BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION: AT HYDERABAD.
FA.No.825/2010 against C C.No.201/2009 District Forum-II, KRISHNA AT VIJAYAWADA.
Between
Star Health and Allied Insurance Co. Ltd.,
No.1, New Tank Road,
Valluvur Kottam High Road,
Nungambakkam, Chennai. ..Appellant/
Opp.party
And
Kolli Hanitha, D/o.Ramesh Babu,
Sri Sai Towers, Karanam Street,
Patamata, Vijayawada-10. Respondent/
complainant
Counsel for the Appellant : M/s.P.Gopal Das
Counsel for the Respondent : Mr.Katta Laxmi Prasad.
QUORUM: THE HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT,
AND
SMT.M.SHREESHA, HON’BLE MEMBER,
FRIDAY, THE THIRTEENTH DAY OF JULY,
TWO THOUSAND TWELVE
Order (Per Smt.M.Shreesha, Hon’ble Member)
***
Aggrieved by the orders in C.C.No.201/2009 on the file of District Forum-II, Krishna at Vijayawada, opposite party preferred this appeal.
The brief facts as set out in the complaint are that the complainant had renewed his Family Health Optima Insurance Plan policy No.P.131211/-1/2009/001972 on 06-2-2009 covering the period from 12-2-2009 to 11-2-2010 which covers his family members i.e. himself , his wife and his daughter. The complainant submitted by virtue of the policy, he and his family members are eligible to utilize Rs.2,00,000/- towards medical expenses. The complainant submitted that originally the policy was obtained in February, 2007 and it was renewed from time to time and during the 1st year of policy period, opposite party had paid hospital charges but thereafter the complainant received a letter on 08-7-2009 stating that the complainant failed to disclose the pre-existing ailment at the time of obtaining the policy. The complainant submitted that in fact opposite party arranged payment of Rs.50,000/- by fax letter dated 11-5-2009 wherein it was also mentioned that if the hospital bills to be higher than the guarantee of payment, a request letter for additional amount needs to be sent to them. The complainant submitted that his daughter was admitted into hospital on 09-5-2009 and was discharged on 19-5-2009 for the ailment of clival chordoma and incurred an expenditure of Rs.2,04,747/- out of which the opposite party arranged Rs.50,000/- and has to pay the balance of Rs.1,54,747/- and instead of paying the same, they addressed letter dated 8-7-2009 stating that the complainant suppressed pre-existing disease. Therefore the complainant got issued a legal notice to the opposite party on 18-9-2009 demanding the amount paid by the complainant to the hospital on 19-5-2009 but the opposite party replied with all false and untenable allegations. Hence the complaint for a direction to the opposite party to pay Rs.1,50,000/- together with interest at 24% p.a. from the date of discharge till the date of payment together with Rs.50,000/- towards mental agony.
Opposite party filed written version denying the averments made in the complaint. It however admitted that the complainant is one of the beneficiaries of Optima Family Health Insurance Plan issued in 2007 to her father and later on renewed by her mother in 2009. It submitted that during the first year of policy tenure, the complainant availed the benefit of medical claim and the claim was settled by the opposite party. Opposite party submitted that all the family members of the complainant are educated and hence they are aware of the policy conditions but the answer to Q.No.3 Has any medication been prescribed in the past 12 months and Q.No.7 Been treated as in patient or out patient for surgery and both were noted as ‘No’. Opposite party further submitted that the complainant’s daughter was admitted into hospital and the treatment expenditure was Rs.2,04,747/- and they arranged Rs.50,000/- initially but after knowing that the complainant suppressed the pre-existing disease intimated the complainant by letter dated 08-7-2009 that she is not entitled for reimbursement. Opposite party further submitted that insurance is meant for future and impending ailments that may unexpectedly erupt in daily routine life subsequently may cause damage to the life of the insured and does not cover pre-existing diseases. Opposite party further submitted that the complainant’s mother is an agent of their company and also for Bajaj Allianz and knowing the stipulations of the policy and non-covering of pre-existing diseases, she misrepresented and deliberately made false claim and hence they are not entitled to recover Rs.50,000/- already paid and submitted that there is no deficiency in service and prayed for dismissal of the complaint with costs.
Based on the evidence adduced i.e. Exs.A1 to A11 and B1 to B8 and the pleadings put forward, the District Forum allowed the complaint directing the opposite party to pay an amount of Rs.1,50,000/- together with costs of Rs.2,000/- within one month failing which the awarded amount shall carry interest at 9% p.a. till the date of payment.
Aggrieved by the said order, opposite party preferred this appeal.
Written arguments of the appellant filed.
The facts not in dispute are that the complainant is one of the beneficiaries of Optima Family Health Insurance Plan issued in the year 2007 and renewed by the complainant’s mother in the year 2009. During the first year policy tenure, the complainant had availed the benefit of the medical claim. This policy covers the period from 12-2-2009 to 11-2-2010 and the family members are eligible to utilize Rs.2 lakhs towards medical expenses evidenced under Exs.B2 and B3. It is the complainant’s case that on 08-7-2009, she received a letter from the opposite party that she failed to disclose her alleged pre existing disease at the time of obtaining the policy. Opposite party paid Rs.50,000/- vide fax dated 11-5-2009. The complainant submits that she was admitted into P.D.Hinduja National Hospital on 09-5-2009 and discharged on 19-5-2009 as evidenced under Ex.A3. It is the opposite party’s case as per the medical record, Ex.A3, the 17 year old patient was operated twice in 2007 and once in 2008 and she also has a history of nasal regurgitation and occasional headaches which was suppressed by the complainant. This patient was admitted on 31-5-2008 and discharged on 11-6-2008 evidenced under Ex.A2, therefore, the learned counsel for the appellant/opposite party contended that the complainant in the proposal form did not honestly answer to question No.3 and 7 wherein she was asked if she was treated as in patient or out patient for surgery and if she was on medication for the last 12 months. The complainant answered both the questions as ‘no’, and therefore has violated the terms and conditions of the policy by suppressing her health condition. It is not in dispute that the patient is 17 years old and is a minor and the proposal form, Ex.B4, is signed by one K.Ramesh Babu and not by the complainant herein. Section 45 of the Insurance Act, clearly states that a period of two years has to be counted from the date on which the policy was originally affected and not from the date of revival of the policy. In the instant case, admittedly the first policy was issued in the year 08-2-2007 and the opposite party questioned on 08-7-2009 about suppression of health condition by the complainant which is more than two years after issuing the policy. Moreover Section 45 also envisages that the suppression should be wilful and fraudulent and in the instant case, the complainant herself has not even signed the proposal form and the opposite party has failed to establish that the suppression is wilful and fraudulent. It is an admitted fact that the opposite party paid a part of the repudiated claim later vide Ex.B8 dated 08-7-2009 repudiated the claim. The learned counsel for the appellant contended that this Rs.50,000/- was paid on pre authorization basis to the hospital and thereafter on realisation of the mistake, opposite party has sought refund of the said amount. It is pertinent to note that opposite party did not choose to cancel the policy though they state in the repudiation letter that they had withdrawn the pre authorization facility given for cashless treatment. Keeping in view the aforementioned reasons and also the fact that the insurance company failed to establish that the alleged suppression was wilfully and fraudulently made by the complainant herein, we are of the considered view that the repudiation by the opposite party is unjustified and we see no reasons to interfere with the well considered order of the District Forum.
In the result this appeal fails and is accordingly dismissed. Time for compliance four weeks.
Sd/-PRESIDENT.
Sd/-MEMBER.
JM 13-7-2012
