DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  12^th  day of January, 2023

Present      :   Sri. Vinay Menon V., President

                  :  Smt. Vidya A., Member                        

                  :  Sri. Krishnankutty N.K., Member                                Date of Filing: 27/09/2019     

     CC/236/2019

V.A.Naseer,

S/o. V.A.Abu,

Vayalassery House,

Lakshmi Nagar,Pottakulam,

Kavilpadu, Olvakkode,

Palakkad – 678 012                                                    -           Complainant

(By Adv. K. Dhananjayan)

                                                                                    Vs

1. Bajaj Allianz General Insurance Co.Ltd.,

Regd. Office at GE Plaza,

Airport Road, Yerwada,

Pune – 411 006, Maharashtra.

2. Bajaj Allianz General Insurance Co. Ltd.,

Regd. Office at GE Plaza,

Airport Road, Yerwada,

Pune – 411 006, Maharashtra,

Rep. by its Managing Director

3. Bajaj Allianz General Insurance Co. Ltd.,

Door No.48, 1^st Floor, Mangalam Towers,

Opp. Town Bus stand, Palakkad – 678 014

                   Rep. by its Branch Manager                                            -           Opposite parties

                    OPs Adv. Ullas Sudhakaran)

O R D E R

By Sri. Vinay Menon V., President

1. Per complaint, the complainant, a robust and able bodied person, without any history of substance abuse, availed health insurance coverage during 2017 after being induced by an agent of the O.P. Said policy was renewed during the year 2018. During the subsistence of the second policy, the complainant was diagnosed with recent AWMI, Thrombolysed with Reteplase. Subsequently he developed cardiac issues and had to expend Rs. 1,36,012/- for treatment. Complainant’s claim for indemnification of this amount was repudiated by the opposite parties on the ground that the complainant was having the history of previous illness. Aggrieved thereby, this complaint is filed.
2. OPs filed version refuting complaint pleadings based mainly on the ground that the complainant was hospitalized on 21/08/2016 for undergoing treatment and claim was repudiated as the complainant failed to disclose the existence of a material fact, ie. Pre-existing disease. They sought for dismissal of the complaint.
3. The following issues arise for consideration: 

1. Whether the complainant had failed to disclose any material facts, rendering the coverage of policy during 2018-2019 period void?
2. Whether there is  deficiency in service/unfair trade practice on the part of the opposite parties?

3.         Whether the complainant is entitled to any of the reliefs sought for?

4.         Reliefs, if any?

4.         Evidence comprised of Exhibits A1 to A9 on the part of complainant. Ext. A8 was objected to on the ground that it is a photocopy. Since this Commission is not bound by the tenets of The Evidence Act, and in the absence of any contention that the said document is a forgery, Ext. A8 is taken on file.

O.P.s marked Exts. B1 to B4.  There was no objection to marking the said four documents.
Issue No.1

5.         Per pleadings, the complainant was healthy and hale and was not suffering from any disease. He availed his first policy during 2017. Nothing untoward happened during this period. He underwent a number of ailments in 2018 during the coverage of the 2^nd policy. Claim under this policy was rejected on the ground of non-disclosure of material facts, which rejection is illegal and tantamount to deficiency in service on the part of the opposite parties.

6.         Ext. A1 is the policy schedule covering the complainant and his family during 23/02/2018 to 22/02/2019. Exts. A2 to A8 are documents that relate to the treatments the complainant had underwent during the coverage period of the 2^nd policy, ie. Ext. A1.

Ext. A1 was issued based on the answers provided by the complainant to the questionnaire in the proposal form. Page 2/13 of Ext. A1 contains the said questions and answers. They are reproduced herein below:

“Q1 – Has any of the persons to be insured suffer from / or investigated for any of the following:

Disorder of the heart, or circulatory system, chest pain, high blood pressure, stroke, Asthma, any respiratory conditions ……………. or any other disease. If yes, indicate in the table given below:

Ans. No.

Q2 – Do you or any of the family members to be covered have / had any health complaints / met with any accident in the past 4 years or prior to 4 years and have been taking treatment / hospitalization? Please provide the details and duration of illness alongwith treatment in below table.

Ans. No.”

The abovesaid reproduction is based on the answers provided by the complainant in the Ext. B2 proposal form, which incidentally is the proposal form for 2017-2018 period. The complainant has answered falsely to questions that directly affect the decision making process of the opposite parties while answering the questionnaire.

7.         Ext. B3 is the discharge summary issued from Dept. of Cardiology, Thankom Hospital, Palakkad, along with medical records of one Sri. Naseer, Hospital number 2016/297978. In Exts. A2, A3 and A4 also, the hospital number of the complainant is  shown as 297978. Further Ext B3 was marked without any objection. Thus we can safely presume that the patient in Exts. B3 and Exts. A2, A3 and A4 are one and the same.

Complainant was hospitalized for two days from 21/08/2016 to 23/08/2016 with complaints of Dyslipidemia and chest pain. The complainant was advised to stop smoking on discharge.  Complainant has informed the treating doctor that he had history of dyslidemia and smoking and his family has history of heart disease.

8.         The next question is whether the materials that were not disclosed were material or not. In 2016, the complainant underwent treatment for cardiac problems and respiratory irregularities. He was admitted in ICCU for 2 days. In 2018, the complainant underwent treatment for cardiac problems. Since the treatment underwent by the complainant in 2016 and 2018 are cardiac related, facts regarding hospitalization during 2016 are relevant material. Non-disclosure had prevented the O.P. a chance to revisit the terms and conditions under which coverage could be granted to the complainant. Hence the non-disclosure was of material facts.

                        Therefore we can reasonably conclude that the complainant has willfully suppressed material facts regarding the treatment and hospitalization he underwent during 2016 at the time of preparation of Ext. B2 proposal form.

Issue No.2

9.                     Having found that the complainant has willfully suppressed material facts relating to the treatment underwent by him in 2016 and hospitalization, the opposite parties are justified in repudiating the claim of the complainant.

There is no deficiency in service or unfair trade practice on the part of the opposite parties. 

10.       Consequently, the complaint is dismissed.

Issue No. 3

11.       The complainant is not entitled to any of the reliefs sought for.

            Issue No. 4

12.       As can be assimilated from the facts and circumstances of the case, this complaint is an abuse of the process of law and a vexatious complaint aimed at illegal enrichment at the expense of opposite parties by willful non-disclosure of material facts and acting with the knowledge that his actions and conduct would result in illegal losses to the opposite parties. Such malicious and vexatious conduct should not go scot free.

Hence a cost of Rs. 10,000/- is imposed on the complainant, payable to the opposite party 3 within 45 days from receipt of a copy of this Order.                       

Pronounced in open court on this the 12^th   day of January, 2023.   

      Sd/-                                                                                                   

                                                                                             Vinay Menon V

                                                      President

                                                            Sd/-

   Vidya.A

                       Member        

       Sd/-                                                                     Krishnankutty N.K.

                                                                                                      Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1   -  Copy of  policy schedule

Ext.A2  –   Original CA report bearing hospital No.297978 dated 17/10/18

Ext.A3  - Copy of lab report dated 18/10/18    

Ext.A4  -  Original discharge summary dated 18/10/18 from department of cardiology, Thankam

                Hospital,   Palakkad

Ext.A5 –  Original CA report dated 25/10/18 from Palakkad Sahakarana Hrudayalaya

Ext.A6  –  Original discharge summary dated 27/10/18 from Palakkad Sahakarana Hrudayalaya

Ext.A7 – Copy of discharge bill dated 27/10/18 issued from Rajiv Gandhi Co-op Hospital

Ext.A8 – Copies of pharmacy receipts

Ext.A9 series – Copies of repudiation letters dated 18/12/2018 & 24/12/18

Exhibits marked on the side of the opposite party

Ext.B1 – Copy of policy schedule

Ext.B2 –  Printout of proposal form dated 25/1/17

Ext.B3 –  Printout of discharge summary dated 23/8/16  from department of cardiology,

                Thankam hospital alongwith medical records maintained in the said hospital.

Ext.B4 –  Copy of repudiation letter 24/12/18

Court Exhibit:  Nil

Third party documents:  Nil

 Witness examined on the side of the complainant: Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.