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Branch Manager, Star Health & Allied Insurance Co. Ltd. & Another v/s Umesh Badani & Others

Company & Directors' Information:- STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED [Active] CIN = U66010TN2005PLC056649

Company & Directors' Information:- STAR INDIA PRIVATE LIMITED [Active] CIN = U72300MH1994PTC076485

Company & Directors' Information:- STAR COMPANY LIMITED [Strike Off] CIN = U67120WB1927PLC005620

Company & Directors' Information:- STAR T V PRIVATE LIMITED [Strike Off] CIN = U51395UP1985PTC007023

Company & Directors' Information:- STAR OF INDIA LIMITED. [Strike Off] CIN = U99999CH1946PLC001119

Company & Directors' Information:- A. S. STAR PRIVATE LIMITED [Active] CIN = U74999RJ2016PTC056637

Company & Directors' Information:- STAR O & M PRIVATE LIMITED [Active] CIN = U74999DL2015PTC281303

Company & Directors' Information:- K. D. STAR PRIVATE LIMITED [Active] CIN = U45201GJ2011PTC067973

Company & Directors' Information:- STAR LTD. [Dissolved] CIN = U99999MH1921PTC000957

    First Appeal No. 414 of 2010

    Decided On, 05 July 2016

    At, National Consumer Disputes Redressal Commission NCDRC


    For the Appellants: K.P. Toms, Advocate. For the Respondents: S. Radha Pyari, Bharat Swaroop Sharma, Advocates, R2, R3, Exparte.

Judgment Text

This appeal has been filed u/s 19 of the Consumer Protection Act, 1986, against the impugned order dated 27.09.2010, passed by the Karnataka State Consumer Disputes Redressal Commission (hereinafter referred to as ‘the State Commission’) vide which, the complaint filed by the respondent No. 1/complainant Umesh Badani was allowed and the appellants and respondent No. 3, Umesh Babu were directed jointly and severally to pay claim of the complainant for his medical treatment, amounting to USD 56,084/- alongwith compensation of Rs.20,000/- and litigation cost of Rs.10,000/-.

2. Brief facts are that the complainant/respondent No. 1 Umesh Badani obtained an overseas travel policy, bearing No. P/141111/03/20090/000260, covering him and his wife for their travel to the USA for a sum assured of USD 2,50,000/- each. The respondent No. 2/OP-3, Paramount Health Care Management Private Limited is the third party administrator (TPA) for the settlement of claims in respect of the policy in question. The respondent No. 3/ OP-4 Umesh Babu is the agent, acting on behalf of the insurers/appellants. It has been stated in the consumer complaint that during his visit to Chicago, the complainant suffered from slight rigors, fever, apart from slight burning sensation, while urinating and noisy chest, while breathing. On 2.10.2008, the complainant was admitted in the Swedish Covenant Hospital (SCH) in Chicago, where he was subjected to several investigations. It is stated that the complainant suffered violent allergic reaction during these investigations and he went into near comatose condition. He was diagnosed by the Hospital for viral pneumonia and septicaemia. The said hospital submitted claim to respondent No. 2/OP-3 TPA on the basis of the policy issued by the appellant/OP-1 & 2 for a sum of USD 56,084.66/-. However, the said claim was rejected by the insurer/appellants, saying that the complainant had suppressed material information about his health, while obtaining the policy in question. He had been suffering from hypertension and diabetes mellitus, which resulted in the condition, for which he had to be admitted in the hospital in USA. The complainant then sent a legal notice dated 18.05.2009 to the OPs, after which the consumer complaint in question was filed, seeking payment of the cost of treatment incurred at the said hospital and compensation for deficiency in service etc.

3. The complaint was resisted by the appellants/OP-1 & 2 by filing a written statement before the State Commission, in which they took the stand that the complainant had suppressed material facts about his health condition and previous diseases at the time of filling the proposal form for obtaining the policy in question. The OP-4/respondent No. 3 agent also filed a separate written version before the State Commission, in which he stated that the proposal form was filled by him (agent) on the dictation given by the complainant himself. The proposal form had, therefore, been filled, based on the information disclosed by the complainant and hence, there was no deficiency in service on the part of the agent.4. The State Commission vide impugned order allowed the consumer complaint and held that the appellant and the agent OP-4 were jointly liable to pay a sum of USD 56084 to the complainant alongwith compensation of Rs.20,000/- and litigation cost of Rs.10,000/-. It is against this order that the present appeal has been filed by the appellants/OP-1 & 2.

5. During hearing, the learned counsel for the appellant reiterated the stand taken by the appellant insurers, saying that the complainant had suppressed material facts about his health condition at the time of obtaining the said policy. The learned counsel pleaded that if the correct position about his health condition had been brought to the knowledge of the insurers, they would have refused to issue the insurance policy or would have restricted the insurance cover. The Ld. Counsel has drawn attention to the copy of the proposal form, saying that the complainant had categorically stated in the said form that he was not suffering from any illness / disease or disability at the time of obtaining the policy in question. However, the report made by the Swedish Convent Hospital at Chicago at the time of admission of the complainant says that as per his past medical history, the complainant was suffering from diabetes, hypertension and cardiac disease and was also treated for the same. The insurer was, therefore, not liable to pay the claim in question. The Ld. Counsel has referred to order passed by the Hon’ble Apex Court in 'Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd.' [(2009) 8
SCC 316], in support of his arguments.6. In reply, the Ld. Counsel for the complainant stated that the complainant was a frequent traveller and had been taking similar policies covering such travels in the past. Because of his old age, he was not in a position to fill the proposal form himself. It had been mentioned in the consumer complaint itself that the proposal form was filled by the OP-4 agent who also signed the same on his own. A copy of the said proposal form was handed over by the agent to the complainant on his return from the USA and that too at his insistence. The complainant was, therefore, totally unaware of the information filled in the said proposal form by the agent. The Ld. Counsel further argued that since the complainant was more than 60 years of age at the time of obtaining the policy, it was incumbent upon the Insurance Company to get his medical tests done, as per the guidelines on the subject, but the appellants issued the insurance policy without getting the said tests done. The Ld. Counsel further argued that there was no material on record to prove that there was any suppression of information by the complainant regarding his health condition. Further, the complainant had been diagnosed for viral pneumonia and septicaemia by the Hospital at Chicago. There was no nexus between these diseases and hyper tension / diabetes etc. The insurance company was, therefore, liable to pay the claim in question and hence, the order passed by the State Commission was in accordance with law.

7. I have examined the entire material on record and given a thoughtful consideration to the arguments advanced by the parties.

8. The main issue that merits consideration in the present case is whether there had been any suppression of material information by the complainant regarding his health condition, while filling the proposal form in question. The material document for consideration in the present case is the written version filed by the OP-4 Agent of the Insurance Company. It has been categorically stated by the OP-4 in his reply that the complainant was having the habit of not writing by himself and hence, he asked the agent to fill the form. After the said agent had filled the form, the complainant took the filled form inside his cabin and affixed his signatures and made a Xerox copy of the same. The complainant delivered the duly signed form to the agent. The State Commission have observed in the impugned order that it could be made out with naked eyes that signatures of the complainant on the proposal form were different from his admitted signatures. A perusal of the signatures on the copy of the proposal form appended with the appeal by the appellants also confirms the view of the State Commission as the signatures are evidently different from the signatures made by the complainant on the affidavits submitted before this Commission during the course of proceedings. The appellants have nowhere raised any plea that such signatures could be compared by calling any handwriting expert etc. it is evident, therefore, that the conclusion arrived at by the State Commission that the signatures in the proposal form are different from the standard signatures of the complainant has not been controverted from the facts on record.

9. The State Commission have further stated in their order that the complainant was a senior citizen and a frequent traveller and he had earlier obtained policies from other insurance companies like the United India and the Oriental Insurance Company etc. While obtaining the said policies, the complainant had been fair enough to narrate that he had been suffering from diabetes and hypertension. The concerned insurance companies had issued the policies knowing the said fact very well. The version of the complainant, therefore, that had he been given an opportunity by the agent to see the proposal form, he would have brought the lacunae in the proposal form to the attention of the OPs, seems to be correct. The conclusion of the State Commission, therefore, that the complainant could not be accused of having suppressed the material information about his health, seems to be in order.10. Another point worth consideration in the present case is that medical examination upon the complainant was not got conducted before issuing the policy, although he was more than 60 years old at the time of obtaining the said policy. The agent has stated in his written reply that the policy opted by the complainant did not require any premedical check-up. The appellants/OP-1 & 2 have stated in their written reply that there was no legal obligation on the insurer to conduct medical tests or evaluation. However, the complainant stated in his written reply that as per the terms and conditions mentioned in the proposal form, the medical examination was required to be conducted in cases, where the insured was more than 60 years old. In any case, the complainant himself stated in his complaint that when he obtained similar policies during earlier travels, he was subjected to medical examination and was accordingly issued a restricted policy. The complainant had also produced copies of the relevant medical record and other relevant documents before the State Commission along with his complaint. It is made out from these facts that the complainant did not supress any material information on his own from the insurance company

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.11. Based on the discussion above, it is made out from the facts and circumstances of the present case that the complainant cannot be held responsible in any manner if true and exact information about the status of his health could not be filled in the proposal form. It is a matter of common observation that while obtaining insurance policies, the proposal forms are usually filled-up by the agents and the insured may not be even aware about the contents of the information filled in the same. Moreover, no proof has been brought on record to establish that the complainant took any treatment for pre-existing diseases. It is clear, therefore, that the appellants have not been able to establish if there was any wilful suppression of material facts on the part of the complainants. I, therefore, do not find any solid ground to interfere with the impugned order passed by the State Commission and the line of reasoning taken by them while passing such an order. It is held, therefore, that there is no merit in this appeal and the same is ordered to be dismissed and the impugned order is upheld with no order as to costs.