By. Sri. K. Gheevarghese, President:-
The complaint filed against the opposite parties by the 1st and 2nd complainants for the repudiation of the Insurance claim.
2. The complaint in brief by the 1st complainant is as follows:- The 2nd complainant is the wife of the 1st complainant and the 2nd complainant is a holder of health saver policy offered by the opposite party. The 2nd complainant had undergone treatments for which around Rs.7,00,000/- spent and she had undergone treatments as inpatient from 16.01.2010 to 06.03.2010 in MIMS Hospital Calicut. The repudiation of the medical expenses by the opposite party was based on frivolous reasons and untenable contentions. There may be an order directing the opposite party to pay the 1st complainant Rs.5,00,000/- towards treatment charges spent for his wife along with cost.
3. The 2nd complainant is arrayed subsequently as the order in IA 189/2011. The 2nd complainant contented that she had undergone treatments. The amount spent for the entire treatments were met by her father and moreover the 1st complainant already filed a diverse O.P in the Family Court Kalpetta. The IA 189 was filed to implead her as the 2nd complainant and the petition was allowed and implead as the 2nd complainant in this case.
4. The opposite party filed version in short it is as follows:- The contentions of the complainant are with ulterior motives and dishonest intention. The life assured did not disclose all the material facts in the proposal form and purposefully kept the facts undisclosed. The clause No.5 of the proposal form filled by the insured is inaccurate and misleading. On that grounds itself the complainant does not deserve any right to file the complaint. The life insured was undergoing treatments for Ulcerative Colitis and availed treatments from 9th October 2000. She had undergone laparotomy with Closure of Perforation of Transverse Colostomy. Followed by that she continued treatment and hospitalized on 3rd February 2001 for Active Ulcerative Colitis. The information which are most vital and necessary making life of the assured access to the policy to be true. The insured and the insurer are bound to act upon the terms and conditions of contract. Another clause in proposal form elucidates that the insured is hospitalized in connection to pregnancy or anything related to that such as abortion or complications of anything consequent to pregnancy, the insurer is not liable to consider the claim. This policy envisages that if the policy holder if not satisfied with terms and conditions of the scheme, the person who desires for the policy can disown it in the “ Free look period”. The 2nd complainant in this case agreed all the policy terms and conditions and the company received the proposal form duly signed by the life assured.
5. If the policy holder had given any wrong information in the proposal form the liability of the insurer ceased to exist. The life insured in this case was admitted in MIMS Hospital from 16.01.2010 to 06.03.2010 after the treatments from MES Hospital Sulthan Bathery. The 2nd complainant under went surgery and the nature of treatment as Laprotomy Iscs, subtotal hysterectomy, damage of abren, leorey and the 2nd complainant was also pregnant during that period. She was hospitalized for abdominal pain and Jaundice. In further observation it is noticed that the life assured was pregnant for a period of 33 weeks. The further observation from the hospital is that she had Ulcerative Colitis, subtotal colectomy, Illeo rectal anastomosis, colonic perforation with diverting colostomy 9 years ago. The life assured had under gone treatments for 7 years and had undergone treatments for Ulcerative Colitis. The 2nd complainant availed treatments as an inpatient from 03.02.2001 to 07.02.2001.
6. The repudiation of the claim of the complainants are on sufficient reasons. While answering the policy contract Clause No.5 (d) & 5 (e). The life assured purposefully concealed the real facts. Suppression of the facts and improper statements made the policy holder not entitled for any compensation. On the other hand the claim of the complainants deserves outright denial.
7. The Points in consideration are:-
1. Whether there is any deficiency in service on the part of the opposite parties in repudiation of the Insurance claim?
2. Relief and Cost.
8. Points No.1 and 2:- The evidence in this case consists of the proof affidavit of the complainant and opposite party. Ext.A1 to A4, B1 to B9 are the documents produced. The oral testimony of the complainant, opposite party and expert witness is also considered.
9. The complainant's case is that the claim of the life assured to compensate the expenses on medical treatment is against reasons. The 2nd complainant in this case is the policy holder. The 1st complainant is the husband who claimed the expenses of the treatment. The repudiation of the claim according to opposite party is consequent to the suppression of the earlier treatments. The medical treatments already availed by the 2nd complainant is also related to pregnancy. Ext.B1 is the health insurance application form given by the 2nd complainant to the opposite party. The personal details of the insured in clause No.5 of the application consist of the questions related to lifestyle and health details. Clause 5 A2,5F answered by insurer that she had no ailment before her inception to policy. On perusing the documents produced by the opposite party the 2nd complainant had undergone treatments from Kasturba Hospital
Manipal, Karnataka for Ulcerative Colitis with Sigmoid Perforation and closure of Perforation of Transverse Colostomy which was during 2000. The insured was admitted in the Hospital on 09.10.2000 as per Ext.B5. She underwent surgery there. The opposite party issued the policy in good faith basing on the statements elucidated in the application form given by the 2nd opposite party.
10. The certificate issued from the Malabar Institute of Medical Science, Calicut by Dr. Sajeesh Sahadevan ie marked as Ex.B9 it also shows that the insured had Intestinal Surgery. The surgery done in MIMS on 16.01.2010 is Laparotomy, Lscs, Subtotal Hystoractomy. In the final diagnosis the insured have 33 weeks pregnancy with IVD of Fetus multiloculated intra abdominal abscess. Doctor who issued certificate is examined as OPW2. According to this witness the insured has previous history of surgery 9 years back. According to this witness the Ext.B4 elucidates that the insurer availed the treatments from hospital and the treatment can said to be a pregnancy related decease. Ext.B2 is the policy documents on the terms and conditions of policy of the assured. The policy terms and conditions Clause 8.19 reads the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by any Insured Person(s) in connection with any treatment arising from or traceable to pregnancy, childbirth, miscarriage, cesarean clause, abortion or complications of any of these including changes in chronic condition as a result of pregnancy, tests and treatment relating to Infertility and in vitro fertilization. In the light of the above inferences the repudiation of the claim of the complainants cannot be considered deficiency in service and the points are found accordingly.
In the result the complaint is dismissed. No order as to cost and compensation.
Pronounced in Open Forum on this the day of 31st January 2012.
Date of Filing:08.12.2010.
