Smt.G.Vasanthakumari, President
Complainant’s case is that the complainant is working as the Secretary of the Asramam Labour Contract Society as well as a social worker, that he had availed a medi claim policy from the opposite party for the period from 25-02-2005 to 24-02-2006 and thereafter renewed from 25-02-2006 to 24-02-2007, that he had paid Rs.2716/- in the first year and paid Rs.2716/- in the current year to the opposite party and as such the complainant is a consumer of the opposite party,
(2)
that he had got admitted in the District Ayurveda Hospital, Kollam as inpatient on 18-01-2006 and discharged on 11-03-2006 and was undergoing treatment for the disease, that the complainant spent Rs.20,253.90/- as the value of the price of the medicines purchased and other expenses incurred for his treatment, that the opposite party is liable to indemnify the complainant for the expenses already spent by the complainant as per the terms and conditions of the policy, that he had filed an application before the opposite party to get the above said amount with all the relevant records in time, that on 27-07-2006 the opposite party informed the petitioner, that the opposite party is not willing to settle the claim put forward by the complainant alleging some untenable and vexatious reasons, that the above denial amounts to deficiency in service on the part of the opposite party, that the mental agony sustained to the complainant is immense and therefore incalculable in terms of money and hence this complaint praying to direct the opposite party to honour the claim put forward by the complainant to the tune of Rs.20,253.90/-, for directing the opposite party to pay Rs.5000/- as compensation for deficiency in service and for directing the opposite party to pay interest and cost to the complainant.
The opposite party entered appearance and filed version admitting the issuance of medi claim policy to the complainant and contenting that the policy was issued on the basis of the proposal form submitted by the complainant and the details furnished by the complainant that he was free from any illness at the time of submitting the proposal form and also on the basis of the declaration given by the complainant in the proposal form, that the opposite party accepted the proposal form with utmost good faith believing the details furnished by the proposer as true and correct and accordingly had issued a policy to the complainant, that the contract of insurance has been formulated and concluded upholding the principles of ‘ utmost good faith ’ which form the very foundation
(3)
of the insurance contract, that in the proposal form submitted by the complainant, he had deliberately suppressed his pre-existing illness for which the complainant was treated and a claim was preferred to this opposite party subsequent to the inspection of the policy, that the complainant had undergone treatment as inpatient at Bhavani Hospital, Thiruvananthapuram, for a period from 15-10-2003 to 23-11-2003 for the disease of Amavadharikaram and Vadharakatharikaram,that the complainant suppressed the above material facts in the proposal form submitted by him with an ulterior motive to make unlawful gain by making use of the insurance policy, that the complainant had obtained insurance coverage from this opposite party from 25-02-2005 to 24-02-2006 and he was admitted in the hospital on 18-01-2006 and discharged on 11-03-2006, for which the present claim was preferred before this opposite party, that the opposite party after receipt of intimation of claim from the complainant, has requested the complainant to produce a medical certificate from the treated doctor, that in the medical certificate submitted by the complainant it is stated that the complainant was referred to the treated doctor by Dr.Aniyanlal, that the opposite party thereafter deputed an investigator Mr.Biju Nobert for conducting a detailed investigation about the previous treatment history of the complainant, that the investigator has approached Dr.P.K.Aniyanlal, Chief Medical Officer, Seva Sadanam Arogya Nikethan, Chittayam, Kollam, where the complainant had undergone previous treatment for his disease, that according to the details furnished by the doctor to the investigator, the complainant was suffering from the disease for the last four years and he was not fully recovered at the time of discharge from the hospital, that on further investigation, it has revealed that the complainant was previously treated at Bhavani Hospital, Trivandrum which is a sister concern of Seva Sadanam Arogya Nikethan, as inpatient from 15-10-2003 to 23-11-2003, for the very same disease against which the claim was preferred, that the investigator had approached the medical officer, Bhavani hospital,
(4)
for collecting the treatment particulars of the complainant and had obtained the treatment particulars, that as per the treatment particulars submitted to the investigator by the Chief Medical Officer of Bhavani Hospital, the complainant had undergone inpatient treatment from 15-10-2003 to 23-11-2003, that the said doctor also opined that the complainant was suffering from the disease for the last four years and was not fully recovered from the disease at the time of his discharge, that the complainant spent an amount of Rs.22,464/- towards the treatment expenses at Bhavani Hospital, Trivandrum, that the investigator also obtained a discharge summary of the complainant from the Bhavani Hospital at Trivandrum, that as per the details collected by the investigator during the course of his investigation and from the finding of the investigator it has conclusively proved that, the complainant was suffering from the disease for which he had treated and submitted the claim, prior to the inception of the policy, which has been deliberately suppressed by the complainant, while obtaining the insurance policy, that since the treatment taken by the complainant against which the claim has been preferred is for his pre-existing disease, the same is excluded from the purview of the insurance coverage as per the exclusion clause given in the policy, that the opposite party is not liable to compensate the complainant as per the definite conditions of the policy, which excludes the insurance coverage for the medical expenses incurred for any pre-existing disease, that the claim of the complainant has been repudiated after making thorough enquiry about the genuineness of the claim and after due application of mind to the relevant factors determining the legal acceptability of the claim, that the opposite party has not committed any deficiency in service to the complainant and the complaint is only to be dismissed with cost to this opposite party.
(5)
The points for consideration are:
1. Whether the complainant is suffering from the disease against which he has preferred the claim with the opposite party, before the commencement of the policy or not?
2. Reliefs and cost?
For the complainant PW1 was examined and marked Exts.P1 to P5. For the opposite party DW1 and DW2 were examined and marked Exts.D1 to D8.
The Points
Admittedly the complainant took Ext.D1 policy from the opposite party with policy No.441400 from 25-02-2005 to 24-02-2006. The complainant got admitted in the District Ayurvedic Hospital on 18-01-2006 and discharged on 11-03-2006 and there he had undergone treatment for the disease of ‘ Vathasonitham ’ and ‘ Sidhmam ’. Ext.P1 is the certificate showing the same issued by Dr.Kishore. The complainant preferred a claim for a sum of Rs.20,253/- as the value of the price of the medicines purchased and other expenses incurred for his treatment. Ext.P4 is the statement showing the same. In this case, complainant was examined as PW1. He would swear before the forum in tune with the allegations in the complaint. The Divisional Manager (OP) was examined as DW1 and Dr.Aniyan Lal as DW2. According to the opposite party on investigation it has revealed that the complainant was suffering from the above disease for the last four years and had taken treatment from different hospitals during the above period and even then he has not recovered from the above disease and the claim preferred is for his pre-existing disease and as per condition no.4(1) of the insurance policy, the company shall not be liable to make any payment in receipt of any expenses incurred by the insured person in respect of all diseases which
(6)
are pre-existing when the cover incepts for the first time. Here the complainant deliberately suppressed about his pre-existing illness at the time of availing the insurance policy and on the basis of the above exclusion clause the claim of the complainant was not payable and accordingly the same has been repudiated with proper intimation to the complainant.
Let us examine whether the contention taken by the opposite party will hold good ? Ext.D2, is treatment details given by Dr.Aniyan Lal, Chief Medical Officer, SevaSadanam, Arogya Nikethanam Chittayam, Kollam to the investigator. Ext.D4 is discharge card dated- 23-11-2003 from SevaSadanam, Bhavani Arogya Nikethanam, Nalanchira, Thiruvananthapuram which would show that the complainant was treated there as inpatient from 15-10-2003 to 23-11-2003 for Vatharaktham (Arthritis) and Sidhmam ( psoriasis). In Ext.D2 the nature of illness is recorded as Amavathavikaram, Vatharakthavikaram. According to DW2, who issued Ext.D2 complainant is suffering from the above disease for the last four years and not cured from the above disease at the time of discharge from the hospital. DW2 has also admitted before the forum that SevaSadanam, Bhavani, Arogya Nikethanam , Nalanchira, Thiruvananthapuram is a sister concern of SevaSadanam, Arogya Nikethanam, Chittayam, Kollam and Ext.D4 is the discharge summary issued from the above hospital and he identified the signature of Dr.V.Leelammal who has signed Ext.D4. According to him, Dr.V.Leelammal is now not in the service of Seva Sadanam, Bhavani Arogya Nikethanam, Nalanchira, Thiruvananthapuram and the above hospital is presently running by a new management.Ext.D7is the inpatinet bill in the name of the complainant for his treatment in Seva Sadanam, Bhavani Arogya Nikethanam, Chittayam, Kollam for the period from 15-10-2003 to 23-11-2003. The IP No. in Ext.D4 and Ext.D7 are one and the same ie , 20031015001. DW2 has also spoken to before the Foum that the disease of the complainant in Ext.D1 and Ext.D4 are one and the same. It follows that the complainant preferred the claim with the opposite party for the
(7)
disease from the year 2003 itself. Ext.D3 is the cash bill dated:18-01-2006 which issued from Seva Sadanam, Arogya Nikethanam, Chittayam, Kollam to the complainant for his treatment. Ext.D5 is the treatment history given by Dr.Leelammal of SevaSadanam, Arogya Nikethanam, Bhavani, Nalanchira, Thiruvananthapuram to the investigator. In that also it is stated that the complainant was admitted there on 15-10-2003 and discharged on 23-11-2003. In that the illness is stated as pain, oedema and tenderness on knee joints, inter phalangeal joints and psoriasis. The complainant got admitted in the Ayurvedha Hospital, Kollam on 18-01-2006 ie; 36 days prior to the expiry of Ext.D1 policy. Condition No. 4 (1) in Ext.D1 policy clearly shows that the company is not liable to make any payment in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of all diseases which are pre-existing when the cover incepts for the first time. Following the evidence adduced in this case, we have no hesitation to conclude that condition no.4 (1) of Ext.D1 is clearly applicable in this case and the complainant is not entitled to receive any amount from the opposite party for the treatment taken by him for his pre-existing disease . Here it is also in evidence that the complainant had deliberately suppressed the material facts about his pre – existing illness in the proposal form submitted by him. The Learned Counsel appearing for the opposite party relied on IV (2009) CPJ 8 (SC) where Our Hon’ble Apex Court held that in the case of medi claim policy the insured has obligation to make true and full disclosure of information with in the knowledge. In Para 12 of the judgment it is further held that a medi claim policy is a contract of insurance falling under the category of contract of uberrimaefidei, meaning contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when information on a specific aspect is asked for in the proposal form, an assured is under solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not.
(8)
The Learned Counsel appearing for the opposite party also relied on III (2008) CPJ 198 (NC) where Our National Commission held that if the insured has suppressed a material fact of illness in the original proposal form and also in the subsequent renewal of the policy the repudiation of the claim by the company is justifiable.
Following the above discussion we have no hesitation to safely conclude that there is no deficiency in service on the part of the opposite party in repudiating the claim of the complainant.
In the result, the complaint is dismissed. In the circumstances of the case there is no order as to costs.
Dated this the 7th day of March 2012.
G.Vasanthakumari :Sd/-
Adv.Ravi Susha :Sd/-
R.Vijayakumar :Sd/-
(9)
INDEX
List of witness for the complainant
PW1 - Sujith
List of documents for the complainant
P1 - Treatment certificate dated :31-07-06
P2 - Copy of good health insurance policy
P3 - Copy of good health insurance schedule
P4 - Copy of statement
P5 - Hospitalization claim
List of witness for the opposite party
DW1 - N.Raju
DW2 - Dr.Aniyan Lal
List of documents for the opposite party
D1 - Medi claim insurance policy
D2 - Treatment details of patient
D3 - Cash bill dated : 18-01-06
D4 - Discharge card dated: 23-11-03
D5 - Treatment details of patient
D6 - Report on investigation
D7 - IP bill
D8 - Hospitalization claim dated : 27-07-2006
