BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.1597/2014

DATED ON THIS THE 10^th February 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 under section 12 of the C.P.Act, 1986, against the opposite party, alleging deficiency in service and unfair trade practice and seeking direction to pay Rs.2,19,433/- towards hospitalization expenses and Rs.2,00,000/- compensation for the mental agony and with other reliefs.
2.     The complainant obtained a Health Insurance Policy from opposite party and the same valid between 29.11.2012 to 28.11.2014.  A pre-medical examination was conducted and on satisfying the information furnished the opposite party issued the policy by collecting a premium of Rs.11,661/-.  As per the policy opposite party is liable to indemnity the insured for any treatment availed and expenses towards treatment etc., The complainant got treatment for hepatitis in May 2012 at Udupi.  Again she took treatment discharged disease in Mysuru on 01.04.2013 and after treatment for the same from hospital on 02.04.2013.  Once again the insured suffered with chronic liver diseases and got treatment at Narayana Hrudayalaya between 17.03.2013 to 29.03.2013 and incurred a sum of Rs.1,51,800/- and the same submitted to opposite party for settling the claims.  The opposite party kept on dodging the matter without settlement of the claim, despite of several requests.  The opposite party repudiated the claim on 06.05.2014.  Subsequently, the insured fell ill and hospitalised on 06.05.2014 and after two days i.e. on 08.05.2014, she died.  An expense of Rs.67,633/- incurred by the complainant and claimed the same also.  On refusal to settle the claim, the complainant alleged the deficiency in service and unfair trade practice by opposite party.  Hence, filed the complaint, seeking reliefs.
3.     The opposite party filed version denying the allegations as false and submits the policy was issued on 21.11.2011 based on the information furnished in the proposal form.  Subsequently, the policy renewed from 29.11.2012 to 28.11.2014.  On scrutiny of the documents submitted by the hospital, opposite party found that the insured was suffering from jaundice prior to the policy.  The insured suppressed the facts and obtained the policy.  Thereby, the insured violated the terms and conditions of the policy and for concealment of the material facts, the policy claims have been repudiated and there is no deficiency in service and are not liable to pay any compensation.  As such, prays for dismissal of the complaint.
4.     To prove the facts, both parties filed their affidavit evidence along with several documents.  Opposite party filed written arguments.  Counsel for complainant and opposite party submitted oral arguments.  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 and unfair trade practice in not settling the claims made under the insurance policy, thereby he is 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 obtained the health insurance policy from opposite party on payment of premium amount and renewed periodically.  The insured with the complaint of hepatitis, initially took Ayurvedic treatment at Udupi in May 2012.  On recurrence of the disease, she took treatment at Vikrma Jyoth Hospital from 01.04.2013 to 02.04.2013.  Subsequently, she got admitted to Narayana Hrudayalaya for treatment for her chronic liver disease from 19.03.2014 to 29.03.2014 and incurred a sum of Rs.1,51,800/-.  The claim made to opposite party, by submitting all the relevant documents, but opposite party denied to settle the claim for suppression of material facts vide its letter dated 06.05.2014.  Again, the insured fell ill on 05.05.2014 and hospitalised for septicaemia septic shock and after two days, died on 08.05.2014.  The hospital collected a sum of Rs.67,633/- towards medical bill.  Again, the opposite party repudiated the claims with a pre-determination for untenable grounds on 01.06.2014.
8.    Subsequently, the complainant obtained clarification from Vikram Jyoth Hospital, regarding the error crept in the certificate issued and claimed for reimbursement of expenses, by submitting the same to the opposite party.  Further, the complainant claims that the insured never suffered with pre-existing diseases and never suppressed any material facts from opposite party and the complainant was went abroad during the period mentioned in the documents issued by the Vikram Jyoth Hospital.  Hence, claimed that he is entitled to the benefits of insurance policy and alleged, the repudiation of claims amount to unfair trade practice and deficiency in service by opposite party.  As such, prays for the reliefs.
9.    The opposite party submitted all the relevant documents in support of their contention for repudiation.  The policy has been issued on the basis of information furnished in the proposal form and the declaration to that effect.  The policy is subject to terms and conditions.
10. The opposite party found that there is concealment of material facts, in obtaining the insurance policy.  As per the terms of the policy, any concealment of material facts, relating to the health status and other particulars, vitiates the policy.  As such, the claims have been repudiated.  Hence, contended that, there is no deficiency in service and unfair trade practice by them and not liable to pay any compensation.  As such, prays for dismissal of the complaint.
11. The documents placed on record established that, the insured suffered diseases relating to liver prior to taking of the policy and by suppressing the material facts, she obtained the insurance policy.  Complainant failed to established that, the insured was not in India, by means of any cogent evidence.  Further, the clarification letter issued by the Vikram Jyoth Hospital on 27.05.2014, has been obtained belatedly after repudiation of the insurance claim by opposite party.  Hence, the same is not acceptable.  Further, the death summary discloses that the insured was a known case of chronic liver disease, not on regular treatment, acute kidney injury.  Hence, the repudiation of insurance policy claims by opposite party is justified and the complainant is not entitled for claims and damages and the complaint is liable to be dismissed.  Accordingly, point No.1 is answered in the negative.
12. Point No.2:- With the above observations, 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 February 2017)

                          (H.M.SHIVAKUMARA SWAMY) 

                                      PRESIDENT     

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

      MEMBER                                         MEMBER