1. THE complainant/appellant''s case is that he along with his wife opened a Mediclaim policy with the opposite party/respondent on 14.12.90 for benefit of their treatment of various ailments. THE wife of the appellant had been treated in Kothari Medical Center. He incurred a expenses of Rs. 8,243/- for the said treatment of the appellant''s wife and he claimed the said sum of Rs. 8,243/- from the opposite party as per the Insurance Policy bearing No. 0532 dt. 14.12.1990. THE Petitioner/appellant made a series of correspondences in this regard with the opposite parties in letter bearing No. 310/60C 17/00056/91 dated 2.3.1992 being annexed I to the petition of complaint the opposite party assured to consider the claim of the petitioner in a lenient way as a gesture of good wishes and to dispose of the matter but ultimately did nothing in the matter, hence the complaint was lodged before C.D.F. and the Complaint being dismissed this appeal has been preferred by the petitioner/appellant.
2. THE crux of contention by the opposite party is that the petitioner/appellant suppressed the material fact in as he did not disclose the illness of hypertention in the proposal form at the time of opening the insurance policy. THE opposite party also contended that subsequent E.N.T. treatment of appellant''s wife at residence does not entitle the appellant to receive the claim amount as claimed by the appellant and in support thereof the opposite party cited the provision of Clause 7 of the policy in his written objection filed in this regard. JUDGMENT
It is admitted position that there was a mediclaim Insurance for treatment of the appellant and his wife for all sorts of ailments covered by that policy. The contention of the opposite party is that there is suppression of material facts in the proposal form as to ailment of hypertension suffered by the wife of the appellant while answering the questions No. 10 and 11 of the proposal form. Whereas the appellant has denied of any such clauses in the proposal form; but the fact remains that opposite party has not produced the proposal form or copy thereof before this commission for its examination and opinion.
Be that as it may we are of opinion that even there be any such clauses in the proposal form, the non-disclosure of hypertension is not suppression of material fact. Temporary or causal suffering from hypertension not being a permanent illness need not be required to be disclosed, no it was a fatal for a acceptance of the Insurance Policy when the acceptance of Policy has duly been accepted by the opposite party. Even if conceding but not admitting that at the time of making the claim the party concerned was suffering from hypertension, but that will not serve the purpose of the O.P., because the time of disclosure should be at the moment when the Insured person''s details were mentioned in the prescribed form in this regard. It might be, specifically when this has not been challenged, that such ailment started in a more later stage when he/she submitted that prescribed form before the O.P.
3. MOREOVER, the allegation as made by the O.P. - Insurance Company must be proved by it, but neither a scrap of paper nor any cogent evidence has been adduced by the Company to establish the allegation. From scrutiny of the paper and the treatment chart shown to us it appears that treatment of the appellant''s wife mainly concentrated for pathological aspects and ENT treatment associated with hypertention. As such the appellant is entitled to the claim as per Clause 7 of the proposal form as reproduced in the written objection by the opposite party. After pathological examinations if treatment is continued at home as was done in the instant case how it stands in the way to receive the claim by the appellant as per provisions of Clause 7 of the proposal form for Insurance Policy. The appellant is entitled to all charges incurred by him at Nursing Home for diagnostic X-Ray or laboratory examination or other diagnostic studies which are very much consistent with or incidental to the diagnostics and treatment of the positive existence of presence of ailments, suffered by the appellant''s wife as per provision of Clause 7, at least when there no allegation has been raised by the opposite party about inconsistency of diagnostic treatment and laboratory examination for the purpose of treatment of the positive existence of ailment of the appellant''s wife. MOREOVER the opposite party by his own admission about taking lenient view about the caste of the appellant/claimant in his letter dt. 2.3.1992 has virtually accepted the claim of the appellant. Inspite of the said fact, the opposite party has caused extreme harassment to the petitioner/appellant and due to negligence and apathetic attitude the Appellant has not only been deprived to get his claim settled in time but also suffered extreme mental agony and harassment.
With deep concern we have observed that it has become the tendency of the insurers in most cases, to by-pass the settlement of the claim by taking plea in the interpretation of the parlance used in the clauses of Insurance Policy in hair splitting way like a demagogue, whereas the insured being ordinary people are generally ignorant about tricky parlance or flaw of stipulations in the Policy of Insurance coverage and depend for interpretation upon the agent or officials of the insurers who explain the same conveniently to procure the business and thereafter take the advantage of said weaknesses of the insured and try to escape through such flaw of parlance in the insurance policy at the time of settlement of the claim of the insured. To us it also amounts to Unfair Trade Practice on the past of the insurers in order to deprive the innocent insureds. Therefore, the contention of the opposite party fails.
4. WE observe in the context that the opposite party is guilty of deficiency in service by not settling the claim of the appellant as per policy within time inspite of repeated demands.
In the light of aforesaid judgment we allow the appeal and set aside the judgment and order passed by the C.D.F. Calcutta in C.D.F. Case No. 247/92.
We direct the opposite party/respondent to pay the claim amount of Rs. 8,243/- together with Rs. 500/- which is awarded towards harassment, mental agony and cost of the proceedings, within 30 days from the date of communication of this order. Appeal allowed with costs.
