O R D E R Smt. Bindhu M. Thomas, Member The crux of the complainant’s case is as follows:- The complainant lured by the advertisement of opposite party purchased a mediclaim policy bearing no. 570600/48/05/8500000377 having currency from 27-06-2005 to 26-06-06 on payment of premium Rs.2089/- for self, his wife and his son. the opposite party offered medical re-imbursement benefit upto 1 lakh to the complainant. The complainant stated that he did not suppress any material facts while purchasing the said policy. On 06/03/06, the complainant suffered heart attack and he was admitted in Amritha Institute of Medical Science and operation was conducted on 09/03/06 and was discharged on 21/03/06. An amount of Rs. 2,00,500/- was spent by the complainant for the aforesaid treatment. Thereafter, he made a claim to the opposite party for Rs.1,00,000/- as the offered policy cover was only Rs.1 lakh. But the opposite parties did not respond to the claim for 7 months, and hence, he sent advocate’s notice to the opposite parties. Evenafter receipt of the said notice the second opposite party chose not to respond. The first opposite party replied to the said notice and informed the complainant that the claim is repudiated on the basis of “suppression of material facts regarding pre-existing diseases’. The complainant averred that at the time of taking the said policy there was no heart disease and he had not taken any treatment for the same. According to the complainant the act of opposite party in not settling the claim and repudiating the same on flimsy grounds is clear case of deficiency in service. Hence the complainant filed a complaint claiming the claim amount with interest @ 18% per annum, compensation Rs. 50,000/- and other reliefs. Notice was served to both the opposite parties. First opposite party filed version. The second opposite party failed to file version evenafter several postings. Hence second opposite party was set exparte. The first opposite party’s version came with the following main points. i) The complainant has been suffering from heart disease before taking the policy and he has concealed this fact from the insurance company. As per the coverage in the policy, the liability of the company with regard to hospital expense limit is as follows. V.T. Anirudhan – Rs.20,000/- Sheeba Raghavan – Rs.5000/-, Anu Krishn – Rs.5000/-. The complainant is not entitled to get Rs.1,00,000/- towards hospitalisation expenses. ii) As per the Medical Certificate issued from the Amritha Institute of Medical Science, complainant had Dysypnoea on exertion class II since 15 years of age. He was evaluated by a physician 8 months back from the first consultation in AIMS and was found to have Valvular Heart disease. But he has taken the policy by concealing the treatment before the physician with regard to his heart disease. ii) As per the terms and conditions of the policy, insurance company is not liable to pay any amount for the disease which is pre-existing when the cover incepts for the first time. Hence the complainant is not entitled to get any compensation. Hence the first opposite party prayed to dismiss the complaint. Points for consideration are: i) Whether there is any deficiency in service or unfair trade practice on the part of opposite parties? ii) Reliefs and costs? Evidence consists of affidavits filed by the complainant and first opposite party, exhibits A1 to A9 and Exts B1 to B5 series and ext X1. Point No.1 Heard the counsels for the complainant and first opposite party and perused the documents placed on record. It is not in dispute that the complainant had taken an LIC policy – “Hospitalisation and Domiciliary Hospitalisation Benefit Policy” bearing no.570600/48/05/ 8500000377 having currency from 27-06-05 to 26-06-06 on payment of premium Rs.2089/-. It is also not in dispute that the complainant was admitted in AIMS on 06/03/2006. That means the alleged hispitalisation occured during the subsistance of the aforesaid policy. The copy of policy certificate is produced by both parties and they are marked as Ext.A3& Ext.B5 respectively. The policy conditions is also produced by both parties and they are marked as Ext.A1&Ext B5(a) respectively. The copy of the discharge summary produced by the complainant is marked as ext.A4. The first opposite party produced a copy of the letter sent by the second opposite party to Dr. V. Satyaprasad of AIMS and it is marked as ext B1. The ext B1 letter intended the clarification of certain things mentioned in the Ext.A4 discharge summary. As per ext.B1, the point put forward for clarification reads as under. “In the discharge summary there is mention about Thickened mitral leaflets, which points towards long duration of the disease. So we need to know the past history of RHD since which age? And details about treatment undergone in the past for the same”. The original certificate issued by Dr.V.Satyaprasad in response to Ext.B1 is also produced and it is marked as ext.B2. Ext.B2 certificate states that the complainant was first evaluated in the department of cardiology of AIMS on 09-01-2006. Ext.B1, further states that as per the case record he was noted to have Dyspnoea on Exertion Class II since 15 years of age. Ext.B2 next stated that the complainant was evaluated by a physician 8 months back from the date of first consultation in AIMS and was found to have valvular heart disease. Relying on ext.B2 certificate the first opposite party’s counsel argued that the complainant has been suffering from heart disease before taking the policy and he has concealed this fact from the insurance company. Eventhough it is stated in ext B2, that the complainant was evaluated by a physician 8 months back and was found to have valvular disease, no scrap of paper is placed on record to prove that the complainant had visited Dr. V.Satyaprasad of AIMS hospital or any other doctor of any other hospital with symptoms of Dyspnoea on Exertion class II and was diagnosed to be having valvular heart disease prior to taking the disputed policy. Moreover no affidavit of any treating doctor stating that the insured was treated by the doctor for Dyspnoea on Exertion Class II and was diagnosed to be having valvular heart disease has been placed on record. The complainant filed petition for the production of treatment records from the AIMS hospital. The said petition was allowed and the treatment records were produced as per the direction of the forum. The treatment records thus produced was marked as ext X1. The learned counsel for first opposite party contented that the descriptive history recorded in the ext X1 and the Ext B2 certificate clearly shows that the complainant has been suffering from heart disease. No doubt, in ext X1 and ext B2, it is mentioned that the insured was noted to have Dyspnoea on Exertion class II since 15 years of age and was evaluated by a physician to have valvular heart disease. In our view, the said descriptive history in ext X1 and ext B2 certificate could not be treated as primary piece of evidence to prove any fact unless and until the doctors who had recorded the said history and issued the certificate had been examined and proved. If a person mentions at the time of having the surgery regarding any ailments that he might have felt, sustained discomfort in health and being noted by the doctor does not mean that he was already aware of the disease. Most people suffer from symptoms of diseases, but realizes much later that the symptoms were indicative of a disease. Had he been aware of the heart disease, he would not have waited endlessly and put himself to further risk of life and would have rushed to get treatment immediately. When the patient is not aware of the disease or the symptoms of the same that would affect him, it cannot be said that there was suppression of material fact by the complainant. The learned counsel for the complainant submitted that the complainant has medical re-imbursement benefit upto 1 lakh. Where as the learned counsel for the first opposite party contented that the liability of the company with regard to hospital expense limit (Medical expenses-domiciliary hospitalisation expenses) for the complainant is only Rs. 20,000/-. On perusing ext A3, policy certificate copy, it is seen that the policy itself is “Hospitalisation and Domiciliary Hospitalisation Benefit Policy”. In ext.A3, the cover of Rs.20,000/- is given under the head “Domiciliary Hospitalisation Limit” then naturally the cover of Rs. 1 lakh given under the head sum insured will be the Hospitalisation limit. The complainant produced the copy of policy conditions and it is marked as ext.A1. In ext A1, the clause 2.4 explains the meaning of “Domiciliary Hospitalisation benefits” as under “Medical treatment for a period exceeding 3 days for such illness/disease/injury which in the normal courses would require care and treatment at a hospital/nursing home but actually taken whilst confined at home in India under any of the following circumstances namely............................................” In this instant case the complainant was admitted in AIMS hospital on 06/03/06, underwent surgery on 09/03/06, and was discharged on 21/03/06. Evidencing the said hospitalisation, the complainant produced Ext A4 discharge summary. Therefore the alleged claim is not for domiciliary hospitalisation benefit but for hospitalisation benefit. The copy of bills issued by AIMS hospital for Rs. 1,30,000/-, Rs. 5000/- and Rs. 2000/- are produced and they are marked as Ext A6, Ext A6(a) and Ext A6(b) respectively. As the hospitalisation limit of the alleged policy is only Rs.1 lakh, the complainant has claimed only one lakh. The material on record show that for the first time the complainant was detected to be having ‘Thickened mitral leaflets’ only on diagnosis being done in the month of March 2006 by the AIMS hospital. Except a mere noting that has been made in the descriptive history of ext X1 and ext B2 regarding the complainant’s history and the diagonosis, no documentary evidence or material has been produced by the opposite party to prove that the complainant has been taking medication for any of the ailments for which he took treatment in the month of March 2006 prior to taking the policy under dispute. In our opinion, the Insurance Company is guilty of deficiency in service because repudiation was not based on full material information. Point No. 1 is found accordingly. Point No.2 In view of the findings in point No.1, the complaint is allowed. The first opposite party will pay the claim amount of Rs. 1 lakh with interest @ 9% per annum from the date of repudiation till realisation to the complainant. The second opposite party will pay Rs.3000/- as litigation cost to the complainant. This order will be complied with within one month of receipt of the order. Smt. Bindhu M. Thomas, Member Sd/- Sri. Santhosh Kesavanath P. President Sd/- Appendix Documents of the complainant Ext.A1-Copy of policy conditions Ext.A2-Copy of premium receipt Ext.A3-Copy of policy certificate Ext.A4-Copy of discharge summary Ext.A5-Original acknowledgement card Ext.A6-Copy of receipt dtd 06/03/06 Ext.A6(a)-Copy of receipt dtd 14/03/06 Ext.A6(b)-Copy of receipt dtd 18/03/06 Ext.A7-Copy of advocate’s notice Ext.A7(a)-Postal receipt dtd 6/12/06 Ext.A7(b)-Postal receipt dtd 6/12/06 Ext.A8-Original acknowledgement card Ext.A9-Advocate’s notice dtd 19/12/06 Documents of the opposite party Ext.B1-Copy of letter dtd 9/9/06 issued by TTK Health Care Ext.B2-Reply letter issued by Dr. V. Satyaprasad Ext.B3-Copy of repudiation letter issued by National Insurance Company. Ext.B4-Copy of reply notice Ext.B4(a)-Copy of postal receipt Ext.B5-Copy of policy conditions. Document produced before the forum from AIMS Ext X1-Original treatment records of AIMS hospital. By Order
| | [HONORABLE Bindhu M Thomas] Member[HONORABLE Santhosh Kesava Nath P] PRESIDENT[HONORABLE K.N Radhakrishnan] Member | | 
