13-04-2015 - Heard Mr. Bibhash Sinha, learned counsel appearing for the O.P.- appellant- Insurance Company on the prayer for condoning the delay of about 32 days in filing this appeal and on merits.
He referred to the limitation petition and prayed for condoning the delay.
2. On merit, he assailed the impugned judgment mainly on the ground that the complainant- respondent did not disclose about the previous disease of his wife at the time of inception of the Health Care Policy taken from the appellant-Insurance Company and therefore the claim was rightly repudiated.
He relied on the judgements reported in (2008) 1 SCC 321 P.C. Chacko Vs Chairman, L.I.C; the order dated 31st July 2012 passed by National Commission in R.P. No. 2130/2007 LIC -vs- Smt. Surekha Shankar Jadhav; and judgement dated 10th July 2009 passed in Civil Appeal No. 2776/2002 by the Hon’ble Supreme Court in the case of Satwant Kaur Sandhu -Vs- New India Assurance Co.
3. The present complaint was filed claiming reimbursement of the expenses of treatment/ hospitalization of Smt. Kiran Singh, wife of the complainant amounting to Rs. 86,458/-. The complainant took a Health Care Policy for two years ( w.e.f. 6.7.2009 to 5.7.2011) which was renewed for further two years i.e. with effect from 6.7.2011 to 5.7.2013 by the Insurance Company for the insured amount of Rs. 4,00,000/- for which, premium of Rs. 22,288/- was paid.
4. On 22.2.2012 Smt. Kiran Singh was admitted in Belle View Clinic, Kolkata for treatment of pain R/F with fissure. She was discharged after the treatment on 25.2.2012 and the final bill of Rs. 82,548/- had to be paid by the complainant as the Insurance Company refused to pay on the ground that the patient had concealed her previous clinical history of Rheumatoid Arthritis and Hyperthyroidism.
5. Admittedly, the complainant’s wife was covered under Health Care Insurance Policy from 6.7.2011 to 5.7.2013. She was hospitalized on 22.2.2012. After about 7 months from the date of renewal of the policy, the Insurance Company terminated the policy and returned the premium amount of Rs. 22,289/- vide cheque dated 3.2.2012, after the complainant made insurance claim.
6. It appears that the complainant himself filed documents of previous treatment of his wife, which were used by the Insurance Company against him but such previous treatment was for other diseases, i.e. Rheumatoid Arthritis and Hyperthyroidism etc. whereas the treatment in question was for another disease i.e. fissure.
7. Apparently, the Insurance Company has committed gross deficiency in service by repudiating the claim on wrong grounds. The judgements relied by Mr. Sinha are of no help to the Insurance Company in as much as in our opinion there has been no suppression of material facts by the complainant in this case , either at the time of inception of the policy in 2007 or at the time of its renewal in 2011.
8. Therefore, even if, the delay of about 32 days in filing this appeal is ignored, we find no merit in this appeal.
9. On this, Mr. Bibhash Sinha submitted that the learned District Forum directed the Insurance Company to pay Rs. 86,458/- i.e. the total claim without deducting Rs. 22,289/-, the amount of premium returned by the Insurance Company.
10. It is not clear, whether the complainant encashed the said cheque dated 3.7.2012 for Rs. 22,289/- sent by the Insurance Company. The learned District Forum has not said that the amount awarded was over and above the amount of premium returned. Therefore, if the said cheque has been encashed, such amount has to be deducted from the claimed amount.
11. Only for this, we do not intend to call upon the complainant- respondent by issuing notice.
Therefore, we modify the operative portion of the impugned order as follows.
12. If the said cheque dated 3.7.2012 for Rs. 22,289/- has been encashed by the complainant, the Insurance Company will pay the balance amount, i.e. Rs. 64,169/- along with Rs.10,000/- as compensation i.e. Rs. 74,169/- within 45 days of this order.
However, if the said cheque has not been encashed and has spent it’s life, the Insurance Company will pay Rs. 96,458/- within 45 days of this order.
If the Insurance Company fails to comply with this order, it will also pay simple interest on the said amount @ 9 % p.a. from the date of this order till the date of payment / realization.
With these observations and directions this appeal stands disposed off.
Issue free copy of this order to all concerned for information and needful.
Ranchi,
Dated:-13/04/2015
