KERALA STATE CONSUMER DISPUTES REDRESSAL
COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL NO.413/2012
JUDGMENT DATED 28/05/2013
(Appeal filed against the order in CC No.185/2010 on the file of CDRF, Malappuram dated, 14/03/2012)
PRESENT:
SMT. A. RADHA : MEMBER
SHRI. K. CHANDRADAS NADAR : JUDICIAL MEMBER
APPELLANT:
The Branch Manager,
Star Health and Allied Insurance Co.Ltd.,
City Trade Centre, Down Hill,
Malappuram.
(By Adv: Sri. P.S. Sureshkumar)
Vs
RESPONDENT:
K. Paramesweran, Alingal Parambil Veedu,
Mullampara, Manjeri (PO),
Malappuram.
(By Adv: Sri. R. Narayan)
JUDGMENT
SMT. A. RADHA : MEMBER
This appeal is preferred by the opposite parties against the order dated 14/03/2012 in C.C.No.185/10 on the file of CDRF, Malappuram. The Forum Below directed the opposite party to pay a sum of Rs.1,67,920/- with 12% interest along with cost of Rs.2,000/-.
2. The complainant’s case is that he availed a Medi-Classic Individual Policy for a period from 17/03/2009 to 16/03/2010. During the subsistence of the policy on 07/12/2009 the complainant was admitted in hospital due to chest pain and had undergone Coronary Angiogram on 10/12/2009 with an advice for surgery within a week. On 18/12/2009 bypass surgery was done and the claim submitted for re-imbursement of treatment expenses was rejected for the reasons of suppression and non-disclosure of pre-existing heart disease in the proposal form. The policy coverage was for Rs.2,00,000/- and it was mentioned that he was a diabetic patient. The complaint is filed for the treatment expenses, compensation and cost of the proceedings from the opposite parties.
3. The opposite parties filed version contending that the policy will not cover the pre-existing disease. The policy of the complainant was admitted. In the proposal form the information furnished by the complainant was incorrect and there had suppression of material facts relating to the health of the complainant. The suppression of material facts itself makes the policy void-ab-initio for getting the policy coverage. The complainant did not disclose the heart problems. The complainant admitted for treatment and had the Angiogram on 07/12/2009 and the report of the Angiogram impression shows that CAG 2008-3 vessel disease and under Recommendation - it was shown Coronary Angiogram. The medical certificate submitted along with the claim form clearly shows that the complainant was suffering from diabetics. It is revealed in the investigation conducted by the opposite party that the complainant had undergone CAG in 2008 and the diagnosis as TVD which shows that the complainant was suffering from heart related disease which falls under pre-existing disease coming under exclusion clause of Medi Classic Policy. The real health status of the complainant is best known only to him and it is the prime duty of the complainant to furnish such information in the proposal form before taking the policy. There is breach of good faith on the part of the complainant and he is not entitled to get the policy coverage. The complainant filed this complaint to tarnish the repudiation of the opposite party as an experimental basis to extract benefits under policy from the opposite party. Hence the complaint is only to dismiss.
4. Both parties filed affidavit and documents marked as Exbts.A1 to A11 and B1 to B6. On appreciation of documents and on hearing the counsels the forum below allowed the complaint as the opposite parties failed to convince that there had pre existing disease to the complainant.
5. When this appeal came up for hearing the counsel for the appellant vehemently argued that respondent was a diabetic patient. While submitting the B2 proposal form the complainant had mentioned under column 11- medical history that the respondent was not suffering from any disease/illness except diabetics. It is also stated that he had not undergone any treatment in any hospital within the period of 3 years prior to the date of submission of proposal form. While admitting the policy it is also pointed out that from the records of treatment at Mims Hospital submitted by the respondent it is clear that he had undergone heart surgery followed by Coronary Angiogram. The policy holder was above 50 years old and as per the records the complainant underwent CAG in 2008 and in the result it was diagnosed as TVD. Therefore, the treatment done with respect to the claim was for a pre-existing disease which is excluded as per exclusion clause No.3(1) of the policy. So it can be inferred that the complainant was suffering from heart disease since 2008 ie., one year prior to the commencement of the policy. The suppression of material facts in the proposal form regarding the pre-existing heart disease before taking the policy comes under exclusion clause. The respondent was bound to disclose the true and correct information regarding his health condition in the proposal form at the time of taking the policy. The existing illness and the treatment underwent were material facts for the issuance of Medi Claim Policy as the policy is issued for a short period of one year. If any vitiating ailments are detected after issuance of the policy the purpose of the policy and contract of insurance become invalid as per column 4(7) of the policy. Therefore, in this case, insurance contract became invalid and policy became void due to suppression of material facts and non disclosure of pre-existing disease. The appellant repudiated the claim on valid, cogent and reasonable grounds as per column 4(7) and exclusion 3(1) of policy conditions Exbt.A1. At the time of issuance of the policy a general medical checkup was conducted wherein it was found out that the respondent was a diabetic patient and it was excluded from the policy. If the respondent had disclosed that he had pre-existing heart disease before taking the policy it would have been excluded in the policy for a certain period. The respondent underwent Coronary Angiogram and bypass surgery at Mims Hospital following the hospitalization in 2009 which is evidenced by Exbt.B6. It is also asserted by the counsel for appellant that the system entry form from the Mims Hospital dated 21/05/2010 shows impression as CAG 2008 – 3 vessel disease. From this it is to be inferred that the respondent had underwent CAG in 2008 and was having heart disease before the inception of the policy and this was disclosed in the proposal form. The insured declared only diabetic problem in the medical history column. The respondent wilfully suppressed the important information regarding heart disease. The date of inception of policy was from 17/03/2009 and the complainant was suffering from heart related disease and it falls under pre-existing disease referred under exclusion clause of the Medi Classic Policy. The real health stage of the complainant is best known to him alone. So the respondent is obliged to furnish such information in the proposal form before taking the policy. He also pointed out that the proposal form contained specific questions regarding prior health conditions of the complainant. The complainant wilfully suppressed the fact that he was having Coronary disease. Exbt.B4 it is produced by the appellant before the Forum Below. It is an act of suppression with malafied motives. The counsel also filed a petition to call for the production of documents ‘System Entry Form’ from the Mims Hospital regarding the treatment of respondent. He also argued that the complainant frivolously obtained the policy suppressing his cardiac treatment at Mims Hospital in 2008.
6. The counsel for the respondent submitted that he was a policy holder of the appellant from 17/03/2009 to 16/03/2010. Under Medi Classic Individual Policy he paid an amount of Rs.5,846/-. While taking the policy, the respondent had undergone medical checkup for the issuance of the policy and found out that the respondent was having diabetics and the claim for diabetic was excluded in the exclusion clause. On 10/12/2009 the complainant had a chest pain and was admitted at the Mims Hospital wherein he was advised for Angiogram and further he underwent a bypass surgery. The total treatment expenses came to Rs.1,60,080/- and Rs.9,470/- for Angiogram and also Rs.25,000/- towards by stander expenses, travel expenses and food. The claim submitted to the appellant was repudiated on the ground that the respondent was having pre-existing disease and suppressed the material facts during the submission of proposal form. The respondent alleging deficiency in service filed the complaint for getting reimbursement of the expenses incurred for the treatment and also for compensation for the mental agony caused to the respondent. It is asserted by the counsel for respondent that the respondent was not aware of any cardiac problems before taking the policy. No claim was submitted for any treatment for the heart disease nor he had undergone treatment at any hospital. It is on 10/12/2009 the Coronary Angiogram was done and detected the block in blood vessels at Mims Hospital. As there had no pre-existing heart disease the respondent is not supposed to write any answers in affirmative for which he had no knowledge. He also argued that Exbt.B4 produced by the appellant is only photocopy wherein the CAG is only an impression. It was not at all proved by the appellant. The rejection of the Insurance Claim is a deficiency in service as the complainant had not suffered any heart disease previously and it is also violation of natural justice who is having a valid policy for a specific period. Hence the appellant is liable to pay the claim amount and the Forum Below rightly allowed the complaint.
7. After considering the documents on record and also hearing the learned counsels, we are of the considered view that there is no documentary evidence before us to show that the complainant was having pre-existing disease. The appellant wholly depends upon the Exbt.B4 regarding the treatment of respondent conducted on 07/12/2009. The appellant is harping upon the impression CAG 2008 3 vessels disease as a pre-existing one which doesnot have any corroboratory evidence. It is to be pointed out that there is no record before us to show that the complainant had undergone CAG in 2008 and whether the CAG report is against the complainant and to that effect the counsel for the appellant filed a petition to call for the (case records) ‘system entry form’ from the Mims Hospital at this appeal stage. The appellant himself produced Exbt.B4 before the forum below whereas he had not produced the whole records at that stage. It is also argued that the non-production of ‘system entry form’ medical record regarding the treatment of the complainant for heart disease at Mims Hospital, will cause irreparable injury and loss as the complainant fraudulently obtained the policy suppressing cardiac treatment at Mims Hospital in 2008. The petition for production of documents is filed as on 29/10/2012. Which definitely will cause mental agony to the complainant who had undergone a heart surgery in the year 2009. Now the case came for hearing and at this belated stage the petition for production of document from the Mims Hospital need not be considered. As per records the complainant had undergone for medical examination and found out that he is a diabetic patient and we find no ground of suppression by the complainant to disclose his heart disease. Further there is no other document to show that the complainant suppressed any pre-existing disease.
In the result, the appeal is dismissed and we have no hesitation to uphold the order passed by the Forum Below. The order is to comply within 30 days on receipt of the copy of the order.
The office is directed to send a copy of this order to the Forum below along with LCR.
A. RADHA : MEMBER
K. CHANDRADAS NADAR : JUDICIAL MEMBER
Sa.
KERALA STATE CONSUMER
DISPUTES REDRESSAL
COMMISSION
THIRUVANANTHAPURAM
APPEAL NO.413/2012
JUDGMENT DATED 28/05/2013
sa
