By Sri. MOHANDASAN.K, PRESIDENT

The complaint U/s 12 of the Consumer Protection Act 1986.

The complaint in short is as follows:-

1.         The complainant was the insurance policy holder of the opposite party vide certificate No.2842/00130623/0026/000/00, which valid from 06/04/2017 to 05/04/2018. The policy covered the complainant, his wife and two children.  The coverage was for Rs.2,00,000/-. While the policy was inforce complainant admitted in EMS Memorial Co-operative hospital Perinthalmanna from 25/10/2017 to 01/11/2017 for Coronary Artery disease.   The complainant spends an amount of Rs.1,43,079/- for his treatment.  The complainant submitted claim form before the opposite party and the opposite party denied the insurance coverage stating that the complainant was diabetic at the time of   inception of policy and so there is voialation of policy condition by the complainant. The complainant produced certificate from the doctor stating that the complainant was not having any disease prior to the present disease.  Hence the complainant alleges deficiency in service on the part of the opposite party and pray for the treatment amount of Rs.1,43,079/- along with compensation of Rs.50,000/- and cost of the proceedings  Rs.10,000/-.

2.         On admission of the complaint notice was issued to the opposite party and on receipt of notice opposite party entered appearance and filed version. 

3.         The opposite party  admitted that the complainant had taken a health master policy from the opposite party or the first time as per policy No.2842/00130623/000/000 for  a period from 06/04/2017 to 05/04/2018 for a family floater (self +spouse+2 children) with total sum insured of Rs.2,00,000/-. The liability as per the policy is subject to various terms, conditions, limitation and exclusions noted in the policy. According to opposite party the policy shall be subject to general exclusions clause C1 which reads no indemnity is available or payable for claims directly or indirectly caused by arising out of or connected to any pre- existing conditions.  It is also submitted that benefits will not be payable for any conditions  as defined in the policy, until 24 consecutive months of coverage for the insured person have elapsed , since inception of the first policy with the insurer. According to opposite party the pre-existing conditions means any condition, ailment or injury or related condition (s) for which an insured person had signs or symptoms and /or received medical advice / treatment within 48 months period prior his /her first policy with the insurer. The opposite party submitted that the complainant was admitted in the hospital - CAG was done, which showed triple vessel disease. The records of discharge summary, treatment from the treated hospital shows that the complainant was patient with history of diabetes which has not disclosed at the time of taking the policy.   The opposite party appointed an investigator and he has reported that the complainant was suffering from diabetes which was pre-existing since 15 years which is prior to the inception of policy. The opposite party also submitted that the complainant had submitted a letter on 03/01/2018 that he had history of diabetes since 15 years and is undergoing treatment at Dr.Ranadev at Edakkara.  Hence the submission of the opposite party is that the present ailment of the policy holder is a complication attributable to diabetes which are existing since 15 years which is prior to inception of policy. So the present ailment was considered as pre-existing disease and the claim is inadmissible and the claim was rightly repudiated as per the terms and conditions of the policy.  So the prayer of the opposite party is to dismiss the complaint with cost to the opposite party.

4.         The complainant and opposite party filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A5.  Ext. A1 is report on coronary Angiogram + Angioplasty issued from EMS hospital Perinthalmanna 25/10/2017.  Ext. A2 is copy of discharge summary dated 01/11/2017. Ext. A3 is copy of letter issued by doctor Somanathan dated 30/01/2018, E.M.S Hospital Perinthalmanna . Ext. A4   is copy of health certificate of insurance dated 25/04/2017. Ext. A5 is health claim repudiation letter dated 07/03/2018.  Documents on the side of opposite party marked as Ext. B1 to B6. Ext B1 is copy of health certificate of the insurance. Ext B2 is copy of discharge summary dated 02/11/2017. Ext. B3 is certificate issued by doctor Somanathan dated 30/01/2018. Ext. B4 is copy of present claim details.  Ext. B5 is a letter issued by the complainant to the opposite party dated 03/01/2018. Ext.B6 is copy of health claim repudiation letter dated 07/03/2018. 

5.         Heard both side, perused affidavit and documents and also notes of argument.

The following points arise for consideration:-

1. Whether there is deficiency in service on the part of opposite party?
2. Relief and cost?

6.         Point No.1

            The grievance of complainant is that he undergone treatment for coronary artery disease at Perinthalmann E M S Hospital during the valid insurance period under the opposite party .The claim for medical expenses for the treatment was repudiated by the opposite party contending pre- existing disease. The complainant alleges deficicneny in service on the part of opposite party and he claims medical expenses along with compensation.   

7.         The contention of the opposite party is that the compliant was having pre-existing disease i.e. a history of diabetes since 15 years and the policy holder is undergoing treatment before doctor Ranadev at Edakkara.   The opposite party also submit that the medical records of discharge summary, certificate from the treated hospital shows that the complainant was a patient with history of diabetes which was not disclosed at the time of taking the policy.  The investigator of the opposite party also reported that the complainant was suffering from diabetes which was pre-existing since 15 years and which is prior to the inception of policy i.e., 06/04/2014.   So the opposite party considered the present ailment of the complainant as pre-existing disease and so the claim is inadmissible as per general exclusion clause C1.

8.         The opposite party produced decisions of National Consumer Disputes Redressal Commission in Revision Petition number 494/2018 and in RP 1608/16 contending that diabetes mellitus (DM) and hyper tension are the known-risk factors leading to developments of CAD, what is more material is that the aforesaid ailments ought to have been disclosed to the insurer at the time of the insurance policy was taken.  It is also mentioned that it is quite possible that had the complainant disclosed the aforesaid existing ailments, the insurer might not have issued the insurance policy or might have asked him to undergo medical checkup including investigation before accepting the proposal of insurance. In short the contention is non-disclosure of pre-existing disease or material fact at the time of inception of policy is sufficient ground to deny the insurance benefit and the opposite party repudiated the claim accordingly.

9.         The complainant produced a decision rendered by the Apex Court reported 2022(1) KHC SN 9 (Page No. 32) (SC).  The reported decision discussed repudiation of claim on the ground of non-disclosure of material fact in detail. The decision lay down certain principals in insurance medical claim policy as follows:-

1. There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.
2. What may be a material fact in a case  would also depend upon the health and medical condition of the proposer
3. If specific queries are made in a proposel form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.
4. If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up.  If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non-disclosure of a material fact, and seek to repudiate the claim.
5.  The insurance company has the right to seek details regarding medical condition, if any, of the proposed by getting the proposer examined by one of its empaneled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and there is no risk of pre- existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contented that there was a possible pre- existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.
6.  The insurer must be able to assess the likely risks that may arise from the status of health existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.
7. In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form or issue a policy or decline to do so. Such an exercise is dependent on the queries made in the proposal form and the answer to the said queries given by the proposer.

10.       Now it can be seen that non-disclosure of material fact including pre- existing disease is vital in considering a medical insurance claim. The question of disclosure and non-disclosure arise at the time of inception of policy. A proposal form is a vital document   to ascertain whether the insured had any material fact or pre-existing disease disclosed or not disclosed. In this complaint the opposite party produced documents     which does not include proposal form. In the absence of proposal form it is not possible to arrive a conclusion that the insured not disclosed any material fact including pre-existing disease at the time of inception of policy.  If there was any ailment existing at the time of inception of policy the insurance company had opportunity to provide appropriate policy to the insured.  A pre- existing disease is not a ground for total denial of issuance of policy. So the contention in this complaint raised by the opposite party that there was non-disclosure of pre- existing disease could not establish.Opposite party also failed to prove that the present disease was  direct result of pre-existing disease.  Hence the denial of insurance coverage on that ground in this complaint is not sustainable.  It is also relevant to note that coronary artery disease can occur in a person who has no history of diabetes mellitus. So we find that there is deficiency in service on the part of the opposite party by repudiating a medical claim which the complainant entitled and we find the first point accordingly.

11.       Point 2

The complainant herein underwent treatment for coronary artery disease and for admitted in E M S Hospital Perinthalmanna on 25/10/2017 and he was discharged on 01/11/2017. The complainant spend amount of Rs.1,43,079/- for the treatment but the claim for the same repudiated by the opposite party without sufficient reason.  So we hold that the complainant is entitled for the treatment expenses.  The complainant also prayed for the compensation of 50,000/- rupees and cost of 10,000/- rupees. Considering the entire aspects we allow this complaint as follows:

1. The opposite party is directed to allow Rs.1,43,079/- (One lakh forty three   

thousand and seventy-nine rupees only) towards treatment expenses of the complainant.

2. The opposite party is directed to pay Rs.25,000/- (Twenty five thousand rupees only) as compensation on account of deficiency in service by repudiating  claim  and thereby caused financial and other hardships to the complainant .
3. The opposite party is directed to pay Rs.5,000/- (Five thousand rupees only) as cost of the proceedings to the complainant.

The opposite party shall comply this order within one month from the date of receipt of copy of this order, failing which the opposite party shall liable to pay 12% interest on above said amount from the date of this order till realization.

Dated this 28^th 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.A1 to A5

Ext.A1: Report on coronary Angiogram + Angioplasty issued from EMS hospital

Perinthalmanna 25/10/2017.

Ext.A2: Copy of discharge summary dated 01/11/2017.

Ext A3: Copy of letter issued by doctor Somanathan dated 30/01/2018, E.M.S Hospital

Perinthalmanna .

Ext A4: Copy of health certificate of insurance dated 25/04/2017.

Ext A5: Health claim repudiation letter date 07/03/2018.

Witness Examined on the side of the opposite party: Nil

Documents marked on the side of the opposite party: Ext. B1 to B6

Ext.B1: Copy of health certificate of the insurance.

Ext.B2: Copy of discharge summary dated 02/11/2017.

Ext.B3: Certificate issued by doctor Somanatan dated 30/01/2018.

Ext.B4: Copy of present claim details. 

Ext.B5: Letter issued by the complainant to the opposite party dated 03/01/2018.

Ext.B6: Copy of health claim repudiation letter dated 07/03/2018. 

MOHANDASAN.K, PRESIDENT

PREETHI SIVARAMAN.C, MEMBER