Kerala

StateCommission

A/15/470

STAR HEALTH AND ALLIED INSURANCE - Complainant(s)

Versus

M AZEEZ - Opp.Party(s)

G S KALKURA

29 Jan 2016

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION, VAZHUTHACAUD, THIRUVANANTHAPURAM

 

APPEAL NO.470/2015

JUDGMENT DATED  29/01/2016

  (Appeal filed against the order in C.C No.250/2013 dt 16/4/2015 on the file of CDRF, Wayanad, Kalpetta)

  

PRESENT:

 

SMT. A. RADHA                                       :         MEMBER

SHRI. K. CHANDRADAS NADAR           :        JUDICIAL MEMBER

SMT. SANTHAMMA THOMAS              :        MEMBER

 

APPELLANTS:

 

1. The Branch Manager,

Star Health & Alied Insurance Company,

Branch Office, Afthab Building,

Near Karuna Hospital,

Sultan Bathery.

 

2. The Manager,

Star Health Allied Insurance Company,

KRM Centre, 6^th Floor, No.2,

Harington Road,

Chetpet, Chennai-600 031.

         

(By Adv:   G.S. Kalkura)    

               

                   Vs

 

RESPONDENT:

 

          M. Azeez, S/o. Khader,

Muringath House, Kuttikaitha,

Ambalavayal Post, Wayanad.

         

(Present in person)  

                

JUDGMENT

 

SMT. A. RADHA  :  MEMBER

 

          This appeal is preferred by the opposite parties against the impugned order passed in C.C.No.250/13 on the file of CDRF, Wayanad.

          2.  The case of the complainant is that on 21/4/2012 the complainant had taken a policy in his mother’s name for Rs.3,00,000/- under Senior Citizens Red Carpet Insurance Policy and paid a premium of Rs.15,000/-.  The policy does not require medical checkup.  It is the case of the complainant that on 20/9/2012 the complainant’s mother fell ill and was referred to the Medical College Hospital, Calicut.  She had to undergo various checkups like CAG and eco test and suggested for aortic valve replacement.  The complainant’s mother was admitted on 4/3/2013 at Moulana Hospital, Perinthalmanna where her operation was held on 5/3/2013 and discharged on 15/3/2013.  The cashless benefit was denied by the opposite party and thereafter the complainant had to pay a bill amount of Rs.2,18,388/- and submitted the claim for reimbursement to the opposite party.  The opposite party rejected the claim on the ground that the complainant’s mother fell ill within a month of taking the policy.  The other reason stated for rejection is that the complainant had suppressed the surgery undergone for knee and this matter was clarified to the opposite parties for which no reply received. The complaint is filed for reimbursement of the hospital expenses amounting to Rs.2,18,388/- and also for compensation of Rs.30,000/-.

          3.  In the version filed by the opposite parties it is contended that the heart disease suffered by the complainant’s mother was within the period of 30 days from the date of inspection of policy.    The opposite parties admitted the policy taken by complainant namely Senior Citizens Red Carpet Insurance Policy for a period from 21/4/2012 to 20/4/2013 for Rs.3,00,000/-.  The policy was issued on good faith based on the declaration made in the proposal form.       As per the contract of insurance the insured had to furnish true and correct answers to the questionnaire in the proposal form for issuing the policy.  The complainant is bound to give the proper information regarding present and past health status at the time of filing the proposal.  It is clear from records that the mother of the complainant was suffering from heart diseases since 3 months from the date of admission.  She was admitted in the hospital on 5/3/2013.             The cashless facility was denied by the opposite party in order to rule out any pre existing illness.  Since insured had been taking treatment for valve complaints from 18/5/2012 the claim falls under exclusion clause No.2 of the Policy.  As per clause-2 any disease contracted by the insured person during first 30 days from the commencement date of policy, the company is not liable to make any payments.  It is also contended that on investigation conducted by the opposite party it is also revealed that the complainant’s mother was having Hyper Tension from 2009, Hyperlipidemia since 2011, OA  (R)   knee since 2010 and was on treatment for these illness.  The health history column of the proposal form does not disclose any of the diseases and based on the declaration the policy was issued.  As per the declaration any particulars stated in the proposal form are found       incorrect the Insurance Company would incur no liability under the policy.  In the instant case, the complainant’s mother suppressed material facts of the pre-existing disease at the time of taking policy.  The suppression of material facts will lead to the insurance contract becomes void and is not liable to indemnify the insured.  The claim of the complainant’s mother was rejected on the ground of exclusion clause No.2 ie. the 30 days waiting period and on suppression of material facts.  Hence there is no deficiency in service on the part of opposite party and the claim repudiated based on the terms and conditions of the policy.

          4.  The evidence consisted of the oral testimony of the complainant as PW1 and documents were marked as Exbts: A1 to A10.  On the part of opposite parties OPW1 was examined and Exbts: B1 to B7 were marked to substantiate the case.                    On appreciation of evidence and documents the Forum Below allowed the complaint in favour of the complainant.

          5.  The counsel for the appellant submitted that the District Forum ignored the documents produced by the opposite party and failed to consider the terms and conditions of the Insurance Policy in its right perspective.  He also pointed out that the treatment         underwent by the complainant’s mother at Maulana Hospital, come within the waiting period of the policy ie. 30 days from inception of policy and ignored clause 2 of the policy condition.  It is argued that the complainant’s mother deliberately suppressed her previous treatment at various hospitals and she is bound to reveal the treatment history.  The principles of insurance law and contract act were not considered in the case of the complainant.                       The complainant’s mother was having hyper tension since 2009 and continued with other illness which was not taken into consideration and this suppression of health history was not disclosed in the proposal form.  The finding made by the District Forum that a senior citizen who took a special policy and repudiation of claim due to minor discrepancies is not fair and is unsustainable in the eye of law.  The opposite parties are exercising abundant caution as public money is held in trust.  The pre-existing illness were not revealed in  the policy and tried to defraud the company suppressing the existing illness.  The terms and conditions of the policy was overlooked by the District Forum and found deficiency in service on the part of the appellant is based on mis-apprehensions of facts, law and evidence.  Hence appeal is to be allowed as there had violation of terms and conditions and suppression of material facts.

          6.  The respondent appeared in person and argued the case.  Attracted by the special insurance policy named Senior Citizens Red Carpet Insurance Policy (60 to 69 years) for those who are having existing illness and also insurance under special insurance policy does not require medical checkup, the policy was taken by the complainant for his parents on 21/4/2012.  It is stated that due to some uneasiness the complainant’s mother was consulted on 29/4/2012 and advised for operation within 4 months.  On 29/10/2012 angiogram was taken and the operation date was fixed on 4/2/2013.  Thereafter the complainant’s mother was taken to Moulana Hospital on 4/3/2012 and underwent the operation on 5/3/2013.  On claiming reimbursement for the treatment expenses the appellant denied the reimbursement on the ground that the patient was under treatment within one month from the inception of the policy.  More over the other grounds raised were the suppression of pre-existing disease.   It is stated in the repudiation that the respondent’s mother was under treatment for other diseases in 2009, 2010 and 2011.                     The respondent’s mother had not undergone any treatment for heart diseases prior to the operation.  The treatment in the Assumption Hospital advised for knee cap and no knee surgery had undergone for the complainant’s mother.  The complainant had never been hospitalized earlier within a year and the reimbursement of the treatment expenses were denied on flimsy grounds.  As per the policy it is specifically mentioned that the policy is  intended for the Senior Citizens without medical checkup and after accepting the premium the appellants are denying the  claim which amounts to unfair trade practice on the part of the appellants.  The policy holder does not need to undergo any medical checkup and is exclusively for the Senior Citizens between the age of 60 to 69 years.  Hence the denial of the treatment expense by the appellant is purely unfair trade practice and the Forum Below allowed the complaint appropriately.

          7.  We have heard both sides in detail and perused the documents.  The contract of insurance is based on good faith.  Every health policy includes certain terms and conditions and insists for its conditions.  In the instant case it is clear from the policy of the appellant that the policy taken for the respondent’s mother comes under Senior Citizens Red Carpet Insurance Policy intended for the senior citizens in between the age of 60 to 69.  It gives protection to the existing diseases and it does not require any medical checkup.  We would like to point out that after giving a wide publicity for such a senior citizens policy, the denial of treatment expenses for the insured in between the age of 60 to 69 without medical checkup, the act of the appellant certainly amounts to unfair trade practice.  Even though the terms and conditions of other policies point out to the conditions like pre-existing disease or medical checkup etc. this type of advertisement on the part of appellant amounts to unfair trade practice by giving false information to attract persons to the policies.  Hence we are of the firm view that the act of the appellant giving false statements to attract the policy is unfair trade practice.  In the instant case we direct the appellants to pay the treatment expenses of Rs.2,18,388/- with a compensation of Rs.1,000/- and Rs.1000/- as cost of proceedings. 

          In the result, appeal is dismissed and we uphold the order passed by the Forum Below.

          The order is to comply within 30 days on receipt of this order, failing which, the respondent is entitled to recover the amount           @ 12% interest for the entire amount till realization.

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

 

 

 

SANTHAMMA THOMAS     :        MEMBER

Sa.

 

 

 

 

 

 

 

 

 

                                                                         KERALA STATE CONSUMER                                                                                 DISPUTES REDRESSAL

COMMISSION,    

                           THIRUVANANTHAPURAM.

 

                                      

 

 

 

 

 

 

 

APPEAL NO.470/2015

JUDGMENT DATED  29/01/2016

 

 

 

 

 

 

 

                                                       

Sa.