ADV. RAVI SUSHA, MEMBER. Complainant for getting treatment amount of Rs.1,24,703/-, compensation and cost. The averments in the complaint can be briefly summarized as follows: The complainant is the account holder of the 1st opp.party and also the policy holder of the 2nd opp.party vide ID No. 11227412. The complainant has availed a health insurance policy from the 2nd opp.party on 10.12.2006. The policy was a period of one year and during that period the complainant suffered chikun gunia and the 2nd opp.party had given amount spent for that treatment. At that time the 2nd opp.party had not made any contentions that there is any violation of policy condition on the part of the complainant. The policy renewed for the another year 2007-08 . All the policy amounts were delivered through the 1st opp.party to the 2nd opp.party. While the complainant was under the policy coverage, complainant suffered a chest pain. Immediately the complainant was rushed to Kerala Institute of Medical Sciences, Thiruvananthapuram. When he was subjected to diagnosis by the expert doctor and it was diagonised that the complainant was having blocks in his heart. The complainant was admitted in the hospital on 3.3.08 and angioplasty was conducted on 4.3.08. The complainant was discharged on 10.3.08. The complainant has expended an amount of Rs.1,24,703/- solely towards the angioplasty and related treatments. The complainant paid that amount. On 13.3.2008 the complainant has submitted a duly filled up claim form to the 2nd opp.party along with all Medical records and original bills of the purpose of processing his claim But the 2nd opp.party has repudiated the claim. Hence the complaint. The first opp.party filed version contending, that the complainant is an account holder of this opp.party No.1 vide A/c. No.218010100046084. The 2nd opp.party is only a facilitator for the insurance policy issued by the 2nd opp.party. The1st opp.party is only to receive the application forms and relevant documents from its interested customers and forward the same to the 2nd opp.party Thereafter if the said customer is found eligible, insurance policy is issued to them directly6 by the 2nd opp.party. The 1st opp.party has no further role in this matter other than that of receiving the application form and forwarding the same and sending the insurance premium to the 2nd opp.party by debiting the account of the complainant The 1st opp.party has not persuaded or insisted the complainant at any point of time to avail a health insurance policy. There is no deficiency in service on the part of the opp.party. Hence the 1st opp.party prays to dismiss the complaint. The 2nd opp.party filed version contending, interalia, that the complaint is not maintainable, either in law or on facts. The 2nd opp.party has issued a Mediclaim policy by name General Contingency Policy vide No.OG-07-1901-9961-00079372 in favour of the complainant on 10.12.2006. The policy expired on 10.12.2007, the validity of the policy, the complainant herein got disease Chicken Guniya. Since he was covered by the policy at the relevant time, the medical expenses incurred by him in connection with the said disease condition was promptly reimbursed by the insurer. Subsequently the complainant renewed the policy for the period 2007-08 vide policy No.OG-o6-9999-00000014. The sum assured under the policy was Rs.1,00,000/- This opp.party is liable to indemnify the insured subject to the limitations conditions and exclusion clause contained in the policy. The complainant in this case preferred a claim with the opp.party for the Angioplasty surgery and related treatment done at Kerala Institute of Medical Science from 3.3.08 to 10.3.2008. The complainant has submitted the Health Insurance claim form duly filled with all medical records relating to his treatment. According to the discharge summary issued by the Department of Cardiology KIMS he was admitted in the hospital on 3.3.08 with history of chest pain [L] sides and radiating to {L] arm which developed while walking 5mts since 2 weeks The discharge summary of the complainant that he was suffering from Diabetes Mellitus for the last 15 years. The Medical records issued from the Department of Cardiology, the insured was suffering from Systemic Hypertension and type-II D diabetes Mellitus also. The investigation done at the MIMS revealed that the patient was having long unstable angina which was occurred due to the long standing illness of diabetics. The present illness of the complainant was due to the prolonged illness of diabetics, which is definitely a risk factor for Coronary Artery disease. Since the claim of the complainant squarely falls within the exclusion clause contained in the policy the opp.party has rightly repudiated the claim put forward by the complainant. There is no deficiency in service on the part of the 2nd opp.party. Hence the 2nd opp.party prays to dismiss the complaint. Points That would arise for consideration are: 1. Whether there is deficiency in service on the part of the opp.parties 2. Re.iefs and costs. For the complainant PW.1 is examined. Ext. P1 to P5 are marked. For the opp.parties DW.1 and 2 are examined. Ext. D1 to D5 are marked. POINTS: Complainant’s case is that on recommend and insist of the1st opp.party the complainant joined the Medical Insurance Scheme by name “General contingency” Policy of 2nd opp.party. The complainant was admitted to the KIMS from 3.3.08 to 10.3.2008 due to formation of blocks in the heart. In KIMS hospital angioplasty was conducted and the expense of treatment amount to Rs.1,24,703/-. For getting the medical expense the complainant submitted claim application to the 2nd opp.party but it was denied. Hence filed this complaint for getting medical bill amount. 1st opp.party’s main contentions are that they are unnecessary party to the proceedings. There is no contract of insurance with the complainant. The contract is between the complainant and the 2nd opp.party and the 1st opp.party is only a facilitator for the transaction by receiving the application from the complainant, sending the same and the monthly insurance premium to the 2nd opp.party by debiting his account with 2nd opp.party. According to 2nd opp.party the complainant was suffering from Diabetic Mellitus for the last 15years and also he was suffering from systemic Hypertension. The complainant suppressed the previous history of existing Diabetic mellitus from the proposed form submitted by him. Hence the repudiation done by the 2nd opp.party is legal. Here the questions to be decided are whether the 1st opp.party has any legal obligation with the complainant for repudiating the claim by the 2nd opp.party and whether the illness for which the complainant had suppressed the previous history of existing Diabetic Mellitus from the proposed form submitted by him. For deciding the 1st question we have to look into the terms and conditions in Ext. D1 the brochure of the 1st opp.party. As per the terms and conditions in Ext. D1 . The contract of insurance is only between the complainant and 2nd opp.party and also any grievance with respect to insurance policy/claims/settlements shall be taken up with 2nd opp.party and 1st opp.party shall not be responsible for the same. Here the insurance policy is issued by the 2nd opp.party directly to the complainant. Hence from the available evidence and from the terms and conditions in Ext. D1 the insurance contract is between the complainant and 2nd opp.party and the 1st opp.party is not responsible for the repudiation of claim made by the 2ndopp.party. Second point to be decided is whether there is suppression of the previous history of existing Diabetic mellitus in the proposal form submitted by the complainant to the 2nd opp.party. According to 2nd opp.party Ext. D4 discharge summary would establish that the Diabetic mellitus was a pre-existing one for the last 15 years. It is obvious that this information was given to the doctors by the complainant himself. According to the complainant in Ext. P5 repudiation letter the charge of pre-existing illness is a fabricated averment of the 2nd opp.party.. But from Ext. D2 policy period is from 2007 to 2008. Ext. D4 revealed that the complainant was suffering from Diabetic mellitus for the last 15 years. Hence it is clear that there is suppression of existence of the illness of diabetics in the proposal form, In the decision of the PC Chacko V/s. LIC, the Hon’ble Supreme Court held that if deliberate wrong answer was given bearing on contract of insurance, if discovered may lead to policy void. There is no case that the suppression of illness ie diabetic in the proposal form is a mistake. In these circumstances we are of the view that the repudiation of the claim under exclusion clause C1 in Ext. D3 is proper. There is no deficiency in service on the part of the opp.party. Point found accordingly. In the result the complaint fails and the same is hereby dismissed. No costs. Dated this the 20th day of May, 2010. . I N D E X List of witnesses for the complainant: PW.1. – Nazarudeen List of documents for the complainant P1. – Copy of policy P2. – Copy of Renewal of Policy P3. – Photocopy of bill issued from KIMS Hospital P4. – Copy of claim Form P5. – Repudiation letter List of witnesses for the opp.party DW.1. – Korah Ebraham DW.2. – Alic John List of documents for the opp.party D1. – Terms and conditions of Health Insurance D2. –Health Insurance Policy D3. – Conditions of policy D4. – Original claim form D5. – Discharge summary | 
