D.o.F:29/06/07D.o.O:16/2/2010 IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD CC.NO. 62/07 Dated this, the 16th day of February 2010 PRESENT: SRI.K.T.SIDHIQ : PRESIDENT SMT.P.RAMADEVI : MEMBER SMT.P.P.SYAMALADEVI : MEMBER Vasantha Shetty, S/o Late K.Ramayya Shetty, R/at Naduhithlu House, Nelakkala Road, : Complainant Anangoor,Kasaragod (Adv.Rajagopala,Kasaragod) 1.Paramount Health Services Pvt.Ltd. No.CC.50/127,Plot No.1, Krishnavihar, Panampilly Avenue,Kochin 682036. 2. Branch Manager, : Opposite parties United India Insurance Co.Ltd, Kasaragod. (Adv.C.Damodaran,Kasaragod for OPs) ORDER SRI.K.T.SIDHIQ : PRESIDENT: Complaint against the repudiation of medi claim by the opposite parties relying on clause 4.1 of the policy that excludes the diseases which was pre existing at the time of taking policy. According to the complainant the policy No.100801/48/06/20/00000168 was for the period from 22/5/2006 to 21/5/2007. But the complainant undergone a bye-pass surgery at Narayanan Hridayalaya, Bangalore on 22/8/2006 . The complainant spent more than Rupees 2 lakhs towards the surgery. On submission of the necessary documents opposite party repudiated the claim footing on exclusion clause of 4.1 of the policy on the ground that the petitioner had pre existing complaint of heart disease and diabetics and hence the claim is not covered as per the policy. According to the complainant opposite party repudiated his claim relying on a typographical error committed by the hospital authorities while issuing the documents though he produced the relevant documents by way of clarification. Complainant states that he has availed the policy bonafidely to safe guard himself from all health hazards and at the time of availing the policy he had no health complaints. 2. Opposite parties resist the claim. According to opposite parties the policy to the complainant was not issued after necessary medical examination. The disease of complainant was contracted prior to the commencement of the policy. The complainant was suffering from the disease 6 years prior to the admission at Narayana Hridayalaya Hospital, Bangalore. The policy availed was not bonafide. The discharge summary with the correction by a doctor who has not treated the complainant cannot be accepted. The correction with regard to the period instead of 6 years to 6 months is made only to attract liability. Even if it is considered that the disease was existing only before 6 months prior to the admission then also the complainant had illness during Feb 2006 itself and policy commencement is from 3rd week of May which clearly shows that the disease was pre-existing and the policy was availed only for the purpose of making the treatment expenses out of the policy amount. The mistake alleged by the complainant is not a typographical error. Complainant was a patient of Dr.B.V.Manjunatha Cardiologist Mangalore. Complainant was a known case of Diabeties Mellitus for 5 years prior to his surgery . Medical certificate produced along with claim form also shows that the disease was pre-existing 6 years prior to the admission. The complainant had furnished the details of his treatmental expenses to the tune of Rs.1,60,000/-. There is no deficiency in service on the part of the opposite party. The policy is availed only after foreseeing the treatment and the effort of the complainant is to enrich himself by suppressing material fact. The complaint is only in experimental nature and not entitled to the reliefs claimed. 3. Complainant filed affidavit and Exts.A1 to A6 marked. Dr.P.K.S. Sharma examined as PW2 and Dr.Ambika Prasad Shetty , the administrator of Narayana Hridayalaya examined as PW3. All the witnesses were cross examined by the counsel for opposite party. On the side of opposite party N.Sudhakaran, Deputy Manager of United India Insurance Co.Ltd Kannur filed affidavit as DW1 and cross examined by the counsel for complainant. Exts.B1 to B12 were marked. Both sides heard . Documents perused. 4. Whether the complainant was suffering from any pre-existing disease at the time of taking the mediclaim policy is the cardinal issue to be settled in this complaint?. 5. The case of the complainant is that his claim is repudiated basing on a typographical error committed by the Narayana Hridayalaya hospital authorities where he underwent heart surgery . According to him, his ailment to the heart was only having a duration 6 months but the hospital authorities mentioned in the discharge summary it as 6 years and relying on the said document opposite party rejected his claim on the ground that the disease was a preexisting one. 6. Complainant has examined as PW1 to testify the mediclaim proposal Ext.B3 and examined PW3 to substantiate the genuineness of Ext.B5 the certificate issued by PW3, the administrator of Narayana Hridayalaya Bangalore. By examining the witness, the complainant attempted to establish that the ailment caused to him was having only a duration of 6 months and not 6 years as mentioned in Ext.B4, the discharge summary issued from Narayana Hridayalaya and that was only a typographical error . Even if it is considered that the duration of the disease was having only 6 months it is difficult for the complainant to succeed the complaint. Ext.B9 (a) is a discharge summary issued from the Division of Cardiology attached to A.J.Hospital Mangalore. As per that, the complainant was admitted on 10/8/2006 and discharged on 11/8/2006. His ailment was diagnosed as coronary artery disease Effort angina class II, Triple Vessel disease, Good L V function, Diabetics mellitus type II systemic hypertension. In Ext.B9(a) the clinical presentation is noted as below; Clinical presentation 52 years old male, diabetic, hypertensive, presented with history of effort angina class II since 6 months, now increased. TMT done outside on April 2006 reported positive. Now admitted here for coronary angiogram. 7. So from Ext. B9(a) it is clear that the complainant had undergone TMT ( Tread Mill Test) in April 2006 and it was found positive. Ext.B2 is taken for the period 22/5/06 to 21/5/2007. So naturally when the TMT was found positive the complainant might have prepared for an expensive treatment like by pass surgery in the nearby future because his prior policy was covering only upto Rs. 25000/. Therefore the contention of opposite party that the complainant availed Ext.B2 policy foreseeing a huge amount for future operation is appears to be well founded. Hence the claim of the complainant was not a bonafide one it ought to have been rejected as opposite party had done and it does not amount to any deficiency in service. Moreover, in Ext. B3 mediclaim proposal form dtd.20/5/06 the complainant in the questionnaire relating to the chest pain or coronary insufficiency or myocardial infraction has answered in the following manner. Did you ever suffer from chest pain or coronary insufficiency or myocardial infarction? If so please give diagnosis and date : No 8. Actually, when the complainant duly filled this proposal he was well aware that he had undergone TMT in April 2006 and the result was reported positive. Further he was also suffering from chest pain on exertion during those days. If that be so, there is lack of bonafideness on the part of complainant since he had suppressed the fact that he was suffering from preexisting disease at the time of proposing the Ext.B2 policy. Since the complainant was well aware about the symptoms of his disease, the decision quoted by the counsel for the complainant reported in 2008 CTJ 347 (CP) (NCDRC) is not applicable in this case. Since that is a case where the policy holders are totally unaware about the symptoms of the disease they have affected with A contract of insurance is a contract uberrima fide. A person who desires to take an insurance policy must disclose to the insurer all the material facts/ circumstances because the insurer knows nothing and the assured knows everything. The special facts are commonly in the knowledge of the insured and the insurer trusts the insured’s representations. The insurer proceeds on the belief that the insured has not suppressed any facts and circumstances in his knowledge and induce the insurer to believe that risk does not exist. Suppression of such material facts is fraud and therefore the policy is void. In the aforesaid circumstances, it is clear that the policy under dispute lacks bonafideness and it is not a contract of utmost good faith. Hence the repudiation of claim do by the opposite party does not amount to any deficiency in service. Therefore, the complaint is dismissed without any order as to costs. MEMBER MEMBER PRESIDENT Exts:- A1-3/9/06-Discharge summary A2-20/2/07- copy of the certificate issued by Narayana Hridayalaya,Bangalore A3-4/4/07-original repudiation letter A4-copy of policy A5-copy of ID card A6- Original bill issued by Narayana Hridayalaya,Bangalore B1- Medi Guard policy B2-Individual medi claim policy B3- Medi claim proposal B4-discharge summary B5-discharge certificate B6-5/11/08-letter sent by OP.2 to Narayana Hridayalaya,Bangalore B7--Reply dt.25/11/08 B8- settlement intimation voucher B9-Angiogram report of A.J.Hospital B9(a)-division of cardiology- discharge summary B10- A.J.Hospital cash bill B11- Medical report B12 series- inpatient bill PW1-K.Vasantha Shetty-complainant PW2-Dr.P.K.S.Sharma- witness of complainant PW3-Dr.Ambika Prasad Shetty- -do- DW1- N.Sudhakaran- Dy.Manager of OP MEMBER MEMBER PRESIDENT Eva/
......................K.T.Sidhiq
......................P.P.Shymaladevi
......................P.Ramadevi | | 
