By Sri. Mohamed Ismayil.C.V, Member
1. The grievances of the complainant is as follows:-
The complainant is availed a Health Plan Insurance Policy (Policy No:120100/ 12586/2017/A007873/PE00590427) titled as Group Assurance Health Plan from the opposite parties on 07/07/2017. As per the policy, the opposite parties will cover the medical expenses of the insured persons for any and all treatments that come within the conditions stated in the policy documents. The complainant, his wife and daughter were covered under the policy. The complainant held an bank account with the second opposite party , who was in collaboration with the first opposite party offered above said insurance plan named “Çanara Bank Group Assurance Health Plan” for the account holder of the second opposite party. According to the complainant , the first opposite party assured the policy holders as the policy was covered medical expenses of the insured group throughout the policy period and the second opposite party collected and paid the policy subscription from the account of the complainant to pay to the first opposite party. The second opposite party introduced about the insurance plan and acted as medium of communication between the complainant and the first opposite party. It was stated in the complainant that the bogus and untrue representation made by the second opposite party on behalf of the first opposite party prompted the complainant to act and invest in the insurance policy. It is stated in the complainant that on 14/05/2018 the complainant was admitted in EMS Memorial Co-operative Hospital and Research Centre, Perintalmanna and diagnosed for Chronic Ischaemic heart disease and undergone treatment therein. On 31/05/2018 the complainant claimed Rs. 98,601/- as reimbursement of medical expenses and submitted relevant documents before the first opposite party . But in replies, the first opposite party sent two letters dated 07/06/2018 and 08/06/2018 terminating the Group Health Individual Policy (Policy No. PE00590427) and rejecting the claim made under claim ID 769821 respectively. The reason for termination and rejection of the claim made by the complainant was that at the time of taking policy, he did not disclose about a percutaneous transluminal coronary angioplasty underwent by the complainant in the year 2016. According to the opposite party non-disclosure of previous medical treatment was in violation to the terms of the policy and the policy is liable to the terminated ab-initio. It is contended in the complaint that the reason stated by the opposite parties to the rejection of the claim was not true. It is stated by the complainant that he made free and full disclosure to the agents of the opposite parties about his health condition.
2. The complainant stated that the history of undergoing angioplasty was disclosed fully and completely to the opposite parties and the complainant was told that angioplasty is not a surgical process and hence would not come under the exclusion of the policy. All health details were revealed and explained to the opposite parties at the time of taking policy. The opposite parties agreed to enroll the complainant to cover the insurance policy after collecting all confirmation about health condition. The complainant disclosed that the opposite parties were acting in malice from the beginning itself and had caused the complainant to wrongfully invest in the policy as he had little knowledge of the terms and treacheries of modern business. The complainant acted upon the representation made by the second opposite party, which was acting at the instance of the first opposite party. So both the opposite parties are equally and jointly liable to make compensation for the loss suffered by the complainant due to the bogus and untrue representation made by the second opposite party. So the complainant approached this Commission praying for an order to direct the opposite parties to reimburse Rs.98,601/- to the complainant towards the medical expenses and also to direct the opposite parties to pay Rs.1,00,000/- to the complainant towards compensations to the mental and physical strain and suffering undergone by the complainant. The complainant also prayed to pay Rs. 10,000/- as cost of the proceedings.
3. The complainant was admitted on file and issued notices to the opposite parties. The opposite parties received notices. The First opposite party filed their version. But second opposite party did not file version and set exparte.
4. The first opposite party contended in the version that the complaint is not maintainable either in law or on facts. The averments in the complaint that the insurance policy was a health plan wherein the first opposite party would cover the medical expenses of the insured person for any and all treatments that come within the terms and conditions stated in the policy documents is false and denied by the first opposite party. According to the first opposite party the policy was issued through due process of filing proposal form, on which good health declaration having specific questions regarding health was confirmed in positive by the complainant and his consent was shared with the first opposite party through OTP on mobile number stated in the proposal form and the policy schedule , in the absence of which it was not possible to issue the policy. The allegation in the complaint that the first opposite party in collaboration with the second opposite party offered a group health insurance plan named Canara Bank Group Assurance Health Plan for the account holders of the second opposite party is false and hence denied by the first opposite party. The further allegation that the first opposite party assured the policy holder to cover the medical expenses of the insured group throughout the policy period is false and denied in the version. According to the first opposite party no such assurance was made to the complainant nor was the second opposite party legally authorised to make representation on behalf of the first opposite party. It is also contended by the first opposite party that no bogus and untrue representations were ever made to the complainant as every benefit of the policy is governed by its terms and conditions. It is also stated in the version that the complainant did not submit any documents along with original cash receipts for reimbursement and not incurred expenses of Rs. 98,601/- as claimed by the complainant. The first opposite party stated that the complainant availed the Apollo Munich Group Assurance Health Plan from the first opposite party and had withheld material information at the time of obtaining the policy and the policy was issued on 07/07/2017 on the basis of the proposal form submitted by the complainant. The complainant had a medical history of percutaneous transluminal coronary angioplasty in the year 2016 and the details of which were not disclosed to the first opposite party so the policy was terminated owing to non–disclosure of material facts. It is also contended that if the complainant had made clear disclosure about his angioplasty then the policy would not have been issued to him. According to the first opposite party once a person undergoes angioplasty there is always a high risk of heart ailment which also evident enough by the complainant’s claim itself for medical reimbursement in connection with Ischemic heart disease. The contention in the complaint that angioplasty is not a surgical process and hence would not come under the exclusions of policy is denied by the first opposite party. In the proposal form, it was stated by the complainant that he himself or any of the members proposed to be insured does not have any disease of the major organs including but not limited to brain, heart, kidney, lungs, liver or mental health disorder. The complainant had further declared that neither he nor the persons proposed to be insured have undergone any major surgery (any surgery done other than those under local anaesthesia) in the last 5 years. It is contended in the version that the complainant is not entitled to an amount of Rs. 98,601/- towards medical expenses. The complainant is also not entitled to an amount of Rs. 1,00,000/- towards alleged physical and mental strain and suffering and an amount of Rs. 10,000/- towards costs of legal proceedings. The first opposite party prayed for dismissal of the complaint with costs.
5. The complainant and first opposite party filed affidavits. The documents produced by the complainant marked as Ext. A1 to A6. Ext. A1 document is the copy of Certificate of Insurance issued by the first opposite party to the complainant. Ext. A2 document is the copy of discharge summary dated 22/05/2018 issued by EMS Memorial Co-operative Hospital and Research Centre, Perintalmanna to the complainant. Ext.A3 document is the copy of discharge bill dated 19/05/2018 issued by EMS Memorial Co-operative Hospital and Research Centre. Ext. A4 document is the copy of letter of termination dated 07/06/2018 issued by the first opposite party to the complainant. Ext. A5 document is the copy of claim rejection letter dated 08/06/2018 issued by the first opposite party to the complainant. Ext.A6 document is the copy of Bank account passbook issued by the second opposite party to the complainant. Even though the first opposite party mentioned about three documents in the affidavit, but did not produced any of them before the Commission.
6. The complainant and first opposite party heard in details. The affidavits and documents perused. The following points arised for the consideration.
1. Whether there was any deficiency of service on the part of the opposite
Parties?
2. Relief and costs?
7. The complainant stated that he availed a health insurance policy titled as ‘Group Insurance Health Plan’ from the first opposite party in which intermediary was the second opposite party. During the period of insurance coverage i.e, on 14/05/2018 the complainant was admitted in the hospital for Chronic Ishaemic heart disease. According to the complainant after undergoing treatment, he claimed Rs. 98,601/- as reimbursement of medical expenses under the policy coverage from the first opposite party. In order to prove the insurance coverage policy, the complainant produced Ext.A1 document before the Commission. The complainant produced Ext. A3 document to prove his claim of Rs. 98,601/- as reimbursement of medical expenses under the coverage of Ext. A1 document. Ext. A2 document is the discharge summary of the complainant from the hospital after his treatment. But the first opposite party issued Ext. A4 termination letter to the complainant. Ext.A4 document states that the health condition of insured member was incorrectly disclosed at the time of making application for health insurance coverage. According to the first opposite party, the complainant had undergone percutaneous transluminal coronary angioplasty in the year 2016 and same was not disclosed at the time of signing proposal form. So the first opposite party also issued Ext. A5 document to the complainant repudiating the claim made for reimbursement of medical expenses.
8. When going through the evidences adduced by the complainant it can be seen that his banker, the second opposite party acted as an intermediary in availing the insurance coverage to the complainant. Ext. A1 document shows the role of the second opposite party in the transaction. Ext. A6 document is the pass book of the complainant which shows that the complainant was an account holder in the bank of second opposite party and through which he remitted insurance premium to the first opposite party. According to the complainant at the time of signing proposal form he had made free and full disclosure to the opposite parties about his health condition. It is contended by the complainant that at the time of purchase of the policy he was hale and healthy person. The complainant vehemently stated in the complaint and affidavit that the history of undergoing angioplasty was disclosed to the opposite parties. In reply, the opposite parties told that angioplasty was not a surgical process and hence would not come under exclusion of policy. The complainant also explained that he revealed all the health details of the complainant to the opposite parties at the time of taking policy. The contention of the first opposite party that the complainant did not disclose medical history at the time of submitting the proposal form cannot be taken into consideration. In order to prove the contention made in the version and affidavit, the first opposite party did not produce the proposal form before the Commission. Even though the first opposite party stated about proposal form in the affidavit the same was not produced before the Commission at any point of time to substantiate their contention. So it crystal clear from the evidences that the complainant had disclosed about his health history at the time of execution proposal form to avail the insurance coverage policy No.120100/12586/2017/A007873/PE00590427.
9. The first opposite party filed a petition numbered as IA 156/2019 to produce the medical records from the hospital wherein the complainant undergone treatment. On 02/03/2020 he hospital authorities produced those medical records before the Commission pertaining to the treatment of the complainant. But the first opposite party did not take any step to mark those documents as part of the evidence. The fact came out in the evidence is that the complainant informed the history of treatment at the time of taking policy and the first opposite party failed to adduce contra evidence by producing the document which was kept in the custody of the first opposite party themselves. So the Commission finds that there is deficiency in service on the part of the first opposite party as the first opposite party failed refund the medical expenses incurred to the complainant as per the conditions of health insurance policy. The second opposite party was only acted as intermediary and no evidence of deficiency in service found against them. As a result of the second opposite party is hereby exonerated from the liability. In the light of the above findings the Commission allows the complaint as follows:-
- The first opposite party shall refund Rs. 98,601/- (Rupees Ninety eight thousand six hundred and one only) to the complainant as the reimbursement of medical expenses as per the terms and conditions of the policy.
- The first opposite party shall pay Rs. 50,000/- (Rupees Fifty thousand only) to the complainant as compensation for the negligent act committed by the first opposite party in making refund of the medical expenses.
- The first opposite party shall pay Rs. 10,000/-(Rupees Ten thousand only) as the cost of the proceedings to the complainant.
The first opposite party shall comply this order within 30 days from the date of receipt of this order otherwise the entire amount shall bear 9% interest per annum from the date of order to till realisation.
Dated this 28th day of October, 2022.
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
APPENDIX
Witness examined on the side of the complainant : Nil
Documents marked on the side of the complainant : Ext.A1to A6
Ext. A1 : Copy of certificate of Insurance issued by the first opposite party to the
complainant.
Ext. A2 : Copy of discharge summary dated issued by EMS Memorial co-operative
hospital and Research Centre,Perintalmanna22/5/2018 to the complainant.
Ext.A3 : Copy of discharge bill dated 19/05/2018 issued by EMS memorial Co-
operative Hospital and Research Centre.
Ext. A4 : Copy of letter of termination dated 07/06/2018 issued by the first
opposite party to the complainant.
Ext. A5 : Copy of claim rejection letter dated 08/06/2018 issued by the first
opposite party to the complainant.
Ext.A6 : Copy of Bank account passports issued by the second opposite party to
the complainant.
Witness examined on the side of the opposite party : Nil
Documents marked on the side of the opposite party : Nil
MOHANDASAN K., PRESIDENT
PREETHI SIVARAMAN C., MEMBER
MOHAMED ISMAYIL C.V., MEMBER
