Kerala

Idukki

CC/63/2018

George T C - Complainant(s)

Versus

Manager Star Health - Opp.Party(s)

Pradeep kumar

26 Dec 2019

ORDER

DATE OF FILING : 27.3.2018

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.63/2018

Between

Complainant : George T.C.,

Thayyil House,

Chappathu P.O.,

Alady, Idukki.

(By Adv: K.M. Sanu)

And

Opposite Parties : 1. The Manager,

Star Health and Allied Insurance

Co. Ltd.,

Kattappana P.O.,

Idukki.

2. The Manager,

Star Health and Allied Insurance

Co. Ltd.,

Darsanam Chamber,

M.C. Road, Perumbavoor – 683 542.

(Both by Adv: K. Pradeepkumar)

3. The Manager,

Star Health and Allied Insurance

Extension Counter,

Mission Hospital,

Kattappana P.O., Idukki.

 

O R D E R

SRI. S. GOPAKUMAR, PRESIDENT

 

Case of the complainant is that :

 

Complainant is a senior citizen. When the complainant went to Mission hospital, Kattappana for the treatment of cold and breathing problem, the 3^rd opposite party approached the complainant and described the specialities of a mediclaim policy having the name 'Senior Citizens Red Carpet' policy. By enticing the specialities and due to persuasion of 3^rd opposite party, the complainant happened to took a policy from 3^rd opposite party by paying Rs.5118/- as the one time premium. This policy having validity from 8.3.2017

(cont......2)

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to 7.3.2018 and a coverage of Rs.1 lakh. While so, on 29.7.2017, the complainant suffered severe heart pain and he was taken to St. Johns Hospital, Kattappana and from there he was referred to Caritas hospital, Kottayam. At there, he was treated to coronary artery disease and an amount of Rs.1,40,000/- was spent there for treatment expenses. Immediately after the discharge, complainant lodged a claim before the opposite parties along with relevant records. But the opposite parties repudiated his claim on the reason that 'suppression of facts' at the time of initiation of the policy.

 

The complainant further stated that at the time of taking the policy, the complainant has no severe ailments. Moreover, the agent who approached the complainant specifically stated that the policy will cover any type of diseases. The complainant disclosed all the material facts at the time of filling the proposal form. The agent who canvassed the complainant, filled the proposal form. The heart disease was diagnosed only in Caritas hospital and the complainant is having no previous heart problems.

 

The complainant further averred that the opposite party company is now repudiating the claim on some lame excuses, in order to evade from the payment of the insurance amount. This act of the opposite party is gross deficiency in service and unfair trade practice. Hence the complainant filed this petition against the opposite parties by seeking relief such as to direct the opposite parties to pay the claim amount of Rs.1 lakh along with compensation and cost.

 

Upon notice, 1^st opposite party entered appearance and filed detailed reply version, by admitting the issuance of the policy having No.P/181219/01/2017/006494 for a sum insured of Rs.1 lakh, commencing from 8.3.2017 to 7.3.2018. At the time of issuing the policy, the complainant was supplied with the terms and conditions of the policy and the terms and conditions were explained to the complainant at the time of proposing the policy.

 

Opposite parties further contended that, in the proposal form, the complainant has specifically declared that he was not suffering from any disease or ailment at the time of submitting the proposal form or at any point of time earlier and that his health condition was good in all respects. In the proposal form, the complainant further declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the insurance company would incur 'no liability' under the policy.

(cont......3)

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Opposite party further contended that the complainant had submitted two claims before the opposite parties. In claim No.CLI/2018/181219/020567, it is submitted that the complainant was admitted at St. Johns hospital, Idukki on 27.7.2017, for treatment of NSTEMI, trop positive, KILLIP I fair LV systolic function, hypertension, chronic obstructive pulmonary disease (COPD). The discharge summary of the St. Johns hospital, Idukki clearly reveals that the complainant was a known case of chronic obstructive pulmonary disease (COPD) and is a current smoker. It is mentioned in the doctor's certificate dated 1.8.2017 that complainant was consulted on 3.9.2015 with history of childhood wheezing and episodes breathlessness for the last few years, he was chronic smoker with smoking index more than 500. After 2015, he was seen at pulmonary department on 13.5.2016 and restarted inhaler. The hospital records of St. Johns hospital dated 23.4.2008 reveals that, the complainant was treated for the disease of COPD. Moreover, the hospital records dated 21.10.2008 clearly reveals that the complainant had history of regular smoking 15 cigarette per day.

 

Opposite party further contended that in such claim, it is submitted that complainant was admitted in Caritas hospital, Kottayam on 29.7.2017 for the treatment of coronary artery disease, lower respiratory tract infection with wheezing, hematoma of right hand, hypertension and COPD. The discharge history of Caritas hospital reveals that, the complainant is a known case of COPD on inhaler, since 2 years. Moreover, the complainant had already admitted in the paragraph No.1 of the complaint that, he had history of breathlessness complaint prior to policy, but not disclosed in the proposal form, which is the basis of contract.

 

The opposite party further contended that from the above records, it is revealed that the complainant a history of COPD and he is wilfully suppressed it in the proposal form which makes the contract void ab initio. Hence the opposite parties had repudiated the claim of the complainant and the policy discussed above was cancelled as per condition No.13 of the policy and had refunded the premium amount of Rs.5118/- to the complainant on 5.2.2018.

 

Opposite party further contended that, the complainant himself approached 3^rd opposite party for taking such a policy and after convincing all the terms and conditions, the complainant had opted for the policy. At the time of taking the policy, the complainant has informed only blood pressure as pre-existing disease and issued the policy after excluding hypertension and its complications in the policy schedule.

(cont......4)

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Facts being so, there is no question of any deficiency in service or unfair trade practice is happened in this matter and at the same time, the complainant himself suppressed the material facts and approached before the Forum against the opposite parties and the complaint is liable to be dismissed with the compensatory cost.

 

Evidence adduced by the complainant by way of proof affidavit and documents. Complainant was examined as PW1 and Exts.P1 to P3 marked. Ext.P1 is the copy of policy certificate, Ext.P2 is the repudiation letter dated 28.12.2017, Ext.P3 is the discharge summary of Caritas hospital.

 

From the opposite side, one Manu Mohan, Assistant Manager (Claims) of opposite parties examined as DW1 and Exts.R1 to R12 marked. Ext.R1 is the original proposal form. Ext.R2 is the policy schedule. Ext.R3 is the terms and conditions of 'senior citizens red carpet health insurance policy'. Ext.R4 is the discharge summary of St.Johns hospital, Kattappana. Ext.R5 is the medical certificate issued by the Dr. John Mthew of St. Johns hospital dated 1.8.2017. Ext.R6 is the copy of case records of the complainant in St. Johns hospital. Ext.R7 is the copy of repudiation letter dated 2.1.2018. Ext.R8 is the discharge summary of the complainant of Caritas hospital. Ext.R9 is the copy of cardiology IP initial assessment record. Ext.R10 is the copy of repudiation letter dated 28.12.2017. Ext.R11 is the copy of letter dated 27.12.2017. Ext.R12 is the copy of intimation regarding the repayment of the premium amount, dated 6.2.2018.

 

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 of both sides and had gone through the evidence.

 

It is an admitted fact that the complainant availed a senior citizen red carpet health insurance policy from opposite parties and it commenced from 8.3.2017 to 7.3.2018. While so, the complainant was taken to St. Johns hospital due to chest pain on 29.7.2017. From there, he was referred to Caritas hospital and treated there as inpatient for coronary artery disease. As per the version of the complainant, the disease caused and treated him in the Caritas hospital

(cont......5)

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within the validity of the above discussed insurance policy and the opposite parties are bound to pay the claim amount.

 

The learned counsel for the complainant vehemently argued that, the agent of the 1^st opposite party canvassed him and due to the persuasion of 3^rd opposite party, he happened to take the policy. At that time, 3^rd opposite party convinced the complainant that the policy will cover all types of diseases. But when the complainant lodged a claim with all relevant documents, opposite parties repudiated it on some baseless grounds and it is a gross deficiency in their service as well as unfair trade practice.

 

On the other hand the learned counsel for the opposite party argued that on the available medical records, it is evident that the complainant had history of chronic obstructive pulmonary disease (COPD) for which treatment has been taken before the inception of the policy and was not revealed in the proposal form at the time of inception of the policy.

 

The learned counsel further argued that as the insured has wilfully suppressed the pre-existing disease in the proposal form, which is the basis of contract at the time of taking policy thereby he intentionally suppressed those facts in the proposal form despite there is specific question in the health history column 92) in column (4), which made the contract void ab initio.

 

The learned counsel further argued that the insurance contracts are contracts of 'uberima-fide'. The opposite party issued the aforesaid policy on good faith based on the declaration made by the proposer / insured in the proposal form. As per the contract of insurance, the insured has to furnish true and correct facts in the proposal form for issuing policy.

 

On evaluating the evidence produced by both the parties and on perusing the deposition of witness, it is seen that as per Ext.R1 proposal form, insured person's details column, it is stated in health history head question No.1, 'Are you in good health and free from physical and mental disease or infirmity. If not give details' answered as 'yes'. Then in the third column head, 'Have you ever suffered or suffered from any of the following' (b) High BP, cholesterol, if yes since when ? The answer is 'BP'. On perusing this document, Ext.R1 proposal form, it is specifically stated that the complainant / insured has not fortify of any disease, except BP. Eventhough in the insured persons details page of the proposal form stated so many questions related to almost all diseases, the complainant disclosed that he is suffered from BP alone. At the

(cont......6)

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same time, Exts.R4, R5 and R6 discharge summary of St. Johns hospital, certificate of Dr. John Mathew, St. Johns hospital, who was treated the complainant and case summary of complainant in the St. Johns hospital reveals that complainant was in under the treatment of St. Johns hospital, Kattappana 'from 3^rd September, 2015 onwards, with the history of childhood wheezing and breathlessness for last five years. However, a chronic smoker with smoking index more than 500. After 2015, he was seen in pulmonary department. On 13.5.2016 restarted inhaler.'

 

Ext.R6 treatment chart of the complainant issued by the St. Johns hospital shows that, he was treated there from 8.6.2007. On further perusal of the document, it is seen that COPD was diagnosed on 23.4.2008. Moreover, he is a smoker and alcoholic.

 

At this juncture, it is very pertinent to note that eventhough column No.4 of the insured person details page of the proposal form, it is specifically stated whether the insured person undergone any medical test, prescribed any medicines, does the person proposed for insurance chew tobacco, smokes or consume alcohol, the answer to all these questions are 'no'. As per the evidence on record, it is very clear that the complainant is a chronic smoker and alcoholic. At least these details can be revealed in the proposal form. But it is seen that, the complainant wilfully suppressed all these ailments, eventhough he was under the treatment of COPD and other related diseases from 2007 onwards. It is against the terms and conditions of insurance contract.

 

As observed by the Hon'ble Justice Dhanajaya Y Chandrachud & Justice Hemant Gupta in the case of LIC Vs. Manish Gupta [III 2019 CPJ 31 (SC)] 'treatment records indicate that the respondent was operated for MVR – Nature of diagnosis has been reflected as rheumatic heart disease – hospital treatment term is along same lines – Documentary materials indicate that there was a clear failure on the part of responsibility to disclose that he had suffered from rheumatic heart disease since childhood. Ground for repudiation was in terms of exclusion contained policy – failure of insured to disclose past history of cardio vascular disease was a valid ground for repudiation.

 

In paragraph 10 of the judgement, the Hon'ble Court further observed that, the declaration which was furnished by the proposer constituted the basis for the issuance of the policy.

 

(cont......7)

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In the present case, the past history has been adverted to as a known case of chronic obstructive pulmonary disease since 2008 onward. This is established through Exts.R1 to R6 medical records. It is pertinent to note that none of these records are not challenged by the complainant.

 

From the deposition of the complainant, it is very clear that complainant himself approached the 3^rd opposite party for taking the policy and as averred in the complaint, nobody from the opposite party convassed him or persuaded him for taking the policy.

 

Hence on the basis of the above discussion, the Forum is of a considered view that, the factum of suppression of pre-historic disease is established by the opposite party with clear and cogent evidence and hence the repudiation of insurance claim in the case is justified and the complainant dismissed. No order to cost or compensation.

 

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......7)

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APPENDIX

 

Depositions :

On the side of the Complainant :

PW1 - T.C. George

On the side of the Opposite Party :

DW1 - Manu Mohan.

Exhibits :

On the side of the Complainant :

Ext.P1 - copy of policy certificate,

Ext.P2 - repudiation letter dated 28.12.2017,

Ext.P3 - discharge summary of Caritas hospital.

On the side of the Opposite Party :

Ext.R1 - original proposal form.

Ext.R2 - policy schedule.

Ext.R3 - terms and conditions of 'senior citizens red carpet health

insurance policy'.

Ext.R4 - discharge summary of St.Johns hospital, Kattappana.

Ext.R5 - medical certificate issued by the Dr. John Mthew of

St. Johns hospital dated 1.8.2017.

Ext.R6 - copy of case records of the complainant in St. Johns hospital.

Ext.R7 - copy of repudiation letter dated 2.1.2018.

Ext.R8 - discharge summary of the complainant of Caritas hospital.

Ext.R9 - copy of cardiology IP initial assessment record.

Ext.R10 - copy of repudiation letter dated 28.12.2017.

Ext.R11 - copy of letter dated 27.12.2017.

Ext.R12 - copy of intimation regarding the repayment of the premium

amount, dated 6.2.2018.

 

 

 

Forwarded by Order,

 

 

 

SENIOR SUPERINTENDENT