DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  15^th day of July,  2022

Present      :   Sri.Vinay Menon V.,  President

                  :   Smt.Vidya A., Member                        

                  :  Sri.Krishnankutty N.K., Member                                              

 Date of Filing: 07/08/2017   

     CC/117/2017

Jayakumar P

Puthanthodi House,

Bheemanad P.O.

Alanallur, Mannarkkad – 678 601

(By Adv.K.Dhananjayan)                                                        -           Complainant

                                                                                                  Vs

1. M/s.Star Health & Allied Insurance Co.Ltd.

       No.1, Tank Street, Valluvarkottam,’

      High Road, Nungambakkom,

       Chennai – 600 034

2. M/s.Star Health & Allied Insurance Co.Ltd.

       No.1, Tank Street, Valluvarkottam,’

      High Road, Nungambakkom,

       Chennai – 600 034

       Rep.by its Managing Director/Manager/

       Authorised Signatory

3. The Branch Manager,

       M/s.Star Health & Allied Insurance Co.Ltd.,

      Sharco Tower,

      TB Road, Ottapalam,  Palakkad – 679 101

            (OPs by Adv.P.Ratnavally & Kiran G Raj)                    -           Opposite parties

O R D E R 

By Sri. Vinay Menon V.,  President

1. In essence, complaint pleadings are to the effect that the complainant was a beneficiary under a health insurance policy issued by the opposite party. While applying for the insurance policy he had disclosed all existing ailments. During the subsistence of that  policy issued by the opposite party, the complainant was admitted in CMC Vellore for cardiac problems and the doctors there opined that he would have to  undergo  an invasive cardiac procedure. No procedures were undertaken at CMC Vellore. Thereafter the complainant  got admitted in Aster Medicity Hospital  to undergo treatment and a total amount of Rs.1,27,078/- was expended by the complainant.  

Opposite  parties repudiated the complainant’s genuine claim for indemnification of the expenses incurred for treatment  on the ground that he had failed to disclose the fact that he suffers from mycosis fungoides which was present at the time of issuance of the policy. Repudiation is illegal and there is deficiency in service on the part of opposite parties. The complainant is aggrieved by the repudiation of his claim.  This complaint is filed seeking indemnification of the amounts expended and for compensation and other incidental relief.

2. The opposite parties filed version   admitting the complaint pleadings but qualifying their pleadings stating that the complainant was also suffering from mycosis fungoides from as early as 2014 and was undergoing treatment for that.  The complainant had withheld this material information in the proposal form while applying for insurance cover. As there was suppression of material facts,  claim of the complainant was repudiated. There is no deficiency in service what so ever.  The opposite parties sought for dismissal of the complaint. 
3.  The following issues arise for consideration

1. Whether there was suppression of material facts on the part of the   complainant ?
2. Whether there is any deficiency in service on the part of   opposite   parties ?
3. Whether the complainant is entitled to any reliefs as sought for ?

     4.    Reliefs,  if any ?

4.         The complainant   filed proof affidavit and marked Exhibits A1 to A5. Even though the complainant sought to mark additional documents, in view of continuous  failure on the part of complainant to mark the documents,  chance was closed and his further evidence done away with.  The complainant  was examined as PW1.  Opposite parties filed proof affidavit and Exts.B1 to B9 were marked. 

            Issue no. 1

5.         It is the unambigous case of the complainant that he had availed the policy after effecting full disclosure in the proposal form for Star Cardiac Care Insurance. Ext.B1 dated 4/1/2015 is the said proposal form. On its reverse, under the heading “Have you  ever suffered or suffering from any of the following”   answer to question A “diabetes mellitus  - if yes, since when”, the complainant has answered in the positive. To rest of the questionnaire, the complainant had answered in the negative.

Ext.B4 dated 14/8/15  is the discharge summary issued from Aster Medicity. In the  section “Diagnosis”, 6^th line reads “CHRONIC DERMATITIS ? MYCOSIS FUNGOIDES” Thereafter the   section “History” shows that the complainant was suffering from “MYCOSIS FUNGOIDES (without sezary syndrome)”. 

OP pleaded that upon seeing mycosis fungoides, the opposite party investigated the precedents of the complainant and came up with the treatment records of the complainant in CMC Vellore which was hitherto not disclosed to the opposite party. Ext.B5 is the discharge summary issued from CMC Vellore.

Ext.B5 dated 3/10/2014   in the name of the complainant issued from the CMC Vellore  pertains to an admission to the said hospital as IP from 17/9/2014 to 3/10/2014 for mycosis fungoides stage 1A and some other related diseases.  In the discussion regarding his condition, it is clearly stated that the complainant was suffering with recurrent itchy skin lesion on the body for over 15 years.  He was admitted for evaluation and management for suspected  mycosis fungoides. A skin biopsy conducted at CMC Vellore  was suggestive of mycosis fungoides.

7.         The complainant was examined as PW1. In page 2 of the testimony, at lines 16 to 19,  complainant admits that he had not disclosed the existence of mycosis fungoides in the proposal form. He also admits that he had sought treatment in CMC Vellore during 2014.

8.         A conjoint reading of the testimony of PW1, Exts.B1, B4, B5 and B6 goes to prove that (a) the complainant had undergone treatment for mycosis fungoides in CMC Vellore during the period  covering 17/9/2014; (b) the complainant deliberately suppressed the factum of this disease and its treatment in Ext.B1 proposal form.   Opposite party insurance company repudiated the claim of the complainant based on and after proper appreciation  of the aforesaid two facts.  We do find any deficiency in service on the part of the opposite parties.

            Therefore we hold that the complaint lack in merits. The complaint is dismissed.

      Issue No.2

9.         Resultantly we hold that there is no deficiency in service or unfair trade practice on the part of the opposite parties. 

Issue Nos.3 & 4

10. In view of the findings in Issue Nos.1&2, the complainant is not entitled to any of the relief sought for.

In the facts and circumstances of the case, we find that the complainant had deliberately withheld informations that were within the knowledge of the complainant and availed a policy from the opposite party. Upon repudiation of the policy based on such non disclosure, the complainant has come in dispute against the opposite party. We do not find any bonafides in the actions of the complainant. The complainant has not approached this Commission with clean hands.  Hence, a cost of Rs.5,000/-(Rupees Five thousand only) is imposed on the complainant payable to  the opposite  parties within 45 days from the date of this order.

            Pronounced in open court on this the 15^th  day of July,  2022.

     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 – Photocopy of Policy certificate bearing No.P/181218/01/2016/001809

Ext.A2 – Photocopy of repudiation letter dated 9/12/2016

Ext.A3 – Photocopy of Medical report  bearing hospital No.033462G

Ext.A4 – Photocopy of patient bill (summary) bearing No.IPCR16/8067 dt.14/8/15

Ext.A5 – Photocopy of discharge summary bearing IP No.16/19755 dt.2/12/2016

Exhibits marked on the side of the opposite party

Ext.B1 – Photocopy of proposal form bearing No.R/2015/2311

Ext.B2 – Print out of  Ext.A1

Ext.B3 – Print out of Policy terms and conditions.

Ext.B4 – Photocopy of discharge summary bearing IP No.15/8983 dated 14/8/15  

Ext.B5 – Photocopy of scanned copy of discharge summary bearing hospital No.033462G

               dt.3/10/2014

Ext.B6 – Printout of repudiation letter dated 10/10/2015

Ext.B7 – Photocopy of request for cashless hospitalization for medical insurance policy

                dated 29/11/2016

Ext.B8 – Printout of  rejection of  pre-authorisation  for cashless treatment dated

                30/11/2016.

Ext.B9 -  Photocopy of receipt dated 12/8/17.

Exhibits  from third party

 Nil

Witness examined on the side of the complainant

PW1 – Jayakumar P

Witness examined on the side of the opposite party

NIL

Court Witness

Nil

Cost :  Rs.5,000/- (Rupees Five thousand only)  

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.