Date of Filing: 30-08-2019
Date of Order:18 -08-2020
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSON – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.VIJENDER, B.Sc. L.L.B., PRESIDENT
HON’BLE Sri K.RAM MOHAN, B.Sc. M.A L.L.B., MEMBER
Tuesday, the 18th day of August, 2020
C.C.No.415 /2019
Between
Athmuri Sudhakar S/o. A.Prasad,
Aged 31 years, Occ: Business,
R/o. H.No.586, Sri Ramnagar Colony,
Plot No.387, Manikonda, Gandipet (M),
Hyderabad, Telangana – 500 089 ……Complainant
And
- Manager,
Manipal Cigna Health Insurance Co.Ltd.,
(Formerly known as Cigna TTK Health Insurance Co.Ltd.,)
Branch office, Office No.12,
IV Floor, Eden Ansri Square
O/o.9-1-87, St.John’s Road,
Sangeeta X Roads, Secunderabad, Hyderabad
Telangana State – 500 003
- Manager TTK Health Insurance Co.Ltd.,
O/o. 401/402, Raheja Tianium,
Western Express Highway, Gorgaon (East)
Mumbai, Maharastra State – 500 063 ….Opposite Parties
Counsel for the complainant : Mr. M.Venkatrayudu
Counsel for the opposite Parties : M/s. M.V.R.Suresh & Associates
O R D E R
(By Sri P. Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint has been preferred under Section 12 of C.P. Act 1986 alleging deficiency of service on the part of the opposite parties and in consequence of it seeking relief of a direction to reimburse the amount spent by the complainant for treatment with interest @ 24% P.A and award compensation for causing deficiency of service and cost of this complaint at Rs.10,000/-.
- The complainant’s case in brief is that having believed the presentation made by the agent of the opposite parties with regard to Pro Health Group Insurance policy he obtained a policy for an assured amount of Rs.5,00,000/- under contributory policy and paid a sum of Rs.8312/- and the policy covers the period from 29-5-2019 to 28-05-2020. The said policy covers the complainant and his wife and while obtaining the policy he made a request with the agent of the opposite parties that he will undergoing of medical tests before issuance of the policy but the agent informed that there is no necessity to undergo for any tests. After obtaining the above said policy the complainant fell sick with history of vomitings 12 to 15 episodes on 7-7-2019 and suffered abdominal pain and loose stools of 2 episodes, hence got admitted in Apollo hospitals, Jubilee Hills, Hyderabad on 8-7-2019 for treatment . After number of diagnostic tests he was treated in the hospital as in patient and spent an amount of Rs.50,610/- in the hospital. Thereafter the complainant approached the opposite parties to reimburse the amount spent as he was entitled for cashless treatment as per the terms and conditions of the policy issued. But the opposite parties denied the claim on the ground that payment for diagnostic tests cannot cover and then the opposite parties sent a letter terminating the policy which were issued to the complainant on 5-8-2019 i.,e two months 9 days after payment of the premium on 29-5-2019. Termination of the policy and refusal to reimburse the claim amounts to deficiency in service and it has caused mental agony to the complainant. Hence the present complaint.
- Opposite parties while admitting the issuance of the policy to the complainant denied the allegation of deficiency of service on their part. The stand of the opposite parties is that Master policy was issued to Andhra Bank as Master policy holder and complainant being an account holder of the Master policy holder was eligible to be enrolled under the said policy. He submitted an enrollment form through the Master policy holder and basing on the information provided by the complainant in the proposal form and as per his requirement the policy certificate was issued covering the period from 29-5-2019 to 28-05-2020. Under the said policy the sum insured amount is Rs.5,00,000/- and premium payable is Rs.8312/- and the same was paid by the complainant and the policy certificate was delivered to him. The policy document delivered to the complainant contained terms and conditions and both the parties are governed by it. Complainant registered claim on 17-7-2019 for reimbursement of expenses incurred for hospitalization at Apollo hospital, Hyderabad. The hospitalization of complainant was due to Acute Gastroenteritis with Hypertension and the complainant underwent conservative Management. As per the claim form submitted by the complainant he was admitted in the hospital on 8/7/2019 and was discharged on 13/7/2019. Scrutiny of the claim documents submitted by complainant revealed that complainant has been a known case of hypertension for two years and has been consuming tablet Telma for hypertension which fact was not disclosed by the complainant while submitting the proposal form. Hence the opposite parties rejected the claim and communicated the same to the complainant by letter dt.26-7-2019.
Had the complainant disclosed his true and correct medical history the company would not have accepted the proposal as persons with history of medical conditions are not eligible to be enrolled under the policy, repudiation of the claim of the complainant is in terms of the policy conditions and there is no unfair trade practice or deficiency in service on the part of the opposite parties. Hence the complainant is not entitled for any relief prayed for and same is liable to be dismissed.
In the enquiry the complainant got filed his evidence affidavit reiterating the material facts of the complaint and to support the same got exhibited four (4) documents which are not in dispute. For the Opposite Parties the evidence affidavit of one Akhil Kulhari stated to be Asst.Vice President-Legal of opposite party No.1 is got filed and substance of the same is in tune with the stand taken in the written version. For the opposite parties four (4) documents are exhibited. Both sides have filed written arguments.
On a consideration of material brought on the record the following points have emerged for consideration.
- Whether the repudiation of the claim of the complainant by opposite parties amounts to either unfair trade practice or deficiency of service ?
- Whether the complainant is entitled for the reliefs as prayed for in the complaint?
- To what relief?
Point No.1: Ex.B1 is the policy document containing the terms and conditions governing both the parties. Issuance of the subject policy after collecting the premium amount of Rs.8,312/- from the complainant is not in dispute. Similarly undergoing treatment by the complainant in Apollo Hospital, Hyderabad as in patient during the period from 8-7-2019 to 13-7-2019 and spending of Rs.50,610/- as evidenced by Ex.A3 receipt is not been denied by the opposite parties. Ex.A2 is the discharge summary containing details of the treatment provided and nature of the ailment suffered by the complainant. The reason assigned by the opposite parties for repudiating the claim is as per the discharge summary issued by the Apollo hospital, Hyderabad the complainant has been a known case of hyper tension and has been on medication which fact was not disclosed by the complainant while submitting a proposal for issuance of the policy. It is pertinent to bear in mind that the complainant in the evidence affidavit has not denied the allegation of the opposite parties in the written version that he suppressed the factum of hypertension and he has been medication even before obtaining of subject policy. Ex.A2 is discharge summary filed by the complainant himself and as per this document the complainant is a known case of hyper tension since two years and used to take tablet Telma once daily which fortifies the allegation of the opposite parties that the complainant has been suffering hyper tension even before issuing of the subject policy. This fact has been not disclosed by the complainant at the time of submitting proposal for basing on which Ex.B1 policy was issued. The documents placed on record fortified the allegation of the opposite parties that the complainant suppressed his health condition by not disclosing that he was suffering with hypertension even before obtaining subject policy from the opposite parties.
The learned counsel for the opposite parties in support of his arguments that when insured suppressed material information in the proposal form the insurer is justified in repudiating the claim placed reliance in the following authorities.
- Life Insurance Corporation of India Vs. Manish Gupta in Civil Appeal No.3944 of 2019 decided on 15-4-2019
- Reliance Life Insurance Co.Ltd Vs.Rekhaben Nareshbhai Ratho in Civil Appeal No.4261 of 2019 decided on 24-4-2019
- Shriram Life Insurance Company Limited & Anr Vs. K.Virija in RP.No.434 of 2017 decided on 15-01-2020 by Hon’ble National Commission
The legal position in the above said authorities is that failure of the insured to disclose his past history of the deceased is valid ground for repudiating the claim. It is quite possible that had the state of the health of the insured been disclosed to the insurer, the insurer would have asked the proposal to undergo further medical evaluation or to pay a higher premium considering the state of his health.
In the light of the above legal position the repudiation of the claim by the opposite parties is justified and the complainant’s allegation that the opposite parties have indulged unfair trade practice and caused deficiency of service has no legs to stand. Accordingly point is answered.
Point No.2 In view of the above findings it is to follow that the complainant is not entitled for any relief as prayed in the complaint.
Point No.3: In the result, the complaint is dismissed without costs.
Dictated to steno, transcribed and typed by her, pronounced by us on this the 18th day of August , 2020.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
For complainant
Mr.Athmuri Sudhakar (PW1)
For opposite parties
Mr. Akhil Kulhari (DW1)
Exs. filed on behalf of the Complainant:
Ex.A1- Termination of certificate No.100100051259/01/00
Ex.A2- hospital discharge summary dated 8-7-2019
Ex.A3- deposit receipt dt.13-07-2019
Ex.A4-EMS Speed post cover (postal) dated 5-8-2019
Exs. filed on behalf of the Opposite parties:
Ex.B1- copy of the certificate of insurance along with terms and conditions
Ex.B2- claim form
Ex.B3- discharge summary dt.13/07/2019
Ex.B4- Repudiation letter dt.26/07/2019
MEMBER PRESIDENT
