ADV. RAVI SUSHA, MEMBER.

            This is  a complaint filed for realization of Rs.1,00,000/- being the Insurance claim.

          The complainant  and his wife Pressanna have  taken “Health Card” under the Scheme “Family Care First” issued by the opp.parties company with policy Nos 0104134936  and .0104138950 respectively through their consultant Sri.M.K. Sudhakaran of Karunagappally branch.   The Insurance Coverage is from 24..7..2008 to 24..7..09.  One lakh eah.   Meanwhile  the complainant felt a pain in  chest on 1..3..2009 and admitted at the Ananthapuri Hospital, Thioruvananthapuram  on 2..3..2009 for treatment.   They  have shown Heal Card to the Doctor and the Insurance personals in the Hospital and promised their help in getting Insurance facilities for the treatment .     Complainant’s Doctor advised for doing “Angioplasty”.   This has also been brought to the notice of the Insurance Officials in time.   Angioplasty has been done  and discharged  on 3.3.2009. No advance payment has been requested  in hospital in the light of the Health Card.   After the discharge  the complainant has  approached the officials of the Insurance company for settlement of the Bill amount to the Hospital,  Unfortunately they expressed their helplessness in this matter at the eleventh hour saying that this claim could be considered only after 3 years.  As per the condition of the policy the company is liable to settle the claim amounting to Rupees one lakh.  Hence filed this complaint fee getting the claim amount of Rs. 1 lakh.

The 2^nd opp.party filed version for and on behalf of 1^st opp.party also.   The complainant is a policy holder vide No.0104134936 under the scheme Family Care First introduced by the opp.parties company and the date of commencement of the policy was on 24^th July 2008 and date of maturity is on 24^th July 2011 the sum assured is Rs.1,00,000/- and the frequency payment chosen by the complainant is annual and the installment premium paid by him is Rs.4,000/-  The policy document was issued by the 2^nd opp.party on receiving a proposal Forum submitted by the complainant, in which he fraudulently mispresented his state of health so as to mislead the opp.parties that the complainant has no diseases and disorder of his cardiovascular system or any other diseases.   This amounts to a suppression of material facts with fraudulent intention to make unlawful monitory gain.  Secondly the claim is for a benefit uncovered by this relevant policy lby its terms and conditions.   An extract of the relevant portions regarding the terms and conditions is  that  “The company shall be liable to make payment for the following illness only from the first Renewal  or Date of Revival, whichever is later, provided these illnesses are diagnosed or Hospitalization or Medial Expenses incurred after the first Renewal date or Revival, whichever is later”  “Tympanoplasty, Valve Replacement, Valvotomy, Cerebral Haemorrhage, Angiographics, Angioplasty [with or without tent], Coronary Artery Bypass Graft unless post Accident”.  The first  Renewal will be due after three years from the policy commencement date.   The  extracts points out certain specific ailments which are not covered by the relevant policy at any point of time before three years, which includes Angioplasty [medical procedure ], to be applied to heart patients.   According to the complainant Angioplasty was done at Ananthapuri Hospital within one year from the date of commencement of the policy ie. 24..7..2009 and the Angioplasty was done 3.3.2009.  Hence the complainant is not eligible for any such claims, since the alleged Angioplasty was done within one year.  He claims this benefit under this policy, only after 3 years as per the relevant provisions of the policy conditions   Hence, the complainant is not eligible for any claim as mentioned in the complaint.  Hence there is no cause of action against  the respondents hence the claim amount raised by the complainant for an amount of Rs.1,00,000/-  is absolutely baseless, never entitles any claim and the complainant is aimed to obtain undue pecuniary gain from the opp.parties.  Hence 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.     Reliefs and  costs.

For the complainant PW.1 was examined and marked Exts. P1 to P4

For the opp.parties DW.1 was examined and marked Exts. D1 to D3

POINTS:

          It is not disputed that the complainant has taken Ext.P2 policy and  that the policy was subsisting when the complainant had undergone treatment  from 2..3..2009 to 3..3..3009 at the Ananthapuri Hospital, Thiruvananthapuram.  The complainant submitted claim before the opp.party which was repudiated by them on two grounds.  One is there is suppression of material facts regarding the health condition in the proposal form and other ground is as per policy condition the opp.party shall make payment to the particular illness of the complainant only from the first renewal date  or revival  whichever is later

          According to the opp.parties there is suppression of material facts on the side of the complainant and violation of policy conditions.  One of the main contention of the opp.parties is that the complainant has suppressed the material facts regarding the health condition in the proposal form.  It is argued that in Ext. D2 proposal form the complainant has fraudulently mis represented his state of health that the complainant has no diseases or dis order of his cardio vascular systems or any other diseases.   According to the opp.party he was a heart patient which was not dis closed in the proposal form.   Opp.party’s counsel argued that the complainant has not produced a single piece of evidence to support his case that he has no heart ailment before taking policy.   The main contention of the opp.party is that before issuance of the policy in question the complainant  was suffering from heart disease for which he took medical treatment and since these facts were not disclosed by the complainant deliberately, therefore he was guilty of   suppression of material facts regarding health and thus on  that ground the claim of the complaint was rightly repudiated by the opp.party

          Here there is no dispute that the complainant was admitted in the Ananthapuri Hospital on 2..3..2009 due to chest pain   and discharged on 3.3.2009  after Angioplasty.   The first question for consideration is  whether the present case was a case of suppression of material facts or not.   Our opinion is that before 24..7..2008 the date of which the policy had come into force, there is nothing on record to show that the complainant had even taken any treatment for the decease of heart.   For that reason it could easily be said that even prior to 24..7..2008 the complainant was not aware that he was a heart patient.  Therefore the case of the opp.party that the complainant had suppressed the disease of heart in the proposal form could not be  found acceptable.   Thus it is held that  non mentioning of the disease in the proposal form by the complainant does not amount to suppression of material fact.

          Another contention of the opp.party is that there is violation of policy condition.   According to them as per condition     stipulated in Ext. D3 the company shall make payment for the hosp0-italizatrion  due to “Tympanoplasty valve replacement, valvotomy, Angiographer, Angioplasty, Coronary artery  by pass etc” only after the 1^st renewal date.  On perusal of Ext. D3, there is such a condition mentioned in it.   As per Ext. D3 the 1^st  renewal will be due after 3 years  from the policy commencement date ie. 24..7..2008.

According  to the complainant, Angioplasty was done at Ananthapuri Hospital within one year from the date of commencement of the policy..  Hence the complaint is not eligible for any such claims.

          It is well settled that a contract of insurance rests on utmost good faith.   From  the available materials we are  of the view that there is no ground of interfere with the rejection of the claim by the opp.parties on the ground of violation of policy condition and that there is no  deficiency in service on their part.  Point found accordingly.

          In the result, the complaint fails and the same is hereby dismissed.  No costs.

            Dated this the   18^th    day of August, 2012.

                                                                       .

I N D E X

List of witnesses for the complainant

PW.1. – P. Prasannakumary

List of documents for the complainant

P1. – Receipts

P2. – Policy details

P3. --  Bills from Ananthapuri Hospital

P4. – Power of Attorny

List of witnesses for the opp.parties

DW.1. – Sangeetha Sooraj

List of documents for the opp.party

D1. – Authorization

D2. – Proposal form

D3. – Policy Terms and conditions