DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  8^th  day of  May, 2023 

Present      :   Sri. Vinay Menon V., President

                  :  Smt. Vidya A., Member                        

                  :  Sri. Krishnankutty N.K., Member                                Date of Filing: 08/09/2021  

                         CC/137/2021

Jishnu K Madhav,

S/o. Haridas K,

Kariyattil House,

“Madhavam”,

Kalladikode P.O.,

Palakkad – 678 596                                              -                       Complainant

       (By Adv. K. Dhananjayan)

                                                                                                Vs

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

              1^st New Tank Street,

Valluvarkottam High Road,

Nungampakkam,

 Chennai – 600 034

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

              Rep.by its Manager / MD/Authorised signatory,

 1^st New Tank Street,

Valluvarkottam High Road,

Nungampakkam,

 Chennai – 600 034    

3.         The Branch Manager,

            Palakkad

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

Fine Centre, Fourth Floor, Sakunthala Jn.

T.B.Road, Palakkad – 678 014                                   -                       Opposite parties

(O.P.s  by Adv. M/s. Ratnavally P.  &  Kiran G. Raj A.)

O R D E R

By  Sri. Vinay Menon V., President

1. Complaint allegations abridged are that the complainant is a beneficiary of a policy issued by the opposite parties. Complainant was diagnosed with Pemphigus Vulgaris (A dermatological disorder) during November 2019 during subsistence of a valid policy. Complainant underwent treatment. Eventhough the complainant was entitled to indemnification of the amounts expended as treatment expenses, the O.P. repudiated  his claim. Aggrieved thereby, this complaint is filed.
2. The 1^st opposite party filed version admitting the existence of the policy, but defended repudiation. Per O.P., the complainant had been suffering from Pemphigus Vulgaris + Eczema herpeticum subsided + steroid induced DM. Complainant was suffering from this condition for 7 months as on 20/01/2020. Since the condition was a Pre-existing disease and the complainant had willfully suppressed this fact, the claim was repudiated. There is no deficiency in service whatsoever.
3. Pleadings and counter pleadings considered, the following issues arise for consideration:

1. Whether the complainant was suffering from Pre-existing disease as contemplated under the Policy Terms and Conditions?
2. Whether the complainant has willfully suppressed material facts?
3. Whether there is any  deficiency in service or unfair trade practice on the part of the O.P.s?

4.         Whether the complainant is entitled to any reliefs sought for?

5.         Any other Reliefs?

4. (i)     Evidence on the part of complainant comprised of proof affidavit and Exts. A1 to A5.

     (ii)              OPs also filed proof affidavit. Documents filed by opposite parties were marked as Ext.B1 to B7. 

Marking of documents were not objected by either sides.

Issue No.1                                                                                                                                                                                                                                

5.         Ext. B5 is the letter of repudiation. Claim was repudiated on the ground that the complainant was suffering from a pre-existing disease and that the complainant had willfully suppressed the said fact.

6.         Inception of the policy was on 31/07/2019.

Complainant was diagnosed with the affliction on 27/11/2019, as can be seen from Ext. A3 Histopathology report.

                        Ext. A4 is a discharge summary dated 21/03/2020 issued from Dept. of Dermatology, Govt. Medical College. Clinical Presentation in Ext. A4 shows that the complainant was suffering from recurrent episodes of oral erosion for 7 months prior to 27/01/2020. Therefore the affliction must have become apparent during June, 2019.

                        Thus, in relation to the policy in question, the complainant was suffering from a  pre-existing disease

7.         But the question is whether the disease is a Pre-existing disease as contemplated under the Policy. To that end, the definition of “Pre-existing Disease” is reproduced below:

“2. Policy Definitions: Pre-Existing Disease  means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and/or were diagnosed, and/or for which medical advice /treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.”

Elements of the definition relevant herein are

1. There is a condition;
2. There were signs or symptoms; and/or
3. They were diagnosed;
4. Medical advice/treatment was received within 48 months prior to the first policy.

8.         Inorder to fall within the strait jackets of the definition of Pre-existing disease, the complainant should satisfy all the 4 elements stated above. Even considering that the complainant was having the disease or was having the signs and symptoms, a diagnosis was made only on 27/11/2019 as is evident from Ext. A3 Histopatholgy report.  Further Ext. A2 reference made by Dr.Suresh, Skin Specialist, shows that the complainant met the doctor only on 19/11/2019.

9.         Thus it cannot be said that the disease suffered by the complainant was not a Pre-existing disease as contemplated and defined under the policy, eventhough it was pre-existing. 

Issue No.2

10.       As already concluded under the discussion in Issue no. 1, diagnosis of the condition was made only during November, 2019. Thus it cannot be held that the complainant had resorted to willful non-disclosure of material facts on during June, 2019.

Issue No.3

11.       Per discussion and conclusion in Issue nos. 1 &2, we hold that there is failure of the part of O.P.s to apply their mind to the case of the complaint. The O.P.s jumped into a conclusion that merely because there was a pre-existing disease, the complainant was suffering from a Pre-existing Disease as contemplated under the Policy and that he had willfully suppressed material facts.

Such an approach will not behove well for the opposite parties and such a conduct is nothing less than arbitrariness and is bad for non-application of mind.

12.       Thus we find that there is deficiency in service on the part of the opposite parties.

Issue Nos. 4 & 5

13.       Apropos the discussion above, we hold as herein below:

A)         The O.P.s are directed to allow the claim of the complainant as permissible under the policy conditions.

B)         The complainant shall be entitled to an interest of 10% on the said amount so payable from the date of claim CLI/2020/18214/0968222 till the date the said amount is paid.

C)         The complainant is entitled to compensation of Rs. 25,000/-(Rupees Twenty Five Thousand only)

D)         The complainant is entitled to a cost of Rs. 15,000/-(Rupees Fifteen Thousand only)

E)         The opposite party shall comply with the direction above within a period of 45 days from the date of receipt of a copy of this Order, failing which the O.P. shall pay an amount of Rs. 500/-   per month of part thereof till the date of final  payment.

                         Pronounced in open court on this the 8^th  day of May, 2023.          

                    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 – Copy of policy bearing No.P/181214/01/2020/002918

Ext.A2 – Copy of prescription dated 19/11/2019 issued by Dr.Suresh  

Ext.A3 – Copy of Histopathology report dated 27/11/2019

Ext.A4 - Copy of Discharge summary dated 21/3/2020

Ext.A5 - Copy of  letter of repudiation

Exhibits marked on the side of the opposite party:   

Ext.B1 – Copy of policy certificate and schedule

Ext.B2 –  Original proposal form

Ext.B3 –  Same as Ext.A3

Ext.B4 –  Copy of communication dated 28/7/2020 regarding repudiation

Ext.B5 –  Same as Ext.A5

Ext.B6 –  Copy of communication dated 11/9/2020

Ext.B7 – Copy of receipt dated 14/9/2020

Court Exhibit:  Nil

Third party documents:  Nil

Witness examined on the side of the complainant: Nil

Witness examined on the side of the opposite party:  Nil

Court Witness: Nil

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.