BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.658/2015

DATED ON THIS THE 13^th April 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 parties, alleging  deficiency of service and seeking a direction to apologise for the inconvenience caused, and to reimburse Rs.92,000/- spent towards hospitalization expenses with interest at 15% p.a. and Rs.50,000/- compensation with cost of the proceedings and such other reliefs.
2.     The complainant purchased a mediclaim insurance policy from opposite party No.1, on 30.10.2013.  His knee got injured in an accident on 17.04.2014 and undergone surgery for ACL tear on 18.04.2014.  After discharge from the hospital, claiming a sum of Rs.92,000/-, submitted all the relevant original documents to opposite party No.1.  The opposite party No.1 repudiated the claims on the ground of non-disclosure of pre-existing problem.  Aggrieved by the same, the complainant filed the complaint seeking reliefs.
3.     The opposite party Nos.1 and 2 denies the contention of the complainant.  A proposal form was submitted with necessary particulars, after thoroughly understanding the policy terms and conditions.  Under the principle of “utmost good faith”, the complainant was under the obligation to disclose all the known material facts and any suppression, lead to violation of policy terms and conditions.
4.     The issuance of insurance policy covering the hospitalization expenses to the tune of Rs.3,00,000/-, was admitted.  On receipt of claim for reimbursement of hospitalization expenses, it has investigated the matter, which revealed, the complainant was suffering from knee problem and has got done MRI, prior to taking the policy.  Hence, the claim has been repudiated for non-disclosure of facts.  As such, contended that there are no negligence nor deficiency in service by them and are not liable to pay any damages as sought and prays for dismissal of the complaint.
5.     The complainant led his evidence by filing affidavit and relied on documents.  The opposite parties led their evidence by filing affidavit and placed several documents to establish their contention.  The complainant filed written arguments and made oral submissions.  Perusing the material on record, matter posted for orders.
6.      The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service on the part of opposite parties in not reimbursement of hospitalization expenses for the treatment undergone to his left knee, under the mediclaim insurance policy and thereby he is entitled for the reliefs?
2.  What order?

7.    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 ::

8.    Point No.1:- The complainant obtained a mediclaim insurance policy from opposite party No.1, w.e.f. 20.10.2013, and paid a sum of Rs.7,523/- towards premium amount, for a sum assured Rs.3,00,000/-. He met with an accident on 17.04.2014 and his left knee got injured.  The doctor diagnosed ACL tear and suggested a surgery.  On 18.04.2014, surgery was held.  On discharge from the hospital, a sum of Rs.92,000/- was claimed towards hospitalization expenses by submitting the relevant documents.  The opposite parties repudiated the claims.  Hence, the complainant sought for the reliefs.
9.    The opposite party contended that, they have issued the insurance policy on receipt of the proposal form with premium amount.  Considering the particulars and the declaration by the complainant, the policy was issued on 30.10.2013, with “Utmost good faith”.  On receipt of the claim form with documents on 08.05.2014, for reimbursement of hospitalization expenses, the opposite party conducted investigations, which revealed, the complainant was suffering from knee problem prior to taking the policy and has got done on MRI on 20.10.2013, reported that “Grade I Changes in Posterior horn of Medical Meniscus”.  Accordingly, the opposite party repudiated the claim vide letter dated 25.07.2014, on the ground of non-disclosure of material facts in the proposal form.  Further, based on the discharge summary dated 23.04.2014, the diagnosis in “ACL tear with medical meniscal tear left knee”, which is directly related to the earlier ailment as reported in MRI on 20.10.2013.
10. Further based on the “clause 6.1” of the policy terms and conditions, the opposite party is not liable to pay any compensation to the complainant.  Further, as per clause 6.13 of the policy conditions, the policy issued was cancelled as void abinitio.  As such, opposite party contended that they have not committed any deficiency in service and are not liable to pay any compensation and prayed for dismissal of the complaint with costs.
11. On perusal of the material available on record, the complainant established that, he took a mediclaim insurance policy from opposite party No.1, on 30.10.2013.  The complainant’s claim for reimbursement of medical expenses was repudiated by opposite parties on the ground of suppression of material facts, prior to taking of the policy.  The documents relied on by the opposite parties clearly established the contention of opposite parties that, the complainant suffered injuries to his left knee and took treatment prior to taking of the policy and the same material fact has not been disclosed in the proposal form, which is certainly attributed as suppression of material facts.  So we opine that, as per clause 6.1 of the policy terms and conditions, hence the repudiation of the claim was justified.  Accordingly, we answer the point No.1 is in the negative.
12. Point No.2:- In view of 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 13^th April 2017)

                          (H.M.SHIVAKUMARA SWAMY) 

                                      PRESIDENT     

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

      MEMBER                                         MEMBER