Kerala

Idukki

CC/185/2018

Bijoy Joseph - Complainant(s)

Versus

Manager LIC of India Divisional Office - Opp.Party(s)

Adv.Vikraman Nair

26 Dec 2019

ORDER

DATE OF FILING : 9.11.2018

IN THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI

Dated this the 26^th day of December, 2019

Present :

SRI. S. GOPAKUMAR PRESIDENT

SMT. ASAMOL. P MEMBER

CC NO.185/2018

Between

Complainant : 1. Bijoy Joseph,

Kerala Automobiles,

Kannamundayil House,

Idukki Jn., Kattappana P.O.,

Idukki – 685 508.

2. Silji, W/o. Bijoy,

Kerala Automobiles,

Kannamundayil House,

Idukki Jn., Kattappana P.O.,

Idukki – 685 508.

(Both by Adv: Vikraman Nair N.G.)

And

Opposite Parties : 1. The Manager (CRM),

LIC of India,

Divisional Office, Jeevan Prakash,

P.B. No.609, Nagampadam,

Kottayam – 686 001.

2. The Branch Manager,

LIC of India,

Satellite Office, 1^st Floor,

G & S Building, Kattappana,

Idukki – 685 508.

(By Adv: P.H. Haneefa Rawther)

 

O R D E R

 

SRI. S. GOPAKUMAR, PRESIDENT

 

Case of the complainant is that :

 

Complainant has taken LIC Jeevan Arogya non-linked health insurance policy on 13.2.2013. This policy covers both complainants, both their life and health. The policy commenced on 13.2.2013 to 13.2.2050 and the mode of premium payment rest with yearly.

(cont....2)

- 2 -

While the policy is alive, the 2^nd complainant sustained severe pain on the left knee. Immediately she was admitted in Aster DH Health Care hospital, Kochi on 1.9.2015, her complaint was diagnosed as left knee secondary osteoarthritis and she was admitted there and undergone a major surgery for total left knee replacement on 2.9.2015 and admitted there till 7.9.2015. An amount of Rs.2,11,715/- was paid for Medical treatment alone. Immediately after the discharge, complainant lodged a claim before the opposite party, but the opposite party repudiated the claim, on the ground that at the time of signing proposal form, there was material suppression by the complainant of her pre-existing diseases. The previous claim was also rejected on this ground.

 

Complainant further averred that at the time of availing the policy, complainant was healthy and had not suffered any ailments. After a detailed medical check up, opposite party issued insurance policy to the complainants. After nearly 3 years of commencement of the policy, the complainant suffered the knee problem. Hence repudiation on some baseless ground amounts to deficiency in service and hence the complainant filed this petition seeking relief such as to direct the opposite party to pay the claim amount as per the policy along with compensation and cost.

 

Upon notice, opposite parties entered appearance and filed detailed reply version by admitting the policy in question. Opposite party further contended that, as per the discharge summary of the 2^nd complainant, none other than the spouse of the principal insured, who was admitted on 1.9.2015 with diagnosis of secondary Osteoarthritis right hip. The history in their discharge summary states that 'known case of rheumatoid arthritis pain in right hip, difficulty in walking, hypertensive and on thyroid medication'. Hence claim was repudiated on the reason that, the 2^nd complainant, Smt. Silji Bijoy had an earlier claim of hospitalisation at CMC Vellore from 16.7.2013 to 23.7.2013. The discharge summary dated 23.7.2013, from CMC Velloor reveals that (1) The insured had a past history of hypothyroidism and hypertension over the last 6 years on regular medications. History of Gestational Diabetes. (2) History of persisting pain and swelling over the left wrist and knee with limping of gait. (3) MRI hip joint done on 21.1.2013 (policy commenced on

(cont....3)

- 3 -

13.2.2013) revealed moderate joint effusion with diffuse synovial thickening in the right hip and associated changes of the right femoral head. (4) Personal history - 1^st pregnancy had to undergo D&C in the 1^st trimester in view of the decreased development of the foetus.

 

The opposite party further contended that the answers in the proposal form submitted by the principal insured under the head 'Health details and medical information', for question No.2, in the proposal form – is the life to be assured currently taking any medication or drug ? - Answer given by the Principal insured is 'No'. Answer to the question No.3 of the proposal form to the question, During the past five years, has the life to be assured ever suffered from any illness which has required any form of medical or specialised examination, including, x-ray, blood tests, ECG, USG, CT/MRI etc., consultation, hospitalisation or surgery ? is 'No'. In question 7(i), 7(vii) and 7(x) are also answered as 'No'. Under the head question applicable to female lives only. In question No.II of the proposal form - Have you ever had an abortion or miscarriage or caesarian section ? The answer is 'No'. Hence as per the terms and conditions of the policy, no benefits are available as stated above and no payment will be made by the corporation for any claim under the policy on account of hospitalisation or surgery directly or indirectly caused by, based on arising out of or howsoever attributable to any pre-existing conditions unless disclosed to any accepted by the corporation prior to the date of commencement of the policy.

 

Under the above circumstances, no deficiency in service can be attributable to the opposite parties and hence the complaint is liable to be dismissed.

 

Evidence adduced by the complainant by way of proof affidavit. 1^st complainant was examined as PW1. Ext.P1 to P5 produced and marked. Ext.P1 is claim repudiation letter dated 9.6.2016. Ext.P2 is the letter from opposite party dated 16.3.2017. Ext.P3 is the policy copy. Ext.P4 is the copy of discharge summary. Ext.P5 is the receipt of payment of premium.

 

From the opposite side, Exts.R1 to R6 produced and marked. Ext.R1 is the copy of proposal form signed by the 1^st complainant. Ext.R2 is the

(cont....4)

- 4 -

policy conditions and privileges book. Ext.R3 is the claim form. Ext.R4 is the copy of hospital treatment forms. Ext.R5 is the discharge summary of Aster Medcity. Ext.R6 is the discharge summary of the 2^nd complainant issued by the CMC Velloor dated from 16.7.2013 to 23.7.2013.

 

Heard both sides.

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties and if so, for what relief the complainant is entitled to ?

 

The POINT :- We have heard the counsels for both parties and had gone through the records. It is an admitted fact that the 1^st complainant availed a Jeevan Arogya policy under plan 903 commenced on 13.2.2013 with principal insured Bijoy Joseph, his spouse insured Silji Bijoy and son Alonso Joseph. This policy is a non unit-linked health insurance policy which provides fixed benefits for hospitalisation and almost all types of surgical procedures irrespective of actual cost incurred.

 

While this policy is on alive, the 2^nd complainant underwent total knee replacement of left knee on 2.9.2015 in Aster DH Health Care hospital, Kochi and admitted there till 7.9.2015. An amount of Rs.2,11,715/- was spent there as treatment expenses. For claiming it, the complainant lodged a claim before the opposite party, but the opposite party repudiated this claim on the ground that at the time of making proposal, there was material suppression of the claiming insured's pre-existing diseases.

 

The learned counsel for the complainant vehemently argued that at the time of availing the policy, the 2^nd complainant was healthy and had not suffered any ailments. After a detailed medical check up, the opposite party issued the policy to the complainants. After 2 years and 7 months only the complainant suffered the ailment of knee pain.

 

The counsel further argued that the insurance companies are misleading the innocent consumers by introducing such unconscionable and misleading for terminologies like pre-existing disease. Hence the act

(cont....5)

- 5 -

of repudiating the claim of the 2^nd complainant by the opposite party is gross deficiency in service.

 

On the other hand, the learned counsel for the opposite party vehemently argued that the claim of the 2^nd complainant was repudiated on the reason that, she had an earlier claim of hospitalisation at CMC Velloor from 16.7.2013 to 23.7.2013. The discharge summary dated 23.7.2013 from CMC Velloor reveals that,

 

1. 1. 1. The insured had a past history of hypothyroidism and hypertension over the last 6 years on regular medication. History of Gestational Diabetes.

      2. History of persisting pain and swelling over the left wrist and knee with limping of gait.

      3. (3) MRI hip joint done on 21.1.2013, ten days before the commencement of the policy, revealed moderate joint effusion with diffuse synovial thickening in the right hip and associated changes of the right femoral head.

      4. (4) Personal history - 1^st pregnancy had to undergo D&C in the 1^st trimester in view of the decreased development of the foetus.

 

For strengthening their plea, learned counsel of the LIC, opposite party, produced the discharge summary of the 2^nd complainant issued by the Christian Medical College (CMC) Velloor. This document is marked as Ext.R6.

 

The learned counsel further pointed out that, eventhough the claimant, the 2^nd complainant, has such a past history of serious ailment as stated in Ext.R6, while filling the prescribed columns of the proposal form, the person who filled it intentionally suppressed all these material aspects.

For fortifying the contention, opposite party produced copy of proposal form signed by the complainants 1 and 2 at the time of availing the policy, marked it as Ext.R1.

 

 

(cont....6)

- 6 -

The learned counsel further argued that, the principal insured none other than the 1^st complainant answered to the question in the head 'Health details and medical information', question No.2 (page No.3) of Ext.R1 to the question 'Have you ever had an abortion or miscarriage or caesarian section ? If so give details – 'No'. In the same page of Ext.R1, to the question, Is the life to be assured currently taking any medication or drug ? Answer given by the principal insured is 'No'. To the question No.3 of Ext.R1, During the past five years, has the life to be assured ever suffered from any illness which has required any form of medical or specialised examination including x-ray, blood test, ECG, USG, CT / MRI etc., consultation, hospitalisation or surgery ? Answer given by the principal insured was 'No'. In question No.7(1) of the proposal form, 'Have the life to be assured ever suffered or suffering from hypertension / High blood pressure ? Answer given by the proposer is, 'No'. All these questions along with the question regarding endocrine disease or thyroid complaint, osteoporosis disease, disorder of bones, joints arthritis, giat etc., the answer given by the principal insured is 'No'. Hence there is a clear case of non-disclosure of pre-existing illness. Hence the repudiation on the reason of non-disclosure of material facts at the time of executing the proposal form is justifiable.

 

On perusing the documents which are produced by the opposite party such as Ext.R1 proposal form and Ext.R6 discharge summary of the 2^nd complainant, issued by the CMC Velloor, it is found that the claimant is a known case of rheumatoid arthritis pain in right hip, difficulty in walking, hypertensive and on thyroid medication. On perusing Ext.R6, it is further found that 10 days before the commencement of this insurance policy, the 2^nd complainant undergone treatment for various illness in CMC Velloor which is described in the above paragraph in detail. The fact is well known by the principal insured, the 1^st complainant, none other than the husband of 2^nd complainant. It is seen that, what are the disease described in Ext.R1 proposal form, the 2^nd complainant is suffering almost all these diseases. All these facts are wilfully concealed by the 1^st complainant at the time of filling the proposal form.

 

The question for considering is as to whether or not, there was suppression of any 'material fact' by the insured having material bearing on

(cont....7)

- 7 -

the repudiation of the claim by the insurance company under the above said policy.

 

In Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. (2009) 8 SCC 316, it has been observed by the Supreme Court that the expression of material fact is to be understood in general terms to mean as any fact which would influence the judgement of a prudent insurer in deciding whether to accept the risk or not. If the proposer has the knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer will entitle the insurer to repudiate their liability because there is clear resumption that any information sought for in the proposal form is material for the purpose of entering it into a contract of insurance, which is based on the principle of atmost faith – uberrima fides. Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of the fact and his believing the contrary. (United India Insurance Company Ltd. Vs. MKJ Corporation [1996], 6 SCC 428 ). It has also been emphasised that it is not for the proposal to determine whether the information sought for the purpose of the policy or not of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known.

 

The Hon'ble National Consumer Disputes Redressal Commission observed in Revision Petition No.967 of 2008 of Life Insurance Corporation of India Vs. Sinks Neelam Sharma (order dated 30.9.2015), that “there was clear suppression of material facts with regard to the health of the insured. It was not for the purpose of the two policies. At any rate, the statement made in the proposal form were untrue and incorrect, falling faul of the above extracted conditions in the policy. We are there for of the opinion that the insurance company was justified in repudiating the claim of the respondent.”

 

At this juncture, it is very pertinent to note that, Ext.R6 document which is produced by the opposite party shows that there is clear suppression of material facts at the time of filling the proposal form. More over, this evidences are unchallenged and complainant miserably failed to counter this document with clear and cogent evidence. (cont....8)

- 8 -

 

It is also noted that complainant has not a case that Ext.R1 is not filled by them.

 

Under this circumstances, the Forum is of a considered view that, the version of the opposite party is admissible and no evidence is produced by the complainant to counter the evidence adduced by the opposite party for substantiating their plea.

 

On the basis of the above discussion, the Forum found that complainant wilfully concealed the pre-existing disease of the 2^nd complainant and it is against the principle of insurance policy bond and hence the complaint dismissed. No order to cost.

 

Pronounced in the Open Forum on this the 26^th day of December, 2019

 

Sd/-

SRI. S. GOPAKUMAR, PRESIDENT

Sd/-

SMT. ASAMOL. P., MEMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(cont....9)

- 9 -

 

APPENDIX

Depositions :

On the side of the Complainant :

PW1 - Bijoy Joseph.

On the side of the Opposite Party :

Nil.

Exhibits :

On the side of the Complainant :

Ext.P1 - claim repudiation letter dated 9.6.2016.

Ext.P2 - letter from opposite party dated 16.3.2017.

Ext.P3 - policy copy.

Ext.P4 - copy of discharge summary.

Ext.P5 - receipt of payment of premium.

On the side of the Opposite Party :

Ext.R1 - copy of proposal form signed by the 1^st complainant.

Ext.R2 - policy conditions and privileges book.

Ext.R3 - claim form.

Ext.R4 - copy of hospital treatment forms.

Ext.R5 - discharge summary of Aster Medcity.

Ext.R6 - discharge summary of the 2^nd complainant issued by the CMC Velloor,

dated from 16.7.2013 to 23.7.2013.

 

 

Forwarded by Order,

 

 

 

SENIOR SUPERINTENDENT