BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.1111/2014

DATED ON THIS THE 10^th March 2017

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                                          B.E., LLB.,    - MEMBER

Sri DEVAKUMAR.M.C,

Member

1.     The complainant filed the complaint alleging deficiency in service and seeking a direction to pay the medical expenses of Rs.1,13,887/- along with damages and 18% interest per annum with other reliefs.
2.     The complainant obtained a health insurance policy from opposite party on 13.09.2010.  She got treated for liver cirrhosis at Adithya Hospital on 13.02.2014, and incurred an expenditure of Rs.44,109/- and discharged on 20.02.2014.  Submitting all the relevant documents claimed for reimbursement of medical expenses.  Again she undergone uterus surgery on 25.04.2014 at J.S.S. Hospital and incurred a sum of Rs.35,278/-.  The opposite party rejected the claims made by the complainant, on the ground of suppression of pre-existing diseases.  The aggrieved complainant, alleging deficiency in service filed the complaint seeking reliefs.
3.     The opposite party admitted the issuance of the easy health individual standard insurance policy covering the complainant and her son, based on the information furnished in the proposal form for the period between 14.09.2010 to 13.09.2011 and the policy was further renewed from time to time and finally for the period 16.10.2013 to 15.10.2014, subject to the policy terms and conditions.  On receipt of all the relevant documents and bills from the Adithya Hospital, the opposite party realised that, the complainant has suppressed the material facts in the proposal form and hence the claim is denied.  So there is no negligence and deficiency and not liable to pay any compensation.  As such, prays for dismissal of the complaint.
4.     Both side parties lead their evidence by filing affidavit and relaying on several documents.  Written arguments filed.  Perusing the material on record, matter posted for orders.
5.      The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service on the part of opposite party, in not settling the health insurance claim amount and are entitled for the reliefs sought?
2.  What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the negative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant purchased a health insurance policy on 13.09.2010, covering herself and her son.  She had taken treatment for liver cirrhosis between 13.02.2014 to 20.02.2014, at Aditya Hospital, Mysuru and incurred a sum of Rs.44,109/-.  Reimbursement was claimed under the policy by submitting all the relevant documents.  Subsequently, on 25.04.2014, she undergone uterus surgery at JSS Hospital, Mysuru and incurred a sum of Rs.35,278/-.  The claims made by submitting all the documents, got repudiated by the opposite party on the ground of suppression of material facts in the proposal form, relating to her pre-existing diseases.
8.      The complainant, undergone surgery and treatment for tuberculosis in the year 1999.  The complainant suppressed this fact while furnishing information in the proposal form.  The opposite party on investigation found the said facts were suppressed by the complainant, at the time of taking the present insurance policy.  Thereby, the complainant has clearly violated the policy terms and conditions, as such, the opposite party has rightly repudiated the claims.
9.     The opposite party relied on judgement rendered by the Hon’ble Supreme Court of India, in P.C.Chacko V/s Chairman, LIC and contended that, any kind of suppression of material facts amounts to violation of policy terms and conditions, which vitiates the contract of insurance as void ab-initio.

10. With the above observations, we opine that the complainant is not entitled for any amount under the health insurance policy and any damages from opposite party.  Accordingly, we answer the point No.1 is answered in the negative.

11. Point No.2:-With the above discussions, we proceed to pass the following

:: O R D E R ::

1. The complaint is hereby dismissed.
2.  Give the copies of this order to the parties, as per Rules.

 (Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 10^th March 2017)

                          (H.M.SHIVAKUMARA SWAMY) 

                                      PRESIDENT     

(M.V.BHARATHI)                           (DEVAKUMAR.M.C.)

      MEMBER                                         MEMBER