By Sri. MOHANDASAN.K, PRESIDENT
The complaint U/s 12 of the Consumer Protection Act 1986.
1. The complainant Abraham.K. Abraham S/o Abraham, who died subsequently, was policy holder of first opposite party. Supplemental complainants are the legal heirs of original complainant. He subscribed the policy called “Senior Citizen’s Red Carpet Health Insurance policy” vide policy No. P/181312/01/2018/002756 valid from 12/09/2017 to 11/09/2018. The sum insured was Rs.2,00,000/- with an annual premium of Rs.9,978/-. The complainant subscribed the policy attracted by persuasion and instigation of the representatives of the first and second opposite parties, that enriching scheme with fabulous benefits irrespective of previous ailments or any sort of complications. The said policy had special feature that the insured can avail a cashless treatment and the insured can claim the amount for treatment directly through the hospital and the insured need not directly pay any amount to the hospital.
2. The complainant admitted to the 3rd opposite party hospital on 25/07/2018 with right sided chest pain radiating to right shoulder and arm. His disease was diagnosed with coronary artery disease and he was treated there till 28/07/2018 and he spend a total sum of Rs.1,28,993/-. Immediately after the admission to the 3rd opposite party hospital the complainant intimated first and second opposite parties regarding the same and required the third opposite party to avail the cash less treatment facility from them. The complainant summited an application on 25/07/2018 while he was undergoing treatment in 3rd opposite party hospital. The first and second opposite parties repudiated the claim stating that the complainant concealed a material fact relating to the health condition of the complainant contrary to the terms of the said policy. They stated that at the time of taking the policy the complainant was suffering from a chronic liver decease, even though all the available medical records were furnished during the inspection of policy. Actually the complainant had intimated the opposite party No.1 and 2 that he had been undergoing treatment for diabetes mellitus and hyper tension and related complication at that time along with whole treatment details available with the complainant. So, the allegation of the complainant is that the denial of cashless treatment benefit is a clear deficiency of service on the part of opposite parties No.1and 2
3. The complainant submitted an application on 30/08/2018 to reimburse the expenses which he had to spend for his treatment at the hospital along with a certificate from the doctor stating that the present heart disease is unrelated to the previous existing decease. But the opposite parties No.1 and 2 repudiated the claim application stating the same reason. The complainant submit that he had to meet the entire treatment expenses of Rs.1,28,993/-. The prayer of the complainant is that to direct first and second opposite parties jointly and severally to pay Rs.1,28,993/- towards the treatment expenses and also to pay Rs.5,00,000/- towards the compensation for the deficiency of service of opposite party and towards mental agony and distress caused to the complainant along with cost of Rs.50,000/-.
4. On admission of the complaint notice was issued to the opposite parties and opposite party No.1 and 2 entered appearance and filed version. The opposite party No.3 though notice served not turned up hence called and set exparte.
5. The first and second opposite parties admitted that the complainant took a senior citizen red carpet health insurance policy as stated in the complaint . But at the time of issuing the policy the complainant was supplied with terms and conditions of the policy. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the policy schedule. It was clearly stated in the policy that “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached “. The complainant has specifically declared in the proposal form that he was not suffering from any disease or ailment at the time of submitting the proposal form except diabetic Mellitus and blood pressure. In the proposal form the complainant had declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the insurance company would incur “No liability” under the policy “. According to opposite party, acceptance of proposal is based on the information and details furnished by the proposer. If the health status of the proposer is found satisfactory based on the fact in the proposal, the insurer would accept the risk and issue policy and the health status is not satisfactory, the insurer would decline the risk. The opposite party submitted that the complainant admitted at third opposite party hospital on 25/07/2018 for treatment of Coronary Artery disease, Acute Coronary syndrome - non-ST elevation, Myocardial infarction, single vessel disease and secondary diagnosis was diabetic mellitus, Systemic Hyper tension & Chronic liver disease – Child A and underwent surgical management and he was discharged from the hospital on 28/07/2018.
6. The opposite parties submit that they received a pre-authorization request for the cashless treatment from the third opposite party hospital which states that the complainant was admitted in the hospital on 25/07/2018 for the complaints of acute coronary syndrome. On receipt of the request the opposite parties forwarded a query letter dated 25/07/2018 to the third opposite party to forward certain documents processing the claim. Accordingly the third opposite party forwarded the previous treatment details of the complainant and the USG of abdomen dated 29/08/2017 which clearly shows that liver coarse echotexture with nodular surface suggestive of chronic liver disease, mild splenomegaly, Few splenic hilar coliaterals, Features of chronic liver disease with portal hypertension , Cholelithiasis & Mild Prostanomaly . The documents issued from third opposite party clearly reveals the complainant was consulted the treating doctor Aneesh Kumar and he had advised to use medications for the ailments. So, it is as per medical records the complainant had history of chronic liver decease for which treatment has been taken before the inception of policy and it was not revealed in the proposal form at the time of inception of policy and so, the opposite parties rejects the cash less facility and the same was informed to the hospital authority and the complainant. The complainant submitted claim form along with discharge summary, bills and reports to the opposite parties. The discharge summary reveals that the complainant had history of diabetic mellitus & hypertension, chronic liver disease –child-A and he underwent endoscopic Barisal ligation in 2012 and history of upper GI bleed on 2014. That means the complainant did not reveal in the proposal form about the history of chronic liver disease complainant willfully suppressed the preexisting disease in the proposal form which is the basis of contract at the time of taking the policy. In the proposal form there is specific question in the health history regarding various treatments including liver complaint and the answer given by the complainant was “No”. The condition No.9 of the policy specifically states that the insurance company shall not be liable to make any payment under the policy in respect of the claim if any information furnished at the time of proposal is found to be incorrect or false. The opposite party content that condition No.13 of the policy is that the company may cancel the policy on grounds of non-disclosure of material fact or non-co-operation by the insured person by sending the insured 30 days’ notice by registered letter at the insured persons last known address. The opposite party submitted that a notice was issued to the insured in the last known address and thus the policy number P/181312/01/2018/002756 in respect of complainant was cancelled due to the non-disclosure of pre-existing diseases.
7. The opposite parties denied the allegation that the agent of opposite parties approached the complainant, but the complainant approached opposite party and after knowing all the terms and conditions of the policy, the complainant had opted the Senior Citizen Red Carpet Health insurance policy. It is also submitted that the complainant informed the opposite party only diabetic mellitus and blood pressure as preexisting diseases and the opposite party issued the policy after excluding diabetic mellitus and hypertension and its complications in the policy schedule. Opposite party denied that the proposal form was filled by the representatives of first and second opposite parties. The opposite parties denied the allegation that they obtained certain signed blank papers from the complainant and also was given certain assurances regarding the claims. There is no deficiency in service or unfair trade practice on the part of the opposite parties and so the complaint be dismissed with compensatory cost to the opposite parties.
8. The complainant and opposite parties filed affidavit and documents. Documents on the side of complainant marked as Ext. A1 to A7. Ext. A1 is copy of insurance policy dated 12/09/2017. Ext. A2 is copy discharge bill dated 28/07/2018. Ext. A3 is copy discharge summary dated 28/07/2018. Ext. A4 is copy of certificate issued by doctor Bijoy on 29/08/2018. Ext. A5 is copy of letter of repudiation issued by the opposite party dated 11/08/2018. Ext. A6 is copy of letter rejecting pre-authorization for cash less treatment dated 27/07/2018. Ext. A7 is copy of letter repudiating insurance claim dated 07/11/2018. Documents on the side of opposite parties marked as Ext. B1 to B11. Ext. B1 is insurance copy of policy schedules and original conditions. Ext. B2 is copy of the proposal form. Ext. B3 is copy of pre-authorization request form. Ext. B4 is copy of query letter dated 25/07/2018 issued by opposite party No.1and 2 to third opposite party. Ext. B5 is copy of USG report dated 29/08/2017 issued by Aster MIMS hospital. Ext. B6 is copy of consultation paper issued by doctor Aneesh kumar dated 29/08/2017. Ext. B7 is copy of prescription dated 29/08/2017. Ext. B8 is copy of rejection for pre authorization, for cashless treatment. Ext. B9 is copy of discharge summary issued by third opposite party dated 28/07/2018. Ext. B10 is copy of repudiation letter dated 07/11/2018. Ext. B11 copy of cancellation letter dated 11/08/2018.
9. Heard both side, perused affidavit and documents.
The following points arise for consideration:-
1) Whether there is deficiency in service on the part of opposite parties one and two?
2) Relief and cost?
2. Point No.1
The case of the complainant is that he subscribed insurance policy of the opposite party called “Senior Citizens Red carpet Health Insurance Policy”. This is valid from 12/09/2017 to 11/09/2018. During this period the complainant was admitted to third opposite party hospital on 25/07/2018 with right sided chest pain radiating to right shoulder arm . He was diagnosed with coronary artery diseases and he was treated as inpatient till 28/07/2018. He spent an amount of Rs.1,28,993/- towards treatment. The complainant approached first and second opposite parties through third opposite party for cashless treatment facility. But the opposite parties denied the same contenting suppression of material fact related to the health condition of the complainant contrary to the terms of the said policy.
The question is the suppression of material facts as stated by the opposite parties will disentitle the insurance claim of the complainant. It is well settled position that insurance contract is a contract in good faith, Uberrime fides. The proposer of the insurance is obliged to disclose all the facts while answering the questions in the proposal form and any incorrect answer will entitle the insurer to repudiate the liability. In this complaint the complainant admit there are certain terms and conditions applicable to the parties as per the policy schedule. Ext. A1 itself state that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc attached. The opposite party produced Ext. B1 document with customer information sheet – Senior Citizens Red Carpet Health Insurance policy. As per condition 4 .9 it has stated that the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf. Ext. B2 is the proposal form signed by the complainant. According to opposite party in column number 2 &3 of the proposal form there is specific question regarding health history. The question on diseases of stomach, intestine, liver, gallbladder / pancreas, kidney urinary blander urinary track disease – the answer of the complainant recorded as No. But the treatment records provided from the third opposite party revealed that the complainant was consulted with Dr. Aneesh Kumar on 29/08/2017 and treated for alcoholic liver disease as well as chronic liver disease. - Child A, past variceal bleed – post EVL, on and of edema legs diabetic mellitus & hyper tension and the treating doctor advised to medication for these ailments. It can be seen that the complainant has no specific allegation of change in the policy conditions or non-disclosure of policy conditions. It is evident from the documents available before the commission that the complainant was having pre-existing disease and which was not disclosed before the opposite parties while incepting the policy. The non-disclosure of material fact disentitle the insurance coverage is a settled position. Insurance being a contract in good faith, non-disclosure of material fact is vital condition. In this complaint the claim of the complainant hit on that ground and we find the complainant is not entitled for the claim as prayed in the complaint and so the commission is not inclined to allow the prayer of the complainant.
In the light of above facts and circumstances the consideration of point No.2 does not arise and complaint accordingly dismissed.
Dated this 24th day of February, 2022.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1to A7
Ext.A1: Insurance policy dated 12/09/2017.
Ext.A2: Discharge bill dated 28/07/2018.
Ext A3: Discharge summary dated 28/07/2018.
Ext A4: Certificate issued by doctor Bijoy on 29/08/2018.
Ext A5: Letter of repudiation issued by the opposite party dated 11/08/2018.
Ext A6: letter rejecting pre authorization for cash less treatment dated 27/07/2018.
Ext A7: Letter repudiating insurance claim dated 07/11/2018.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B11
Ext.B1: Insurance copy of policy schedules and original condition.
Ext.B2: Proposal form.
Ext.B3: Pre authorization request form.
Ext.B4: Copy of query letter dated 25/07/2018 issued by opposite party No.1and 2 to third
opposite party.
Ext.B5: Copy of USG report dated 29/08/2017 issued by Aster MIMS hospital.
Ext.B6: Copy of consultation paper issued by doctor Aneesh kumar dated 29/08/2017.
Ext.B7: Copy of prescription dated 29/08/2017.
Ext.B8: Copy of rejection for pre authorization, for cashless treatment.
Ext.B9: Copy of discharge summary issued by third opposite party dated 28/07/2018.
Ext.B10: Copy of repudiation letter dated 07/11/2018.
Ext.B11: Copy of cancellation letter dated 11/08/2018.
MOHANDASAN.K, PRESIDENT
PREETHI SIVARAMAN.C, MEMBER