DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 2^nd   day of September, 2022

Present      :   Sri.Vinay Menon V.,  President

                  :   Smt.Vidya A., Member                        

                  :  Sri.Krishnankutty N.K., Member             Date of Filing: 01/12/2018    

     CC/159/2018

Kumaran U.

S/o. Ramachandran

Kedaram, Palayappetta, Palakkad – 678 001

(By Adv. K. Dhananjayan)                                                      -           Complainant

                                                                                    Vs

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

      No.15, Sree Balaji Complex, 1^st Floor,

      Whites Lane, Royapetta, Chennai – 14

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

       No.15, Sree Balaji Complex, 1^st Floor,

       Whites Lane, Royapetta, Chennai – 14

      Rep.by Managing Director/Manager /

      Authorised Signatory

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

      Zonal Office, 4^th Floor,

      Carmel Towers, Cotton Hill Post,

      Vazhuthacaud, Trivandrum

4.   The Branch Manager,
        M/s.Star Health & Allied Insurance Co.Ltd.,

       Fine Centre, 4^th Floor,

       TB Road, Palakkad – 678 014                              -           Opposite parties

      (OP1 to 4 by Adv.P. Ratnavally & Kiran G. Raj)

O R D E R 

By Sri. Vinay Menon V.,  President

1. Complainant, a beneficiary under a Family Health Optima Insurance Policy issued by the opposite parties, is aggrieved by the repudiation of his claim for amounts expended for an invasive cardiac procedure. The complainant claims that while availing the said policy he had made full disclosure of the ailments suffered by him and the cardiac diseases were diagnosed only after inception of the policy. He vouches by a report dated 02.09.2017 wherein, as the complainant claims, “report clearly observed that he is not having any pre-existing diseases or have the possibility of cardiac malfunction.”(Lines 7-9, Paragraph 4, page 4 of the memorandum of complaint).  Hence he states that the repudiation on the ground of pre-existing disease is illegal and a deficiency in service on the part of the opposite party. He seeks for an order directing the opposite parties to pay the expended amount with interest and for cost and compensation.
2. Opposite parties entered appearance and filed detailed version. They admitted the subsistence of a valid policy but refuted the contention of the complainant that his cardiac condition was not a pre-existing one. The complainant had expressly answered that he was not having cardiac problems in the proposal form while he was undergoing cardiac treatment even during 2017, ie. one year prior to inception of policy. They sought for dismissal of the complaint.
3. The following issues arise for consideration.  

1. Whether the complainant was suffering from a pre-existing disease?
2. Whether the complainant had willfully and deliberately suppressed material information regarding his cardiac ailments in the proposal form?
3. Whether there is any deficiency in service / unfair trade practice on the part of opposite parties?
4. Whether the complainant is entitled to any reliefs as sought for?
5. Reliefs, if any?

4.         Evidence comprised of proof affidavits on the side of both parties and Exts.A1 to A10 on the part of complainant.  Exts. B1 to B11 were marked on the part of the opposite parties.

Issue Nos. 1 & 2

5.         For convenience, these two issues can be considered together. Complaint pleadings made out a case that the opposite parties had repudiated the claim of the complainant even after he had disclosed all the ailments suffered by him. The complainant underwent cardiac procedure during 2018. On 02.09.2017, per complainant, a medical report had stated that the complainant was not suffering from any adverse cardiac condition.

6.         Inorder to ascertain what the aforesaid medical report we need to look into that document. The said report dated 02.09.2017 is marked as Ext. A4.  Ext. A4 is the Echocardiogram Report dated 02.09.2017 issued from District Hospital, Palakkad. The impression of findings is as below:

            1.         No RWMA

            2.         Good LV Systolic Function.

            3.         LV Diastolic Dysfunction.

            The 3^rd impression shows, contrary to what the complainant asserts, that the complainant was suffering from Left Ventricle Diastolic Dysfunction.

7.         The opposite parties bank upon Exts. B5, B6 and B7  to substantiate their case of pre- existing disease. All these documents were marked without any objections from the part of complainant. 

                        Exts. B5 dated 24.08.2017 and B6 dated 24.10.2017 are prescriptions for medicines issued by doctors in Dept. of Cardiology, District Hospital, Palakkad for one Kumaran, O.P. No. 210058.

                        Ext. B7 dated 02.11.2017 is a prescription issued from Department of Dentistry in the name of Kumaran, O.P. No. 271236/17. Ext. B7 shows that the patient is a cardiac patient on medication.

8.         Ext. B1 is the common proposal form dated 11.01.2018 filled by the complainant for availing the  policy. In page 4/6 of Ext. B1, to question 4, “Has the persons proposed for insurance ever suffered or suffering from any of the following”, Sub clause (c) “Heart Disease – If yes, since when”, the complainant has answered in the negative.

9.         Thus, on a conjoint reading of Exts. A4, B1, B5, B6 and B7, we conclude that the cardiac problems suffered by the complainant were pre-existing and that the complainant was aware of the condition. Further, the condition suffered by the complainant was material in so far as issuance of the policy in this case is concerned. And the complainant has willfully and deliberately withheld the material information at the time of preparation of proposal.

            Issue No. 3.

10.       In view of the findings in the issues above, we hold that there is no deficiency in service on the part of the opposite parties.

            Issue Nos. 4 and 5

11.       The complainant is not entitled to any of the reliefs sought for.

12.       In the facts and circumstances of the case, we find that there is a clear case of non-representation of material facts. Date check also shows that the proposal form was wrongly prepared without revealing material facts after finding out of the cardiac conditions being suffered by the complainant. The complainant has filed the case against the company for rightfully repudiating the claim.

            Hence this is a vexatious litigation and the complainant has not come forward with a clean hand. The opposite party is therefore entitled to a cost of Rs. 2,500/- payable by the complainant, within 45 days from the date of receipt of a copy of this Order.  

            Pronounced in open court on this the 2^nd  day of September,  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 – Copy of common proposal form dated 11/1/2018 (incomplete)

Ext.A2  -  Copy of policy schedule along with communication     

Ext.A3 –  Copy of trans Thorasic Echo Report dtd.28/11/2011

Ext.A4 –  Copy of Eco Cardiogram Report dated 2/9/2017

Ext.A5  –  Copy of Coronary Angiogram Report dated 12/3/2018

Ext.A6 –  Copy of Discharge bill dated 16/3/2018

Ext.A7 –  Copy of Tax Invoice dated 14/3/2018

Ext.A8 –  Copy of Discharge summary dated 16/3/18

Ext.A9 –  Copy of request letter for supporting document dated 18/6/2018

Ext.A10 – Original repudiation letter dated 3/7/2018

  Exhibits marked on the side of the opposite party

Ext.B1 –  Copy of common proposal form dated 11/1/2018 (complete)

Ext.B2 –  Same as Ext.A2  

Ext. B3 – Original of Policy Terms and Conditions

Ext.B4 –  Same as Ext.A8

Ext.B5 –  Scanned copy of OP record dated 24/8/2017 of Dist. Hospital, Palakkad

Ext.B6 – Scanned copy of prescriptions dated 24/10/2017 made by Dr.Ranjith R Nambiar

Ext.B7 – Scanned copy of OP record dated 2/11/2017 of Dist. Hospital, Palakkad

Ext.B8 – Copy of Ext.A10

Ext.B9 – Copy of communication dated 7/7/2018 from complainant to OP

Ext.B10 – Copy of receipt dated 9/7/2018  

Ext.B11 – Original Authorisation letter dated 10/5/2019

 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

Cost : Rs.2,500/-   allowed as cost.                      

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.

Forwarded/By Order,   

Assistant Registrar

Fair copy on        :  20/09/2022

Despatched on: