him has changed the Insurance Company and preferred to have the renewed mediclaim policy from opponent Insurance Company and that makes it necessary for the complainant to disclose all the material facts and had the opponent Insurance Company known about the medical history of the complainant, then in that case the opponent could have incorporated some exclusion clause or premium could have been enhanced.