Kerala

StateCommission

A/16/124

BRANCH MANAGER HEALTH INSURANCE - Complainant(s)

Versus

BABY V M - Opp.Party(s)

ANITHA AJI

09 Aug 2018

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION SISUVIHARLANE VAZHUTHACADU THIRVUANANTHAPURAM

APPEAL NUMBER 124/16

JUDGMENT DATED : 09.08.2018

 

(Appeal filed against the order in CC.No.497/2014 on the file of CDRF, Ernakulam order dated 30.10.2014)

PRESENT

HON’BLE JUSTICE SRI.S.S. SATHEESACHANDRAN   : PRESIDENT

SRI.T.S.P. MOOSATH                                      : JUDICIAL MEMBER

SRI.RANJIT. R                                         : MEMBER

 

APPELLANT

The Branch Manager, LIC of India, Branch Office,

Moovattupuzha – 686661

 

Represented by the authorized officer, Manager L& HPF LIC of India, Divisional Office, Thiruvananthapuram

(By Adv.Smt.AnithaAji)

VS

RESPONDENT

Baby.V.M, Vettukallel House, Edayar.P.O,

Koothattukulam, Pin – 686 662

(By Adv.Sri.Tom Joseph)

JUDGMENT

SRI.T.S.P.MOOSATH                              : JUDICIAL MEMBER

Opposite Party in CC.No.497/14 of the Consumer Disputes Redressal Forum, Ernakulam, in short, the district forum, has filed the appeal against the Order passed by the district forum by which the appellant was directed to consider the claim of complainant and to give eligible amount due to him under the insurance policy and compensation of Rs 1,00,000/- (Rupees one lakh only) with cost of Rs 10,000/- (Rupees ten thousand only).

          2.      The averments in the complaint are in brief as follows. Complainant had taken a Jeevan Raga Policy from the opposite party M/s.LIC, Koothtattukulam Office. On 14.11.2011 complainant was subjected to a through medical examination before issuing the policy. The panel doctor of the opposite party had conducted various tests including ECG test for hypertension, cholesterol, diabetes etcto rule out the existence of any such disease. Complainant was issued the policy on the basis of the medical report approved by the opposite party. Complainant was again subjected to a medical examination by a panel of opposite party on 13.08.2013 for the purpose of revival of the policy which lapsed due to nonpayment of the premiums. Confirmedof the medical fitness of complainant, the policy was revived. Thereafter on 27.02.2014 complainant approached Apollo Hospital, Chennai with complaints of chest pain. His complaint was diagnosed as triple vessel coronary artery disease and he was subjected to an operation in that hospital on 28.02.2014. Complainant had incurred an amount of Rs 2,38,000/- towards the treatment expenses, for claiming it he lodged a claim before the opposite party.  Claim was repudiated by opposite party by letter dated 17.04.2014 on the ground that at the time of making proposalthere was material suppression by complainant. Reason stated for repudiation of the claim is unsustainable. Opposite party had denied the genuine claim of the complainant. Complainant is entitled to the benefits as per the policy, and he is also entitled to get costs and compensation. 

          3.      Opposite party appeared and filed version raising the following contentions. Complainant had filed a representation to the opposite arty and that representation is under active consideration of the opposite party. Meanwhile the complainant had filed this complaint before the forum,which is premature. Without prejudice to the above contention, the opposite party submits that the complainant did not pay the premium which was due on 30.06.2013 in time and the policy was lapsed. However, on payment of arrears and production of satisfactory evidence the policy was revived. Complainant was admitted in Apollo Hospital, Chennai on 27.02.2014 during the currency of the policy following complaints of Angina and it was diagnosed that the complainant was suffering from triple vessel disease. He underwent a surgery on 28.02.2014. At the time of admission in hospital complainant had disclosed that he suffered from hypertension for the previous three years.  Even prior to taking JeevanArogya Policy complainant had some heart problems. At the same time in answer to query No.9(7) in the proposal complainant had stated that he was not suffering from hypertension /blood pressure, heart attack, chest pain etc. Complainant had concealed his major ailment of the heart in the proposal form and also suppressed material facts regarding his health. The mere fact that the medical officer of LIC was satisfied that the life assured was good is not much of any consequence. False answers given by the complainant in the proposal form would vitiate the contract of insurance which is based on good faith. In the discharge summary issued by the Apollo Hospital, it is stated that complainant was hypertensive for the last three years. This is based on the information correctly furnished by the patient to help the surgeon to make a correct evaluation and proper diagnosis of the disease. Under clause 7 (1) any pre-existing condition unless disclosed to and accepted by the Life Insurance Corporation prior to the date of cover the benefit of the policy would be excluded. Therefore, there is no deficiency in service on the part of the opposite party and the complaint is liable to be dismissed. 

          4.      No oral evidence was adduced by both sides. Exts. A1 to A5 were marked on the side of complainant and Exts.B1 to B3 were marked on the side of opposite party. After considering the evidence adduced by the parties and hearing both sides the district forum has passed the impugned Order.

          5.      Aggrieved by the Order passed by the district forum the opposite parties have preferred the present appeal.

          6.      Heard both sides. Perused the records.

          7.      Complainant had taken a Jeevan Suraksha Arogya Policy from the opposite party, insurance company. Exts.A1 & B2 are the copies of insurance policy, and Ext.B1 is the proposal form. Ext.B3 is the copy of the conditions and privileges of Jeevan Suraksha Arogya Policy. Complainant underwent heart operation at Apollo Hospital, Chennai on 28.02.2014. Exts A3, A4 & A5 are the copies of medical records regarding the treatment of complainant. Complainant lodged a claim before the opposite party insurance company. His claim was repudiated by the insurance company as per Ext.A2 repudiation letter. There is no dispute to these facts. It is the case of opposite party that the complainant was suffering from hypertension and that fact was not disclosed by him in Ext.B1 proposal form. So there was nondisclosure of material fact by the complainant and that would entitle the opposite party to repudiate the claim. Clause No.9 of Ext.B1 deals with the health details and medical information of the insured. In sub clause no.7 of clause no.9 to the question ‘Has the life to be insured ever suffered or is suffered from hypertension / high blood pressure’ the answer given by complainant was in the negative, stating ‘No’. As observed by the district forum in Ext.B1 no space is provided to make voluntary disclosure on the part of complainant with regard to any symptomsof illness which he suffered and the answer to be given is either ‘Yes’ or ‘No’. Opposite party has no case that the complainant was earlier admitted in any hospital for treatment suffering from any disease shown in Clause No.9 of the proposal form. Only contention of the opposite party is that in the discharge summary issued from the Apollo Hospital, the doctor had stated that the patient (complainant) was hypertensive for the last three years. It is an admitted fact that before issuing the insurance policy complainant was examined by a doctor in the panel of opposite party, and, later, in the year 2013, at the time of revival of the policy after it lapsed complainant was subjected to examination by a team of doctors but they could not detect any disease to the Complainant had filed the proposal form in 2011. He was admitted in hospital for treatment in the year 2014. So it cannot be stated that the complainant was aware of his disease earlier. The mere fact that the doctor in the Apollo hospital who prepared the discharge summary had made a passing reference that the complainant was hypertensive since last three years cannot be taken as a ground for repudiating the claim of complainant. The doctor who prepared the discharge summary was not examined before the forum.

          8.      In ‘ICICI Prudential Life Insurance Bank Ltd V/s Veena Sharma & another’ (IV (2014) CPJ 580 (NC) it was held that insurance company is required to prove with credible evidence that the complainant was suffering from preexisting decease and had knowingly failed to disclose the same. Mere production of discharge card containing an adverse remark is not enough. In ‘Satish Chander Madan V/s Bajaj Alliance General Insurance Co.Ltd’ (1 (2016) CPJ 613 (NC) it was held that hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Treatment for heart problem cannot be termed and equated as a preexisting decease. In the light of the dictums laid down in the above cited decisions, and considering the facts of the case it is seen that the finding of district forum that repudiation of the claim of complainant by the opposite party on the ground that complainant had preexisting decease and he had knowingly failed to disclose the same in the proposal form is not proper and there was deficiency of service on the part of the opposite party, is correct. So, the direction given by the lower forum ordering the opposite party / insurance company to scrutinize the claim of complainant and give him admissible amount spent by him in the hospital on the basis of the insurance policy does not call for any interference. Amount of Rs 10,000/- (Rupees ten thousand only) ordered as cost is just and reasonable and no interference thereof is called for. The district forum found that the complainant is entitled to get Rs 50,000/- (Rupees fifty thousand only) as compensation for deficiency in service and he is also entitled to get Rs 50,000/- (Rupees fifty thousand only) as compensation for the unfair trade practice from the opposite party. Considering the facts and circumstances of the case we find it just and reasonable that the amount of compensation ordered has to be reduced and limited to Rs 25,000/-.Unfair trade practice means a trade practice which for promoting sale, use or supply of goods of for the provision of services adopts any unfair method or unfair or deceptive practice. Insurance company repudiated the claim on an unsustainable ground based on the entries in discharge card of complainant cannot at all postulate that it has adopted an unfair trade practice. So the sum of Rs 50,000/- (Rupees fifty thousand only) awarded to complainant holding that insurance company adopted unfair trade practice is liable to be set aside, and we do so. Order of the lower forum shall stand modified as indicated.

In the result, the appeal is partly allowed. Order passed by the district forum directing the opposite party to scrutinize the claim of complainant and give him the admissible amount spent in the hospital and to pay cost of Rs 10,000/-, (Rupees ten thousand only) is upheld. Sum granted as compensation is modified and reduced to Rs 25,000/- (Rupees twenty five thousand only) and the sum of Rs 50,000/- (Rupees fifty thousand only) awarded towards unfair trade practice is set aside.

Parties are directed to suffer their respective costs.

Release the amount of Rs 25,000/- (Rupees twenty five thousand only) deposited by the appellant, at the time of institution of the appeal, to the respondent / complainant, on his application.

 

JUSTICE S.S. SATHEESACHANDRAN         : PRESIDENT

 

T.S.P. MOOSATH       : JUDICIAL MEMBER

 

RANJIT.R                     : MEMBER

Be/

 

 

 

 

 

 

 

 

 

 

KERALA STATE

 CONSUMER DISPUTES

REDRESSAL COMMISSION

SISUVIHARLANE VAZHUTHACADU

THIRVUANANTHAPURAM

 

APPEAL NUMBER 124/16

JUDGMENT DATED : 09.08.2018