Date of Filing:24/08/2016
Date of Order:13/12/2018
BEFORE THE BANGALORE I ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHANTHINAGAR BANGALORE - 27.
Dated: 13TH DAY OF DECEMBER 2018
PRESENT
SRI.H.R. SRINIVAS, B.Sc., LL.B. (Rtd. Prl. District & Sessions Judge) And PRESIDENT
SRI D.SURESH, B.Com., LL.B., MEMBER
COMPLAINT NO.1161/2016
COMPLAINANT: | | MR.MOIN SHARIEFF, S/o Shri Hyder Sharieff, Aged about 32 years, R/o. No.21, 1st Cross, Munni Reddy, Bangalore South, Karnataka, Bangalore560 004. (Sri Kapil Dixit Adv. for Complainant) |
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V/s
OPPOSITE PARTIES: | | M/s. THE STAR HEALTH & ALLIED INSURANCECOMPANY LIMITED, Esteem Tower No.71, IIIrd Floor, Railway Parallel Road, Kumara Park West, Bangalore-560 020. (Sri Adv. Y.P.Venkatapathi for O.P.) |
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ORDER
BY SRI.H.R. SRINIVAS, PRESIDENT
1. This is the complaint filed by the complainant through her Special Power of Attorney against the Opposite Party (hereinafter referred to as O.P) under Section 12 of the Consumer Protection Act, 1986 praying this Forum to direct the O.Ps to pay a sum of Rs.1,10,274/- being the hospital charges, Rs.70,000/- towards compensation and Rs.10,000/- towards litigation expenses and for other reliefs as this forum deems fit under circumstances of this complaint.
2. The case of the complainant in brief is that: the sister of Special Power of Attorney holder of the complainant Moin sheriff has filed this Complaint on behalf of Mrs. Nagina Sheriff who took health insurance from O.P commencing from 20.12.2015 to 19.12.2017 under Policy No.P/700002/01/2016/040820 and also declared that she was having BP, thyroid as preexisting disease. Premium also been paid. On 07.06.2016 on account of her illness was admitted to N.H. Mazumdar Shaw Medical Center at Bengaluru and after getting treatment was discharged on 11.06.2016 and again admitted on 16.06.2016 and discharged on 20.06.2016. The hospital has charged Rs.1,10,274/-. Whereas, the insured amount is Rs.1,00,000/-. When she made a claim for reimbursement of the hospital charges with O.P, the same has been repudiated. A legal notice has also been issued but O.p has issued untenable reply and not complied with the request. The cause of the action of the complaint arose on 20.06.2016. Hence this complaint.
3. Upon the notice of the complaint, O.P appeared before the Forum filed their version denying the allegations made against it para wise and further contended that the complaint is not maintainable and there is no deficiency in service on their behalf. This forum has no jurisdiction to decide this case. The complaint suffers from suppression and misrepresentation of facts. Sympathy cannot be shown to the complainant which is contrary to the terms and conditions of the insurance. It has admitted that subject to the terms and conditions and exclusions, insurance policy was issued to Mrs. Nageena Sherif for a period from 20.12.2015 to 19.12.2017 for a sum of Rs.1,00,000/-. She made first claim for the treatment obtained from 07.06.2016 to 11.06.2016 and another claim from 16.06.2016 to 20.06.2016 and both the claims were within six months from the date of issuing the policy. The policy was issued to the complainant under the terms of atmost good faith and that the proposer has to give and disclose all the facts and supposed to have not to misrepresent and not to suppress the facts.
4. It is further contended that the complainant had Renel Failure since November 2015. She obtained the insurance policy on 20.12.2015 without disclosing the preexisting Renal Failure Disease. The Discharge summary issued by the hospital has mentioned that it was detected to have severe Renal failure with accelerated Hypertension in November 2015 and the same was struck off and a hand written note that recently detected Renal Failure and Hypertension.
5. According to Condition No.7 of the policy, if there is any misrepresentation/non-disclosure of the material fact whether by insured or by any other person acting on his/her behalf, the company is not liable to make any payment in respect of any claim and condition No.11 of the policy states that the company may cancel the policy on the ground of misrepresentation of material facts, moral hazard, non disclosure of the material as declared in proposal form or at the time of claim or non-cooperation of the insured person. A premium of Rs.11,267/- has been refunded to the insured by cancelling the policy. Hence the complainant is not entitle for the relief claimed and they repudiated the contract of insurance and there is no deficiency in service on their part and hence prayed to dismiss the complaint.
6. On the other hand, the Complainant and O.P have filed their affidavit evidence and produced documents. Heard the arguments. The following points arise for our consideration:-
1) Whether the complainant has proved
deficiency in service on the part of the
Opposite Party?
2) Whether the Complainant is entitled to
the relief prayed for in the complaint?
7. Our answers to the above points are:-
POINT NO.1 & 2: In the Negative.
For the following.
REASONS
POINT No.1 and 2:-
8. Both the parties have reaffirmed their allegations and defence as per their complaint and version in the affidavit filed in lieu of their evidence. It is not in dispute that, sister of the complainant obtained insurance from the O.ps for a sum of Rs.1,00,000/- vide policy bearing No.P/700002/01/2016/040820 commending from 20.12.2015 to 19.12.2017. It is also not in dispute that the claim made by the complainant has been repudiated by O.ps on the ground that she has not disclosed the pre-existing medical condition /disease and the policy issued under utmost good faith.
9. It is the specific defence of the O.ps that in the discharge summary issued by the hospital authorities, it was mentioned that the complainant’s sister was detected to have severe Renal Failure with accelerated hypertension in November 2015. This was printed in the Discharge Summary. The document produced by the complainant clearly shows that the said words have been struck off and it has written in hand that recently detected Renal Failure and Hypertension. It is also brought to the notice of this Forum that the complainant’s sister obtained the policy on 20.12.2015 much after getting to know that she was having Kidney failure. The documents which both parties relay that is discharge summary clearly amplified the same. When the sequence of facts are taken into consideration, the complainant sister much knowingfully well that she was having Renal Failure, obtained the policy without disclosing the same. It is just a few days after knowing her medical problem, complainant’s sister purchased the policy without disclosing the same which amounts to obtaining the policy by misrepresenting the facts, suppressing the medical condition and not acted in utmost good faith. Hence the repudiation by the O.P and also cancellation of the insurance and refunding the premium amount in our view will not amount to deficiency in service or unfair trade practice. Hence we answer Point No.1 and 2 in the Negative and hence complainant is not entitle for any of the reliefs and pass the following:-
ORDER
1. The Complaint is dismissed with cost.
2. The Complainant is directed to pay Rs.10,000/- to the O.P for dragging them unnecessarily to the Forum to defend the case by engaging counsel.
3. The Complainant is hereby directed to comply the above order within 30 days from the date of receipt of this order and submit the compliance report to this forum within 15 days thereafter.
4. Send a copy of this order to both parties free of cost.
Note:You are hereby directed to take back the extra copies of the Complaints/version, documents and records filed by you within one month from the date of receipt of this order.
(Dictated to the Stenographer over the computer, typed by him, corrected and then pronounced by us in the Open Forum on this 13th of DECEMBER 2018)
MEMBER PRESIDENT
ANNEXURES
1. Witness examined on behalf of the Complainant/s by way of affidavit:
CW-1:Mr. Moin Sharieff - Complainant.
Copies of Documents produced on behalf of Complainant/s:
Doc.No.1: Copy of the Insurance policy.
Doc.No.2: Copy of Customer Identification card.
Doc.No.3: Copy of Premium certificate.
Doc.No.4 & 5: Copy of Final Bill dated 22.06.2016 and 20.06.2016.
Doc.No.6 & 7: Copy of Claim form-A dated 11.06.2016 and claim Form-A Dated 20.06.2016.
Doc.No.8, 9 and 10: Copy of Legal Notice, Receipt and Reply notice.
2. Witness examined on behalf of the Opposite party/s by way of affidavit:
RW-1: Sri G.Mahadevan, Local Regional Office.
Copies of Documents produced on behalf of Opposite Party/s
Document No.1: Copy of the Details of Insurance.
Document No.2: Copy of the policy Schedule.
Document No.3: Copy of policy Conditions.
Document No.4: Copy of the Discharge Summary.
Document No.5 & 6: Copy of the Repudiation claim.
Document No.7: Copy of Legal Notice.
Document No.8: Copy of Reply Notice.
MEMBER PRESIDENT
