By Sri. MOHANDASAN.K, PRESIDENT
1. The complainant is 108 ambulance driver and he subscribed Covid-Corona Rakshak Policy as per policy No.H0585378. He met with Covid 19 ailment and was referred from primary health center to the Covid treatment center at Muttipalam, Manjeri, on 14/02/2021. Subsequently he recovered from Covid ailment. Thereafter he approached the opposite party for the benefit of Covid policy along with all the treatment records. But the opposite party denied the policy stating that the complainant was having diabetic complaint, which was not revealed while subscribing the policy. Thereafter the complainant was instructed to produce medical report regarding diabetic complaint. The doctor issued a certificate stating that he was a diabetic patient. Actually, the complainant was not a diabetic patient and no medicine was taken for the same. As per the insurance policy the coverage is for Rs.2,50,000/-. The complainant approached the opposite party at different offices but it was vain. Hence the prayer of the complainant is to direct the opposite party to pay Rs. 2,50,000/- to the complainant and also 50,000/- rupees on account of mental agony and in conveniences and cost of Rs.25,000/-.
2. On admission of the complaint notice was issued to the opposite parties and the opposite parties entered appearance and filed version in detail.
3. The opposite party admitted that the complainant had purchased policy No.H0585378 with effect from 05/01/2021 to 16/10/2021 from the opposite party by filing out a proposal form. There was a question in para No.8 section A in the proposal form that have any of the persons proposed to be insured ever suffered from / are currently suffering from any of the following : ii diabetes. To which the answer of the complainant was No.
4. The opposite party submitted that the complainant had submitted a claim to the opposite party which was received by the opposite party on 18/03/2021 for contracting Covid disease diagnosed on 14/02/2021. The opposite party submitted that on examination of the document submitted along with claim it was noticed that in the discharge summary issued by medical college, Manjeri that he was suffering from diabetics. On 18/03/2021, immediately on receipt of the claim form, requested the complainant to submit the certificate from the treating doctor on the exact duration of diabetes mellitus. On 20/03/2021 the complainant submitted a certificate issued by Dr. Ameen Faisal, Medical officer, Family Health Center, Munda P.o, Vazhikadavu, which stated that the complainant was suffering from diabetes mellitus for the last one year. Dr. Ameen Faizal is the doctor who diagnosed the complainant with Covid and advised hospitalization. Hence the submission of the opposite party is that at the time of submitting the proposal form, the complainant was suffering from diabetes mellitus.
5. The opposite party submitted that the diabetes mellitus compromises immunity of person and makes him more easily susceptible to catching diseases. In such a case if the person suffers from diabetes mellitus, the insurer may consider the risk of infection very high and may refused to issue the policy. That is the reason according to opposite party for inserting the question in the proposal form. The opposite party submitted that the policy document it is clearly stated that the records with respect to pre existing illness / conditions etc. are as declared by the insured. If the information given above to found to be either incomplete or incorrect or concealed at the time of claim, the same shall be construed as a case of non- disclosure of material fact. The relevant definition number 3.5 and 8.1 of CRB policy reads that – disclosure of information: The policy shall be void and all premiums paid thereon shall be forfeited to the company in the event of misrepresentation, mis description or non-disclosure of any material fact by the policy holder. The opposite party repudiated the claim vide letter dated 07/04/2021 since there was a non-discloser/misrepresentation regarding diabetic mellitus condition of the complainant. The submission of opposite party is that repudiation has been done after the due application of mind and after considering all the documents before the opposite party. Hence the prayer is to dismiss the complaint with cost of the opposite party.
6. The complainant and opposite parties filed affidavit and documents. The documents on the side of complainant marked as Ext. A1 to A12. The documents on the side of opposite party marked as Ext. B1 to B3. Ext. A1 is insurance receipt issued by IFFCO-TOKIO General insurance company limited for Rs.2,863/- issued on 05/01/2021. Ext. A2 is copy of Covid 19 test report dated 14/02/2021. Ext. A3 is discharge card issued from MCH, Manjeri dated 21/02/2021. Ext. A4 is copy of query letter issued by insurance company dated 18/03/2021. Ext. A5 is copy of claim receipt dated 20/03/2021. Ext. A6 is referral letter issued by Medical Officer family Health Center Munda P.O, Vazhikkadev dated 14/02/2021. Ext. A7 is copy of medical certificate issued by medical officer family health center Munda Po Vazhikkadav to the complainant dated 20/03/2021. Ext. A8 is copy of 2019 Corona Negative certificate dated 01/03/2021. Ext. A9 is copy of repudiation letter issued by the IFFCO-TOKIO General insurance company to the complainant dated 07/04/2021. Ext. A10 is copy of letter issued by the complainant to the opposite party. Ext. A11 is a letter issued by the opposite party to the complainant. Ext. A12 is power of attorney. Ext. B1 is copy of Corona Rakshak policy issued by the opposite party to the complainant. Ext. B2 is copy of receipt for the insurance policy dated 05/01/2021 along with policy wording. Ext. B3 is copy of medical certificate issued by medical officer to the complainant dated 20/03/2021.
7. Heard both parties, perused affidavit and documents and the following points arise for consideration-
- Whether there is deficiency in service on the part of opposite party ?
2) Relief and cost?
8. Pont No.1 and 2
The opposite parties admit the issuance of insurance policy covering Covid disease and there is no dispute that the complainant met with covid disease also. But the opposite party declined the insurance coverage contenting non-discloser / suppression of material fact while subscribing the insurance policy. The opposite party submitted that the complainant had diabetic complaint during Covid treatment and that can be seen from the medical report / discharge summary marked as Ext. A3 and so the averment of the complainant that the complainant never had any diabetic problem is absolutely false and that is to mislead the Commission. According to opposite parties as per insurance policy it is averred in clause 2 that the “the above records with respect to pre existing illness / conditions etc are as declared by the insured. If the information given above is found to be either incomplete or incorrect or conceal at the time of claim, the same shall be construed a non-disclosure of material facts“. It is also contended that” this policy shall be void and all premium paid thereon shall be forfeited to the company in the event of misrepresentation, mis- description of non-disclosure of any material fact by the policy holder”. So the case of the opposite party is definite and clear that the complainant was having diabetes mellitus while subscribing policy and that was not disclosed at the time of subscription and so the policy stands void.
9. The issue is that whether the complainant was having diabetes mellitus at the time of subscribing the policy and whether he suppressed the same with his knowledge. The document Ext. A3 is the discharge summary issued from the treated hospital while he was taken for Covid treatment. Ext. A3 does not reveal that he was having diabetes ailment while incepting insurance policy. The opposite party after verification of Ext. A3 directed the complainant to produce document from the doctor on the exact duration of diabetes mellitus as per Ext. A4. The complainant with all bonofides approached the medical officer for a medical certificate regarding his diabetic issue and the medical officer issued Ext.A7 document stating that the complainant is suffering from diabetes mellitus for the last one year. But the document Ext. A7 do not reveal whether he had prescribed any medicine to the complainant for the diabetes mellitus and even not mentioned that he had treated the complainant for the same. The complainant sent e-mail to the opposite party on 08/04/2021 and he contended in the e-mail that he was not a diabetic person but the doctor wrote in the report that he was suffering from diabetics for the last one year. He also stated that he had never checked his sugar level at any point of time and never taken tablet for diabetic control. He also submitted that the opposite party can check any of his medical report to that effect also. So the only document to support the opposite party is the Ext. A7 certificate issued by the medical officer. It can be seen that Ext. A7 do not reveal that the issued doctor had treated this complainant for the diabetic issue and even not prescribed any medicine also. So it will be proper to discard the document Ext. A7 to establish that the complainant was suffering diabetic mellitus at the time of subscribing the insurance policy. Except Ext. A7 document the opposite party has not produced any document to show that the complainant was suffering from diabetes mellitus. We consider the averment in Ext. A10 e-mail sent by complainant to the opposite party as genuine one. It can be seen that the complainant was serving as 108 ambulance driver during the Covid Pandemic period. The complainant with abundant caution subscribed the policy of the opposite party to save the crisis during the covid pandemic period. It is also to be noted that there was no specific clause in the policy that the persons who suffering from diabetic aliment are not eligible to subscribe the Covid insurance policy. It is also to be noted that Covid Pandemic was affected to the people at large irrespective of whether the people are suffering diabetes mellitus or not. In short the non- disclosure of diabetes mellitus in a Covid Pandemic policy is not a material fact to be disclosed while subscribing the policy. So we find that the complainant was rightly preferred the claim application as per the insurance scheme with all material documents, but the opposite party repudiated the claim without ensuring that the complainant was really suffering from diabetes mellitus while subscribing the policy. Considering the entire aspects we are of view that the complainant is entitled the insurance benefit as per Ext A1 policy.
10. In the alight of above facts and circumstances we allow the complaint as follows: -
- The opposite parties are directed to pay Rs.2,50,000/- to the complainant
as the insured amount.
- Opposite parties directed are directed to pay Rs.25,000/- as compensation on account of deficiency in service and thereby caused inconvenience and hardship to the complainant.
- The opposite party is also directed to pay Rs.5,000/- as cost of this
proceedings.
The opposite parties directed to comply this order within one month from the date of receipt of copy of this order, failing which the compensation and cost will carry interest @9% per annum from the date of this order till realization.
Dated this 29th day of August, 2022.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
APPENDIX
Witness examined on the side of the complainant: Nil
Documents marked on the side of the complainant: Ext.A1 to A12
Ext.A1: Insurance receipt issued by IFFCO-TOKIO General insurance company limited
for Rs.2,863/- issued on 05/01/2021.
Ext.A2: Copy of Covid 19 test report dated 14/02/2021
Ext A3: Discharge card issued from MCH, Manjeri dated 21/02/2021.
Ext A4: Copy of query letter issued by insurance company dated 18/03/2021.
Ext A5: Copy of claim receipt dated 20/03/2021.
Ext.A6: Referral letter issued by Medical Officer family Health Center Munda P.O,
Vazhikkadev dated 14/02/2021.
Ext.A7: Copy of medical certificate issued by medical officer family health center
Munda Po Vazhikkadev to the complainant dated 20/03/2021.
Ext.A8: Copy of 2019 Corona Negative certificate dated 01/03/2021.
Ext.A9: Copy of repudiation letter issued by the IFFCO-TOKIO General insurance
company to the complainant dated 07/04/2021.
Ext.A10: Copy of letter issued by the complainant to the opposite party.
Ext A11: Letter issued by the opposite party to the complainant.
Ext.A12: Power of attorney.
Witness examined on the side of the opposite party: Nil
Documents marked on the side of the opposite party: Ext. B1 to B3
Ext.B1: Corona Rakshak policy issued by the opposite party to the complainant.
Ext.B2: Copy of receipt for the insurance policy dated 05/01/2021 along with policy
wording.
Ext.B3: Copy of medical certificate issued by medical officer to the complainant dated
20/03/2021.
Mohandasan K., President
PreethiSivaraman C., Member
Mohamed Ismayil C.V., Member
