DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 9th day of October, 2024
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member Date of Filing: 11/07/2022
CC/123/2022
- Mohanan Unnithan,
No.94, RK Naidu Lay Out,
Middle Street, Venkitapuram,
Coimbatore, Tamilnadu – 641 013
Presently residing at
Puthen Veetil, Thirunarayanapuram,
Thiruvazhiyod, Near Cherpulassery,
Ottapalam Taluk, Palakkad – 679 514
- Divya Mohan,
No.94, RK Naidu Lay Out,
Middle Street, Venkitapuram,
Coimbatore, Tamilnadu – 641 013
- Ananthu Mohan,
No.94, RK Naidu Lay Out,
Middle Street, Venkitapuram,
Coimbatore, Tamilnadu – 641 013 - Complainants
(By Adv. K. Dhananjayan)
Vs
- Max Bupa Health Insurance Co. Ltd.,
Block B-1/1-2, Mohan Co-Op.Industrial Estate,
Madura Road, New Delhi – 110 004
- Max Bupa Health Insurance Co. Ltd.,
Block B-1/1-2, Mohan Co-Op.Industrial Estate,
Madura Road, New Delhi – 110 004
Rep. by Its MD/ Manager / Authorised Signatory
- The Federal Bank Ltd.,
Federal Bank Towers,
Aluva, Ernakulam
- The Federal Bank Ltd.,
Federal Bank Towers,
Aluva, Ernakulam
Rep.by Manager/MD/Authorised Signatory
- The Manager,
Federal Bank Ltd.,
Oyoor Branch, Oyoor,
Kollam. - Opposite parties
(OPs1 &2 by Adv. M/s. Saji Isaac K.J & Ullas Sudhakaran
OPs 3,4&5 by Adv. S.T.Suresh)
O R D E R
By Sri. Vinay Menon V., President
- Complainants are the legal heirs of one deceased D. Girijamma. They were granted leave under S. 35(1)(c) to conduct the proceedings jointly since they were having the same interest.
- Crux of the complaint pleadings is that Complainants are the legal heirs of one deceased D. Girijamma. D. Girijamma had availed 2 loans from Oyoor Branch of Federal Bank, who is O.P. 5. Head office of O.P. 5 is O.P.s 3 and O.P.4. At the time of availing loan, in connection thereof, the deceased had availed 2 health insurance policies from O.P.s 1 Insurance Company for Rs. 5,00,000/- and Rs. 8,00,000/-. Aforesaid D. Girijamma was not suffering from any pre-existing disease. Unfortunately, she contracted Metastatic Melanoma and died on 23/8/2021 during the subsistence of a valid policy. But the claim raised by the complainants for benefits under the policy was repudiated by OPs 1 & 2 on two grounds;
1) Treatment done on 31/12/2020 falls outside member coverage period from 20/6/2019 to 19/6/2020;
2) Deceased had failed to disclose material facts that insured was suffering from Diabetes Mellites since 4 years and Dyslipidemia for 2 years prior to execution of membership form/proposal form.
So, claim was repudiated. It is aggrieved by this repudiation that the complaint is filed. The prayers also relate to payment of Rs. 5,00,000/- and Rs. 8,00,000/- being the Sum Assured in two policies.
- OPs 1 & 2 entered appearance and filed joint version admitting the complaint contention upto the extent of repudiation of claim. In the proposal form, to the questions pertaining to the aforesaid diseases, the complainant had answered in the negative indicating that she was not suffering from any pre-existing disease. They maintained that subsequent to death it was found that the insured was suffering from Diabetes Mellites since 4 years and dyslipidemia for 2 years prior to executing the proposal form. Hence repudiation was proper. She had resorted to non-disclosure of material facts. The policy had become void ab initio.
- OPs 3 to 5 are the Bankers. They filed version stating that they had never forced the deceased to avail the loans. These opposite parties do not have direct knowledge regarding the health condition, treatment details and subsequent hospitalization of D. Girijamma. Only OPs 1 & 2 are able to answer the claims. There is no deficiency in service on the part of these OPs.
- Following issues were framed for consideration:
- Whether the ground for repudiation of claim valid in the facts and circumstances of the case?
- Whether there is any deficiency in service or unfair trade practice on the part of OPs 1 to 2 & 3 to 5?
- Whether the complainant is entitled to any of the reliefs sought for?
- Any other reliefs?
6. (i) Documentary evidence of complainants comprised of proof affidavit filed by husband of the deceased and Exhibits A1 to A6.
(ii) OPs 1 & 2 filed proof affidavit and marked Exts. B1 to B5.
(iii) OPs 3 to 5 filed proof affidavit but did not mark any document.
(iv) Document called forth from Kovai Medical Centre Hospital pertaining to the treatment rendered to the deceased was marked as Ext.X1.
Issue No.1
7. It is the complainants’ case while under the coverage of health insurance policies issued by OPs 1 & 2. The deceased happened to contract Metastatic Melanoma and succumbed to her conditions. OPs 1 and 2 repudiated the claim of the legal heirs.
8. Issuance of the policy is not disputed. Exts. A1 & A2 shows that the coverage was from 20/6/2019 to 19/6/2022. Ext.A4 is the communication of repudiation. Reason for repudiation is reproduced herein below:
“Treatment done on 31 December, 2020 falls out side member coverage period from 20 June, 2019 to 19 June 2020.
Non-disclosure - as per received medical document condition and scrutiny done by us it was found that insured has been suffering from – Diabetes since 4 years and Dyslipidemia x 2 years prior to policy which he has not disclosed at time of inception of policy so claimed is repudiated as per definition 12.
Date of accident is after policy coverage”.
9. It can be seen that the OPs 1 to 3 has given 3 reasons for disallowance of claim.
1. The treatment was done on 31/12/2020 which falls outside the coverage period.
2. Non-disclosure of material facts.
3. Date of accident is after policy coverage.
10. On a repeated perusal of Ext. A4 we find that claim detail for Rs. 5,00,000/- is repudiated on the ground of non-disclosure. Other two reasons are shown, yet no amount is seen billed. So, this Commission need to resort to that section wherein claim for Rs. 5,00,000/- was repudiated alone and no further. We fail to understand why the Insurer resort to such confusing manner of issuing communications.
11. Thus, we need to resort to assay the ground of repudiation of Non-disclosure alone.
12. Member enrollment form executed by the deceased is marked as Ext. B1. Clause 3 deals with medical history of the member.
Item B of the medical history deals with diabetes / high blood sugar / sugar in urine. To this query the member has answered ‘No’, indicating that she is not suffering from diabetes, high blood sugar or sugar in urine.
To query No. N, i.e. Are you currently in good health and not suffering from or have been treated for or expect to be treated for any physical or neurological disorders, any deformity or disability or any other ailment or disease not mentioned about in this enrollment form, the complainant has answered ‘Yes’ indicating that she is perfectly healthy.
To query I i.e. whether the applicant is suffering from HIV, AIDS, haemophilia, thalassemia, any blood or immune deficiency disorders the complainant has answered in the negative indicating that she is not suffering from any blood related complaints.
It is based on these replies given by the applicant that Exts.A1 & A2 policies were issued. Inception of the policy is from 20/6/2019.
13. The insured underwent treatment for Metastatic Melanoma in Kovai Medical Centre Hospital. The treatment records pertaining to the complainant was called forth and marked as Ext.X1.
Sheet 1 (numbered by hospital on right hand top of the sheet) is the initial evaluation record dated 14/8/2020. Reverse of sheet 1 shows that Girijamma was a known case of DM and hypothyroidism and on regular medication.
Sheet 20 of Ext.X1 is also another initial evaluation record dated 15/10/2020. Reverse of this page shows past medical history. It shows that the deceased was a known case of T2 DM for 4 years and was on medication. She was having history of hypothyroidism and hyperlipidemia for 2 years and was on medication for these two complications.
14. Thus, we can see that the deceased was suffering from DM from 2016 onwards. She was also suffering from hyperlipidemia from 2018 onwards. Since she was under medication, it can easily be presumed that the applicant was aware of the conditions suffered by her.
15. Ext.B1 was perepared only on 21/6/2019. Being of subsequent execution from the date of developing diabetes and hyperlipidemia, the deceased had willfully suppressed and mis-represented the fact of existence of the said conditions in Ext. B1 proposal form causing issuance of insurance policies based on incorrect answers. Nature of the queries were so vital; her answers could have decided the fate of the application and subsequent issuance of the policies. Hence the non-disclosure herein is a major violation of policy terms and conditions.
16. Policy terms and conditions were marked as Ext. B2. Clause 5.3 (ii) relating to cancellation, states that the company may cancel the policy at any time on grounds of misrepresentation, non-disclosure of material facts, fraud by the insured person by giving 15 days written notice. There would be no refund of premium or cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud.
17. We therefore hold that the complainant has suppressed/withheld material information and has resorted to non-disclosure of material fact. Thus, repudiation of the claim is in accordance with the terms and condition of Ext.B1 policy.
Issue Nos..2,3 & 4
18. Consequently, we hold that there is no deficiency in service on the part of OPs.
19. The complainants are not entitled to any of the reliefs sought for.
20. Complaint is accordingly dismissed. Parties are directed to bear their respective costs.
Pronounced in open court on this the 9th day of October, 2024.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - Original certificate of insurance bearing Certificate No.105000006675
Ext.A2 – Original certificate of insurance bearing Certificate No.105000006674
Ext.A3 - Print out of death certificate dated 6/9/2021
Ext.A4 - Copy of letter of repudiation
Ext.A5 - Printout of heirship certificate dated 15/11/2021
Ext.A6 - Original certificate dated 10/12/2020 issued from KMC
Exhibits marked on the side of the opposite party:
Ext.B1 – Print out of scanned member enrolment form
Ext.B2 – True copy of policy terms and conditions
Ext.B3 – Print out of scanned progress report of treatment record in KMC
Ext.B4 - Print out of scanned discharge summary dated 31/12/2020
Ext.B5 – Copy of repudiation letter
Court Exhibit: Nil
Third party documents:
Ext. X1 – Medical records from KMC
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
