PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 31st day of March 2012
Filed on : 20/07/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member. Member.
Smt. C.K. Lekhamma, Member
C.C. No. 383/2011
Between
C.P. Eldhose, : Complainant
Churackakuzhi house, (By Adv. Tom Joseph, Court
Thonnicka, Kolencherry P.O., Road, Muvattupuzya)
Pin -682 311..
And
M/s. United India Insurance Ltd : Opposite party
2nd Floor, Manickanamparambil (By Adv. R. Ajith Kumar Varma,
building, Layam road, 39/1747, Chittoor road,
Tripunithura-682 301. Ernakulam South,
Cochin-682 016)
O R D E R
C.K. Lekhamma, Member.
Brief facts of the complainant’s case is as follows:
The complainant has been a family mediclaim policy holder of the opposite party from 04-08-2008 onwards. While so, during the period of the policy the wife of the complainant Smt. Gini consulted Dr. Annie Soman on 11-05-2011 with the complaint of abdominal discomfort. The disease was diagnosed as ovarian cyst and she was subjected for Laparoscopic ovariotomy. She was treated there as inpatient from 19-05-2011 to 23-05-2011. The complainant incurred Rs. 28,300/- towards treatment expenses. The complainant lodged a claim before the opposite party. But the claim was repudiated by the opposite party stating the reason that the complainant suppressed material facts in the proposal that the wife of complainant having hypertension. The above said reason given for repudiation of the claim is not correct and unsustainable. The complainant’s wife was not having a history of hypertension prior to the date of the proposal. She had not taken any medicines prior to the date of proposal also. Moreover the claim is preferred in connection with ovarian cyst and not for hypertension. The allegation of hiding of material facts is not correct and hence the repudiation of the claim on that ground amount to deficiency of service. The complainant is entitled for the claim amount of Rs. 28,300/- along with interest. Hence this complaint.
2. The version of the opposite party is as follows:
The issuance of policy is admitted by the opposite party that Smt. Gini Eldhose had stated in column no 12 of the proposal that she was in good health and free from physical disease or infirmity or medical complaints. Further, in column 13 ( c ) she has stated that she has no high blood pleasure or other circulatory disorders. Then again in column No. 17 she has stated that she has no knowledge of the existence of any ailment sickness or injury which may require medical attention. In annexure A questionnaire regarding hypertension, she has answered “No” to the six questions asked. In the inpatient-discharge summary issued by the MOSCM Medical College Hospital, Kolenchery it is stated that she is hypertensive for the past 3 years, thereby showing that she has been hypertensive since 19-05-2008. As earlier submitted, in the proposal form dated 05-08-2008 . Therefore the insurance company has no liability to honour her claim. Hence there is no deficiency of service on the part of the opposite party and the complaint is only to be dismissed.
3. The complainant and the opposite party represented through counsel. Both sides were adduced only documentary evidence only. Ext. A1 to A4 and Ext. B1 to B3 were marked on both sides. Thereafter, we have heard the respective counsel.
4. The points that arose for determination are as follows:
i. Whether the repudiation of insurance claim is justified?
ii. What are the relief if any?
5. Point No. i. The claim for treatment expenses of the complainant was repudiated by the opposite party due to the reason that the patient is hypertensive prior to the inception of the policy. According to the complainant the claim was in connection with the ovarian cyst and not for hypertension.
No dispute is with regard to the coverage of policy and the hospitalization. Ext. B3 is the discharge summary of the complainant’s wife Mrs. Gini issued from MOSC Medical college Hospital, Kolenchery. In which towards the heading ‘History and clinical features’ it is mentioned that “Hypertensive for past 3 year”. The said document shows that the patient had undergone Laparoscopic ovariotomy due to ovarian cyst. The opposite party failed to adduce any independent evidence to prove that the complainant had medication for hypertension or hospitalization before taking the policy. Moreover the doctor who treated the insured was not examined. The Hon’ble National Commission has rendered a decision in Life insurance Corporation of India Vs. Shri Anil Kumar Rastogi 2009 (4) CPR 130 (NC) In which it is mentioned that
“If a person mentions at the time of having bypass surgery regarding any ailments that he might have felt, sustained discomfort in health and being noted by the doctors does not mean that he is already aware of the disease. Had he been aware of heart disease, he would not have waited endlessly and put himself to further risk of life and would have rushed to get treatment immediately. When the patient is not aware of the disease or the symptoms of the same affect him, or the doctors are not aware of the symptoms of the disease and the insurance company does not do any medical check up before reviving the policy, it cannot be said that there was suppression of material facts by the respondent. “
In view of the above we are of the opinion that the opposite was not justified in repudiating the complainant’s claim. Hence we have no hesitation to hold that the complainant is entitled to get the medi-claim amount with interest for the treatment of his wife from the opposite party. But there is no evidence before us to prove the expenses incurred for treatment. Therefore, the opposite party is liable disburse the insurance amount as per norms. We are not ordering any cost, since we have already directed to pay to the claim amount.
6. Accordingly we allow the complaint in part and direct the opposite party shall pay insurance claim amount to the complainant as per norms together with interest @ 12% p.a. from the date of complaint till realization
The above said order shall be complied with within a period of one month from the date of receipt of a copy of the order.
Pronounced in the open Forum on this the 31st day of March 2012.
Sd/-
C.K. Lekhamma, Member.
Sd/-
A Rajesh, President.
Sd/-
Paul Gomez, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : copy of health insurance
policy-gold
A2 : Copy of Health Insurance
A3 : Copy of Medical
certificate/attending doctors
certificate.
A4 : Copy of letter
Opposite party’s Exhibits : :
Ext. B1 : Copy of Individual Health
Insurance policy-2009.
B2 : Copy of medi-guard
Insurance-Proposal form
Insured person details
B3 : Inpatient discharge summary
Copy of order despatched on :
By Post: By Hand:
