Sri Shyamal Gupta, Member

This Appeal is directed against the order dated 15.01.2016 of the Ld. DCDRC, Kolkata—I (North) passed in CC/59/2012 by the Appellant/OP.

That the case of the Respondent/Complainant is that during validity period of the said policy she accidentally felt down on the road on 21.05.2011 and for the same she was suggested to underwent surgery on 22.05.2011 by her doctor. Accordingly she was admitted in Sana Nursing Home Mumbai and for such treatment she had to incur a sum of Rs. 98,000/- in total. Thereafter one claim was also lodged with the Appellant. As such claim has not been paid on ground of pre existing disease and suppression of such pre existing disease in the proposal form, she filed the complaint petition before the Ld. Forum praying for different relief/s as per the prayer of said complaint petition.

On hearing both sides, Ld. DCDRC allowed the Complaint Case with cost of compensation.

Being aggrieved with the said order dated 15.01.2016, OP filed the Appeal.

The observation of the Ld. DCDRC is as follows:-

“O.P No. 1 is directed to pay to the Complainant a sum of Rs. 98,000/- (Rupees ninety eight thousand) only towards the claim amount and is further directed to pay compensation of Rs. 40,000/- (Rupees forty thousand) only for harassment and mental agony and litigation cost of Rs. 10,000/- (Rupees ten thousand) only.”

Perused the BNAs filed by both sides.

During the course of argument Ld. Advocate of the Appellant raised point a ‘suppression of earlier diseases’ etc.

Now the observation of Apex Court on the point of ‘suppression of material fact’ is as follows:-

D.Srinivas –Vs-SBI Life Insurance Co. Ltd & Ors. 2019(1) CPR 16 (SC)

“When the pre-condition of medical examination of the insured before accepting the premium is not adhered to, it may be inferred to have been waived.”

LIC of India-Vs- Manish Gupta III(2019) CPJ 31 (SC)

“Non-disclosure of any health event is specifically set out as a ground for excluding the liability of the insurer.”

Sulbha Prakash Motegaonkar & Ors –Vs- LIC of India (Civil Appeal 8245 of 2015)

“Claim cannot be repudiated on the ground of suppression of previous disease, if it has no connection or nexus with death.”

Mithoolal Nayak –Vs- LIC of India AIR 1962 SC 814

“No policy of life insurance , after the expiry of 2 years from the date on which it was effected , be called in question by an insurer on the ground that a statement made in the proposal for insurance was inaccurate or false.”

LIC of India –Vs- Asha Goel (2001) 2 SCC 160

“For determination of the question whether there has been suppression of any material facts it may be necessary to also examine whether the suppression relates to a fact which is in the exclusive knowledge of the person intending to take the policy and it could not be ascertained by reasonable enquiry by a prudent person”. “No policy can be questioned on any grounds after the lapse of 2 years. Sec 45 of Insurance Act.

Life Insurance Corporation of India-Vs- Smt G.M. Channabasamma (1991) 1 SCC 357

“It is well settled that a contract of insurance is contract uberrimae fidei and there must be complete good faith on the part of the assured. The assured is thus under a solemn obligation to make full disclosure of material facts which may be relevant for the insurer to take into account while deciding whether the proposal should be accepted or not.”

In this particular case, the policy started on 29.08.2007 and Complainant admitted to Nursing Home on 22.05.2011 which is more than 3/3-4 years after the initiation of policy. Accordingly, question of ‘Suppression’ does not stand here.

Now regarding the reimbursement of Rs. 98,000/- for medical expenses, O.P is directed to pay the said amount subject to furnishing the original bills + vouchers within 60 days from this order.

Regarding ‘compensation’, the observation of the Apex Court is as follows:-

Charan Singh –Vs- Healing Touch Hospital & Ors (2000) 7 SCC 68

“It is for the Consumer Forum to grant compensation to the extent it finds it reasonable, fair and proper in the facts and circumstances of a given case according to the established judicial standards.”

V. Krishna Kumar –Vs- State of Tamil Nadu & Ors (2015) 9 SCC388

“The principle of ‘restitution in integrum’ should be followed while deciding the amount of compensation.”

Godfrey Philips India Ltd –Vs- Ajay Kumar (2008) 4 SCC 504

“The compensation can be allowed only when there is loss or injury suffered by the complainant due to negligence of the opposite party.”

In view of the said premises, Compensation amount is reduced to Rs. 10,000/- instead of Rs. 40,000/-.

Thus the instant Appeal is allowed in part. The impugned order dated 15.01.2016 is hereby modified as mentioned above.