Sri. P. Satheesh Chandran Nair (President):

The complainant filed this complaint u/s.12 of the C.P. Act 1986.

2. The case of the complainant is as follows. The complainant joined a business insurance scheme with opposite party and remitted                       Rs. 11,920/- on 10/04/2015 and subsequently he renewed the scheme from 10/04/2016 to 09/04/2017 as per the policy No. 140700/22001/2016/A005379/PE00204127.  According to the complainant as per rules and regulations of the scheme he and his wife are eligible to get, compensation in this case of death or disablement. It is contended that on 04/07/2016 the complainant was admitted at Muthoot Medical Centre, Pathanamthitta for Urinary retention and Hematuria.  He was discharged on 08/07/2016 after a surgery and he paid an amount of Rs. 58,910/- to the above said hospital.  On 10/07/2016 again he was admitted for Hematuria Post Trup and discharged on 18/07/2016.  It is contended that as per the policy he is eligible to get the medical bill from opposite parties since the scheme is cashless one.  It is further contended that though he claimed for re-imbursement the opposite party rejected the claim by informing that he was totally terminated the policy because his wife is an Arthritic person.  According to the complainant the act of the opposite parties are clear deficiency in service and they are liable to the complainant.  Hence this complaint for the reimbursement of the medical bill amount of Rs. 44,189/- with 10% interest, compensation, cost etc. etc.
3. This Forum entertained the complaint and issued notice to the opposite parties for their appearance. Both the opposite parties entered appearance but 1^st opposite party along file their version.  The version of 1^st opposite party is as follows.  According to the opposite parties the complainant is not maintainable either in law or on facts.  It is admitted that the complainant who availed a Health Insurance Policy from 1^st opposite party and the said policy was a family floater basis covering the complainant and his wife.  The sum insured is for Rs. 3,00,000/-.  It is further contended that when taking the policy complainant declared that “I confirm that I and other members proposed to be insured under this policy are in good health and have not suffered in last 5 years from any major disease/disorder/ailment of deformity”. The complainant had not disclosed to the effect that the complainant’s wife had Rheumatoid Arthritis with a total knee replacement in 2013 prior to the inception of the policy.  Therefore the policy has become void ab intio and therefore it was terminated by the company.  According to the opposite party the track of insurance are contracts ‘uberrima fides’ and every material fact must be disclosed or otherwise it would be a good ground for rescinding of the contract.  It is further contended that the complainant also signed a declaration that the statements are true complete in all aspects and also agreed the terms and conditions of the policy.  According to this opposite party he has not committed any deficiency in service against the opposite party as alleged by the complainant.  Therefore this opposite party prayed to dismiss the complaint with cost. 
4. We peruse the complaint version and records before us and framed the following issues for consideration:

1. Whether the complaint is maintainable before this Forum?
2. Whether the opposite parties committed any deficiency in service against the complainant?
3. Regarding the relief and costs?

5.  In order to prove the case of the complainant, the complainant he who filed a proof affidavit in place of chief examination and he is examined as PW1.  Ext. A1 to A3 and Ext. B1 to B3 were also marked through PW1.  Ext. A1 is the copy of the bill amount Rs. 44,189/- issued by the Muthoot Medical Hospital, Pathanamthitta.  Ext. A2 is the copy of the Petitioner ID Card issued from the 1^st opposite party.  Ext. A3 is the copy of the receipt of the cheque issued by the 1^st opposite party to the MGM Muthoot Medical Centre Pvt. Ltd. Hospital.  Ext. B1 is the copy of enrolment form dated: 10/04/2015.  Ext. B2 is the certificate of insurance policy with terms and conditions.  Ext. B3 is the policy terminate letter dated: 12/07/2016.  The opposite party filed an I.A 20/2017 for the production of document from the Superintendent of Mar Gregorious Memorial Muthoot Medical Centre and this Forum allowed I.A 20/2017.  The superintendent of Mar Gregorious Muthoot Medical Centre produced the records before this Forum on 13/06/2017.  Since the opposite party has not raised any objection for marking this document this Forum suo-moto marked this document as Ext. B4 to Ext. B6. Ext. B4 is the treatment history of the wife of the complainant Mariyamma George on 21/08/2013.  Ext. B5 is the treatment history she was admitted at Muthoot Medical Centre for Rheumatoid Arthritis on 07/07/2016.  Ext. B6 is the Medical Records in the same history for the same diseases on 23/01/2015. After the closure of evidence we posted this case for hearing. 
6. Point No.1:   When we go through version of 1^st opposite party it is to be noted that 1^st opposite party has taken a stand to the effect that the case is not maintainable either in law or on facts.  When we evaluate the evidence adduced by both the parties in this case, it is to see that the complainants he who availed a Health Insurance Policy from the opposite party for a period of 10/04/2016 to 09/04/2017 and he paid an amount of Rs. 58,910/- for the said policy.  Therefore we can easily come to a conclusion that the complainant is an insured and the opposite party No.1 is the insurer of the complainant.  In otherwise we can say that the complainant is a consumer and the opposite party No.1 is the service provider of the complainant.  Therefore, we can found Point No.1 in favour of the complainant. 
7.  Point Nos. 2 and 3:   For the sake of convenience, we would like to consider Point No.2 and 3 together.  As we stated earlier when the complainant is examined as PW1, he deposed more or less as per the tune of his complaint.  As per the testimony of PW1 it is revealed that he availed this Health Insurance Policy for the reimbursement of the medical claim.  It is also clear that on 04/07/2016 and on 10/07/2016 the complainant had admitted in Muthoot Medical Centre for Urinary Retention and Hematuria and complaint paid an amount of Rs. 58,910/- for the said surgery.  It is also proved that on 10/07/2016 he was again admitted for Hematuria Post Turp for 10/07/2016 and discharged on 18/07/2016 from the same hospital.  It is also admitted that the complainant he who filed a claim before the 1^st opposite party and the claim rejected by the opposite party so that the policy was terminated by the opposite party for the reason ‘suppression of material fact’.  At this stage we have to consider that whether the complainant’s suppressed any material fact at the time of the inception of the policy.  We do admit that at the time of filing the proposal form the complainant declared “I confirm that I and other members proposed to be insured under this policy are in good health and have not suffered in last 5 years from any major disease/disorder/ailment of deformity (other than common cold, fever, loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetes, without any complications or hypertension without any complication)”.               

We are also of the view that the contract of insurance is a contract ‘Uberimmae fidei’ and parties are bound to observe utmost good faith upon it.  It is proved that the complainant had admitted for Urinary retention and hematuria for two time and spend an amount of Rs. 58,910/-.  In order to prove this fact complainant produced and marked Ext. A1.  Ext. A2 is an ID card issued from 1^st opposite party with the mention of 2^nd opposite party’s name.  Ext. A3 is a document to show that 1^st opposite party has issued a receipt of claim dated: 11/01/2017 for an amount of Rs. 55,454/- (stated as settle amount).  In order to rebut the contention of PW1 and substantiate the case of 1^st opposite party, opposite party marked Ext.B1 to Ext. B3 through PW1.  Ext. B1 is the copy of the enrollment form of the complainant to this insurance scheme and Ext.  B2 is a certificate of insurance and health in favour of the complainant.  It is to be noted that the complainant he who signed Ext. B1 in paragraph 3 page 1 of Ext. B1 there is a declaration and warranty on behalf of all persons to be insured.  When we go through the contents of this declaration we can find that it is the duty of the insured to declare that the insured are in good health and have not suffered any major disease/dishonored ailment or deformity (other than common cold, fever, loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetes, without any complications or hypertension without any complication)”.  Ext. B2 is the certificate of insurance of health in favour of the complainant. When we go through Ext. B2 we can see the terms and conditions of the said policy including procedure for claim key exclusions etc.  The main contention of the opposite party is that the complainant he who suppressed the Rheumatoid complaint and history of knee replacement of his wife at the time of the inception of the policy.  In order to substantiate this contention the opposite party produced and marked Ext. B2. When we refer Ext.B3 which is a letter to the complainant shows that the complainant’s wife Mariyamma George had a past history of Rheumatoid Arthritis with a total knee replacement in the year 2013 prior to the policy inception.  According to the opposite party the complainant purposefully suppressed the knee replacement of 2013 for availing the policy and receiving the benefits.  It is stated that the complainant was not disclosed this surgery at the time of filing the application for Health Insurance Coverage (Proposal Form).  When we peruse the proposal form we can see that the complainant had not mentioned the details of the knee surgery at the time of the application for availing the policy.  The next question to be considered is whether the opposite party proved this fact before the Forum.  When we go through Ext. B4 the treatment history of the wife of the complainant Mariyamma George on 21/08/2013 can be seen.  She was admitted in Muthoot Medical Centre for the knee replacement surgery and her complaint is recorded as ‘knee Rheumatoid Arthritics’ and on 22/08/2013 onwards different laboratory test also was conducted on her.  As per Ext. B5 it is also proved that on 07/07/2016 she again admitted at Muthoot Medical Centre for Rheumatoid Arthritis.  Ext. B6 also shows that 23/01/2015 she was again admitted for the same diseases.  Anyway it is come out in evidence to see that the complainant’s wife was suffering Rheumatoid complaint in her knee and she was admitted 3 times in Muthoot Hospital for treatment.  The complainant admitted that he joined the said insurance scheme and remitted a premium amount of Rs. 11,920/- on 10/04/2015 and subsequently it is required from 10/04/2016 to 09/04/2017.  Subsequently on 04/07/2016 the complainant George C Koruthu was admitted in Muthoot Medical Centre, Pathanamthitta for Urinary Retention Hematuira and a surgery was conducted and he was discharged on 08/07/2016 and a bill amount is Rs.58,910/- was paid to 1^st opposite party for the surgery.  When we refer Ext.B3 we can see that the insurance policy of the complainant was terminated on 12/07/2016 for the reason of suppression of pre-existing diseases of his wife.  The said notice is deemed as a notice of 30 days for the termination of the policy.  Anyway at the time of the admission of the complainant at Muthoot Medical Centre the policy was valid and no termination is affected.  The learned counsel appearing for the opposite party filed and argument  note  and  argued that the complainant  filed a declaration to the effect that he and other Members proposed to the insured under the policy were in good health and had not suffered any Major diseases/disorder/ailment or deformity prior to 5 years of the ailment of the policy.  When we go through the evidence adduced by the opposite party through Ext. B4 to B6 it is crystal clear to see that complainant’s wife was admitted for rheumatoid complaint prior to the inception of the insurance policy dated: 10/04/2015.  No doubt, it is a clear violation on the part of the complainant.  In order to substantiate the contention of the opposite party, they cited a decision reported in (2001)2 SCC 160 by our Hon’ble Supreme Court in Life Insurance Corporation Vs. Asha Goel.  It is held that contract of insurance including the contract of life insurance are contracts uberrima fides every material facts must be disclosed, otherwise, it would be a good ground for residing of the contract.  Our Hon’ble Supreme Court in Satwant Kaur Sandhu Vs. New India Assurance Company Limited (2009) 8 SCC 316 also agreed the prior finding.  The decision of our National Commission in Life Insurance Corporation Vs Kuldeep Singh is also applicable to the fact and the circumstances of this case.  It is also argued that contract of insurance is a contract based on the terms and conditions of the policy of the opposite parties are liable only according to the terms and conditions, limitation and exclusion of the policy.  Anyway consider the whole evidence before this Forum we can easily come to a conclusion that the complainant herein is suppressed the pre-existing diseases of his wife at the time of filing the proposal form/application form for availing the health insurance policy.  If so the repudiation of the claim application of the complainant cannot be seen as an ultravirus act of the opposite party.             We find that the repudiation of the insurance policy by the opposite party was not

comes under the deficiency in service as defined in Consumer Protection Act 1986.  The complainant miserably failed to establish any deficiency in service on the part of opposite parties and therefore this complaint is liable to be dismissed.  Hence Point No.2 and 3 are also found against the complainant. 

8. In the result we pass the following orders:

             (1). The case is dismissed.

             (2). No order for cost.    

                    Dictated to the Confidential Assistant, transcribed and typed by her, corrected by me and pronounced in the Open Forum on this the 04^th day of August, 2017.

                                                                                              (Sd/-)

                                                                   P. Satheesh Chandran Nair,                                                                                                                                                                                                                                              

                                                                                          (President)

Smt. Sheela Jacob (Member)               :  (Sd/-)

Appendix:

Witness examined on the side of the complainant:

PW1  : George C Koruthu.

Exhibits marked on the side of the complainant:

A1 : Copy of the bill amount Rs. 44,189/- issued by the Muthoot Medical

       Hospital, Pathanamthitta.

A2 : Copy of the Petitioner ID Card issued from the 1^st opposite party.

A3 : Copy of the receipt of the cheque issued by the 1^st opposite party to the MGM

       Muthoot Medical Centre Pvt. Ltd. Hospital.

B1: Copy of enrolment form dated: 10/04/2015.

B2: Certificate of insurance policy with terms and conditions.

B3:  The policy terminate letter dated: 12/07/2016.

Witness examined on the side of the opposite parties: Nil

Exhibits marked on the side of the opposite parties:

B4 : Treatment history of the wife of the complainant Mariyamma George on

       21/08/2013.

B5 : Treatment history she was admitted at Muthoot Medical Centre for

       Rheumatoid Arthritis on 07/07/2016.

B6 : The Medical Record in the same history for the same diseases on

        23/01/2015 issued by Muthoot Medical Centre.             

                                                                                              (By Order)

Copy to:- (1) George C. Koruthu,

                     Chakkala Mannil Kizhakum Madathil Veedu,

                     Muttathukonam Muri,

                     Chenneerkara.P.O, Pathanamthitta Dist.

2. The Manager,

                     Appollo Munich Health Insurance Co. Ltd. (Reg. off)

                     Appollo Hospital Complex, Jubily Hills,

                     Hyderabad – 500033, Telangana.

3. The Manager,

           Indian Overseas Bank,

           Chenneerkara.

4. The Stock File.