(1.) This revision is directed against the order dated 19.3.2003 of State Consumer Disputes Redressal Commission, West Bengal, Kolkatta dismissing appeal against the order dated 23.6.1998 of a District Forum whereby petitioner/opposite party-Insurance Company was directed to pay the claim of the respondent-complainant after checking the calculations and examining medical bills, etc.
(2.) Respondent had purchased Mediclaim policy bearing No. 101902/MED/00120/96 having currency from 6.2.1996 to 5.2.1997 for self and his wife, Smt. Namita Kundu under scheme 'A' category of the petitioner. It was alleged that on having problem of cough and cold the wife of respondent consulted the family physician - Dr. Susanta Kumar Kundu on 3.5.1996. Dr. Kundu prescribed certain medicines and advised to consult a Cardiologist. Dr. A.K. Banerjee, Cardiologist was consulted on 23.6.1996 and he advised Echocardiography. Echocardiogram, Cardiac Catheterization and Angiography were done in B.M. Birla Heart Research Centre. Thereafter, Mitral valve repair of respondent's wife was done on 8.10.1996 in the said hospital and she was discharged on 18.10.1996. On seeking reimbursement of medical expenses of Rs. 70,100/-, claim was repudiated by the petitioner by the letter dated 26.6.1997 on the ground that it related to treatment of a pre-existing illness and was excluded under Clause 2.1.14 of the policy. Thereafter, alleging deficiency in service the respondent filed complaint which was contested by the petitioner on ground similar to that taken in the repudiation letter dated 26.6.1997.
(3.) Based on the report dated 19.4.1997 of Dr. Atanu Mukherjee (copy at pages 28 and 29), the submission advanced by Mr. Kishore Rawat for petitioner was that Namita Kundu was suffering from rheumatic heart disease much before the purchase of mediclaim policy and this material fact had been suppressed in the proposal form. Said report would show that rheumatic heart disease cannot develop abruptly and in this case it originated in pre-insurance period. Copy of prescription of Dr. Susanta Kumar Kundu is paced at page 11 while that of Dr. A.K. Banerjee at page 12. Copy of another prescription of Dr. Subha Datta is at page 13. Copy of report of B.M. Birla Heart Research Centre is placed at pages 15 and 16. At the cost of repetition it may be stated that the respondent's wife on developing problem of cough and cold, first consulted Dr. Susanta Kumar Kundu. Prescription slip at page 11 would show that Dr. Kundu advised to consult a Cardiologist. Prescription slip at page 12 would show that Dr. Banerjee on 23.7.1996 advised for Echocardiography. Prescription slip at Page 13 would indicate that Dr. Dutta who has been associated with B.M. Birla Heart Research Centre, referred Namita Kundu for Echocardiography test to that centre on 5.8.1996. Report of Echocardiogram as noticed against the column 'non-invasive investigations' revealed that Namita Kundu was having mitral stenosis, Orifice area : 1.0 sq. cms. Grade II + mitral regurgitation. This report further notices the result of cardiac Catheterization and Angiography at the end. Based on this report Namita Kundu was asked to undergo Mitral valve repair for which she was admitted in the said centre, operated and thereafter discharged on 18.10.1996. Combined reading of the said prescriptions and report would show that for the first time Namita Kundu was detected to be having Mitral stenosis Grade III + mitral regurgitation only on Echocardiogram being done some time in the month of August, 1996. It is settled law that Insurance Company cannot avoid consequences of insurance contract by simply showing inaccuracy or falsity of the statement made by a policy holder. Burden is cast on the insurer to show that statement on a fact had been suppressed which was material for the policy holder to disclose. It is further to be proved by the insurer that that statement was fraudulently made by the policy holder with the knowledge of falsity of that statement or that the suppression was of material fact which had not been disclosed. Origin of aforesaid disease is attributed to rheumatic fever. A layman does not know what this rheumatic fever is? In this backdrop, it is difficult to hold that Namita Kundu knew about her suffering from said fever/disease and she suppressed that fact at the time of purchase of policy on 6.2.1996. There is, thus, no illegality or jurisdictional error in the orders passed by Fora below warranting interference in revisional jurisdiction under Section 21(b) of Consumer Protection Act, 1986. Accordingly, revision petition is dismissed being without any merit. No order as to cost. R.P. dismissed.