BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.

Date of filing : 17.12.2014

Date of order : 18.10.2019

PRESENT:

Shri. Cherian K. Kuriakose, President

Shri. V.Ramachandran Member

CC.No.930/2014

Between

O R D E R

V.Ramachandran, Member

1. A brief statement of facts of this complaint is as stated below:

The complainant Sri.Faizal V.A. had taken policy No.51006519 from the opposite party (Health Surakha Policy, Silver Plan) on 12.12.2013 for Rs.3,00,000/-. The complainant had taken the policy initially on 12.12.2011 which was being renewed from year to year. As per the terms of the policy, the complainant had paid premium of Rs. 17,110/- for 2013-2014. Later the complainant was having hypertension which could not be controlled by medication and after conducting several tests and investigations by various Doctors he was diagnosed with ‘Bilateral Renal Artery Stenosis’. The complainant was admitted in MIMS Hospital on 01.09.2014. On 02.09.2014, Renal Percutaneous Transluminal Angioplasty and Stenting to bilateral renal were done in MIMS hospital and discharged on 05.09.2014. When the complainant requested the opposite party to provide the facility of cashless treatment, the opposite party refused to do so stating that there was a possibility of the present ailment being a complication of the pre-existing disease. After the treatment was over, the complainant submitted all supporting original documents. On 11.09.2014 the complainant submitted the claim for Rs.1,82,839/- as reimbursement for medical and other expenses. The complainant was directed by the opposite party on 29.09.2014 to get a certificate from the treating doctor mentioning the exact etiology for present ailment and confirm whether the present ailment is a complication of HTN/Dyslipidemia”. As directed by opposite party, the complainant obtained a certificate from his Nephrologist. In the certificate the Doctor has clearly stated that Bilateral Renal Artery Stenosis is not a complication of HTN/Dyslipidemia. The certificate given by the Doctor was given to the opposite party on 28.10.2014. On 28.10.2014 the complainant received a letter from the opposite party stating that the complainant is having a history of Hypertension for the last 9 years and that pre-existing conditions will not be covered until 48 months of continuous coverage have elapsed since inception of the first health Suraksha policy. The complainant did not claim for any reimbursement for treatment for hypertension. The complainant therefore filed this complaint seeking directions from this Forum to the opposite party to pay compensation of Rs.1,82,839/- equal to the amount denied to the complainant along with Rs.20000/- as compensation for wrongful denial of the claim. The opposite party is legally liable to honour the claim of the complainant. Hence the complainant has asked for a compensation of Rs.1,82,839/- equal to the amount denied to the complainant along with Rs.20,000/- as compensation for wrongful denial of the claim. The 1^st opposite party is liable to pay interest @of 12% annum to the complainant from the date of filing the complaint till realization.

2) Notice was issued to the opposite party and the opposite party filed their version in response to the notice served on the opposite party.

2. Version of the opposite party.

The opposite party stated in their version that the complainant had availed the above policy on 12.12.2011 which was being renewed yearly. During the 2^nd renewal of the policy from 11.12.2013 to 11.12.2014 he was admitted in MIMS hospital Calicut as inpatient and undergone Renal Percutaneous transluminal

angioplasty and studying to bilateral Renal arteries on 02.09.2014. After the treatment the complaint forwarded the claim for reimbursement of medical and other expenses for Rs.1,89,839/- to the opposite party which was repudiated and hence the complaint. The opposite party stated in the version that the complainant had suppressed material facts/past medical history of him at the time of inception of policy and the opposite party is not liable under the above mentioned policy as there was suppression in undertaking/declaration given by the complainant in the terms and conditions of Exbt.B1. The telephone conversation details also were produced by the opposite party. The complainant had suppressed his past history of ailments. It was mandatory on issuance of policy which result in the alteration of the risks covered under the policy and premium amount. The opposite party has in good faith issued the policy and hence the claim cannot be honoured.

3. The evidence in this case consisted of the oral evidence adduced by the complainant as PW1 and the documentary evidences furnished by the complainant which were marked as Exbt.A1 to A8. The opposite party adduced oral evidence through their witness DW1. The opposite party furnished documentary evidences which were marked as Exbt.B1 to B7.

4. Issues to be decided in this case are as follows:

1. Whether the complainant has proved any deficiency in service or unfair trade practice on the part of the opposite party?

2. Whether the complainant is eligible to get any compensation form the opposite party?

5. Issue No. (i)

As regards to issue No. (i), the complainant had not revealed about the ailment or about the treatments which he had undergone earlier either at the time of the telephone conversation made by the opposite party for granting subscription to the complainant into the insurance scheme. Moreover, as per Exbt.B1 produced by the opposite party, it is evident that the insurance coverage cannot be claimed with retrospective effect. Exbt. B1 to B7 shows that the complainant was suffering from ailments for which the claim is asked for prior to the subscription date of the insurance policy. Since the complainant has suppressed the material facts from the opposite party and since the policy conditions in Exbt.B1 is against the complainant, we do not think that there is any deficiency of service on the side of the opposite party and hence the complainant is only to be dismissed.

6. Issue No. (ii)

Having found the issue No. (i) against the complainant, we are not inclined to consider and decide issue No (ii).

In the result, the complaint is found liable to be dismissed and the complaint is accordingly dismissed.

Pronounced in the open Forum on this the 18^th day of October 2019

Sd/-

V. Ramachandran, Member

sd/-

Cherian K. Kuriakose, President

Forwarded by Order

Senior Superintendent

APPENDIX

Complainants Exhibits

Opposite party's Exhibits:

Depositions ::

PW1 :: Faizal V.A

DW1 :: S. Sanjay Kumar

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