IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Thursday the 31st day of December, 2015
Filed on 06.12.2014
Present
- Smt. Elizabeth George (President)
- Sri. Xavier Antony (Member)
- Smt.Jasmine.D. (Member)
in
C.C.No.330/2014
between
Complainant:- Opposite Parties:-
Sri. Thomas Mathew 1. M/s. AEGON Religare Life Insurance
Peedikayil House Co. Ltd., Third Floor, Unit No. 1
Kunnam Post, Thazhakkara Village Nesco, IT Park, Express Highway
Mavelikara – 690 108 Gargaon, Mumbai – 400 076
(By Adv. C.K. Thomas)
2. The Territory Manager, M/s. AEGON
Religare Life Insurance Co. Ltd.
Unit No.65, Syda – Building, Kaloor
Kadavanthra Road, Ernakulam
(By Adv. Chandralekha P.T. – for
Opposite parties 1 and 2)
3. M/s. Muthoot Wealth Management
Services, Second Floor, Cochin Dental
Clinic Building, Near High Court
Cochin – 682 018, represented by
Manager (By Adv. Chandralekha P.T. –
for opposite parties 1 and 2)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant is a retired employee living at his native place Kunnam in Mavelikara. Believing the representation made by the opposite parties, complainant agreed to take a Health Insurance Policy for self and wife and gave a proposal. The benefit to the insured was among other things, linked to the premium amount under category Silver. The complainant issued a cheque bearing No. 005986 dated 22.3.2011 for Rs.34,705/- drawn on Alleppey District Co-operative Bank Ltd., Mankamkuzhy, Mavelikara towards first annual premium. As a pre-condition for issuing the health policy, the complainant and his wife underwent a medical examination on 31.3.2011 at Philip Memorial Hospital, Mavelikara as arranged by the opposite parties. Thereafter, in due course, the first opposite party sent to the complainant a Health Insurance policy bearing No. 611030047962 valid for the period from 12.4.2011 to 11.4.2012 and accepted by him. Surprisingly, the policy document is in microscopic print which cannot be conveniently read and when this was pointed out to the opposite parties, they assured the complainant about their integrity and prompt payment. In the circumstances, for the second year also, the policy was renewed on the same terms and conditions, valid from 12.4.2012 to 11.4.2013 on annual premium of Rs.34,705/- which was also duly paid in advance by the complainant by cheque No.080781 dated 9.4.2012 drawn on the Federal Bank, Mavelikara Branch. In the month of May, 2012 as he started feeling discomfort from a swelling in the mouth, he consulted doctor in Pushpagiri Hospital, Thiruvalla. There the swelling was removed by surgery and sample of the tissue was sent for biopsy. He was under hospitalized treatment in the said hospital from 30.5.2012 to 12.6.2012. Pending receipt of report of hystopathological examination (biopsy), the complainant forwarded on 30.6.2012 a claim with all original documents as prescribed for reimbursement for the said treatment. In the meanwhile, the result of the biopsy was received which was found positive and he had to undergo hospitalized radiological treatment for cancer in Amrutha Hospital, Ernakulam. In the said hospital, he underwent treatment from 13.8.2012 to 21.9.2012 (40 days) but no claim was then made as the opposite party told that it should be submitted only after the earlier claim is cleared. As nothing was heard from the opposite party, complainant had to enter into continuous correspondence with the opposite party. On 20.12.2012 he received a letter dated 14.12.2012 from the first opposite party stating that his claim stood rejected. Thereafter complainant sent letters to the first opposite party seeking reconsideration and payment, but opposite parties have not cared to look into the matter. Hence the complaint is filed seeking the following reliefs:-
- Directing the opposite parties to pay to the complainant an amount of Rs.3,98,200/- towards the amount due under insurance.
- Directing the opposite parties to pay to the complainant an amount of Rs.1,40,594/- towards interest till date.
- Granting further interest till payment.
- Allowing the costs of the complaint.
- Granting such other relief or reliefs which this Hon’ble Forum may be pleased to grant in the circumstances of the case.
2. The version of the opposite parties 1 and 2 is as follows:-
Complaint is not maintainable. The Forum has no jurisdiction to entertain the complaint. The complainant had availed AEGON Religare Health Plan having policy with risk commencing date on 12.4.2011. The opposite party rejected the claim of the complainant as the claim made by him is arising out of pre-existing condition. The discharge summary issued by the Pushpagiri Hospital, Thiruvalla states that complainant had a history of clinical diagnosis of irritation fibroma and extraction of 20 years back symptom fee swelling since then, which mildly regressed. Complainant was duty bound to disclose all the material facts having a bearing on the insurability of complainant and risk to be covered by the opposite parties 1 and 2. The complainant had signed the declaration clause of the proposal form declaring the information mentioned therein is true and correct, though the complainant had knowledge that he had given incorrect information. The opposite parties 1 and 2 crave leave to refer to the declaration clause of the proposal form. There is no deficiency in service on the part of the opposite parties.
3. Notice issued against the third opposite party served, but did not turn up. Hence third opposite party was set ex-parte.
4. Complainant was examined as PW1. The documents produced were marked as Exts.A1 to A21. The first opposite party was examined as RW1. The documents produced were marked as Exts.B1 to B7. Ext.B6 marked subject to objection.
5. The points that arose for consideration are as follows:-
- Whether the complaint is maintainable?
- Whether there is any deficiency in service on the side of the opposite parties?
- If so the reliefs and costs?
6. Point No.1:- According to the opposite parties no cause of action arose within the jurisdiction of this Forum and hence this Forum has no territorial jurisdiction to entertain this complaint. As per Ext.A1 Folio 14 the comprehensive medical checkup of the complainant was conducted at Philip Memorial Hospital and the premiums of the policy were paid by the cheque drawn on bank at Mavelikara. According to the complainant, he issued a cheque bearing No.005986 dated 22.3.2011 for Rs.34,705/- drawn on Alappuzha District Co-operataive Bank Ltd., Mankamkuzhy, Mavelikara towards first annual premium. It was not denied by the opposite parties. Hence we are of opinion that a part of cause of action took place at Mavelikara within the terrorial jurisdiction of this Forum. Hence the complaint is maintainable.
7. Point No.2:- It is an admitted fact that the first opposite party had issued a Health Insurance Policy for the period from 12.4.2011 to 11.4.2012 under category silver to the complainant. It is also an admitted fact that the policy was renewed from 12.4.2012 to 11.4.2013. According to the complainant he underwent surgery and treatment in Pushpagiri Hospital, Thiruvalla including inpatient treatment from 30.5.2012 to 12.6.2012 for a swelling in the mouth which was diagnosed as cancerous. Thereafter complainant submitted a claim dated 15.6.2012 to the first opposite party for insurance benefits. After a continuous follow-up by the complainant he got a letter dated 20.12.2013 from the first opposite party repudiating his claim. According to the opposite parties, the claim made by the complainant is arising out of pre-existing condition which is specifically excluded from the ambit of payment coverage. According to the complainant he was having small swelling in mouth and a tooth was removed 20 years ago, and there was no further problem and he was not at all suffering from any ailment at the time of making the proposal. There is no documents produced by the opposite parties to prove that the complainant is suffering from any ailment at the time of making the proposal. More over if the complainant was having a small swelling in the mouth about 20 years ago whether that swelling amounts to cancerous is not proved by the opposite party. Both parties produced the discharge summary dated 29.6.2012 issued by the Pushpagiri Medical College Hospital, Thiruvalla. On verifying it, under the title clinical history and findings it is stated that, “C/O pain swelling in left lower jaw (retro-molar region) of 6 months duration. H/O clinical diagnosis of irritation fibroma and extraction of 38, twenty years back symptom free swelling since then which mildly regressed. Incisional biopsy was done in Dental OPD on 28.4.2012.” It would show that the said swelling remained symptom free for 20 years and incisional biopsy done on 28.4.2012. Apart from that prior to the issuance of policy the complainant underwent a detailed medical examination arranged by the insurer on 31.3.2011 and that report is negative as to any disease. The said report is produced and marked as Ext.A1 series (14). Moreover in Ext.A5 health claim form under title ailment details (as diagnosed) the endorsement of the hospital shows that the illness was first detected on 10.5.2012 and symptoms “nodule six months duration.” It is an admitted fact that the complainant had made the proposal on 20.3.2011 as per Ext.B5. Policy was issued after a medical examination of the complainant in which no abnormality was found. The opposite party did not produce any evidence to prove that the complainant was having knowledge that he was suffering from cancer. When the complainant was not in the know about his ailment, he was not supposed to disclose the fact in proposal form. Moreover no evidence on record to prove that after the swelling that occurred before 20 years back complainant was suffering from recurrence of disease and took treatment. Hence the suppression of pre-existing disease is not established. So the contention of the opposite party that the complainant was suffering from cancer as a pre-existing disease and he had taken the policy suppressing the disease is not proved and hence it is not sustainable. The repudiation of the claim of the complainant by the opposite party amounts to deficiency in service.
8. Point No.3:- According to the complainant as per the policy conditions, he is entitled to receive payments as follows:-
A. For hospitalized treatment in Pushpagiri Hospital, Thiruvalla:-
Sl. No. Head of claim Policy Ref: (Ext.A1) Amount(Rs.)
- Daily Hospitalization Cash benefit @ Rs.2200/-
Per day for 14 days from 30.5.2012 to 12.6.12 Para 3 I & 5.3 30,800/-
(ref. Ext.A5) including no claim bonus
ii. Intensive Care Unit benefit @ Rs.2200/- per
day for 2 days from 30.5.12 to 31.5.12 Para 3.2 & 5.3 4,400/-
iii. Surgical Cash Benefit-lumpsum *read with
procedure No.624 of list of surgeries notified Para 3.3* & 5.3 2,20,000/-
by OP1(Ext.A9)
Total i to iii 2,55,200/-
B. In Amrutha Hospital, Ernakulam for treatment of cancer:-
Sl. No. Head of claim Policy Ref: Amount(Rs.)
i Daily hospitalization Cash benefit @ Rs.2200/-
per day from 13.8.12 to 21.9.12 (40 days) Para 2.i & 5.3 88,000/-
(Ext.A6 p.3)including no-claims bonus
- Critical illness Benefit-lumpsum Para 3.4 & 5.3 55,000/-
Total 1,43,000/-
Sub Total C = (A + B) 3,98,200/-
with interest.
The complainant by producing the relevant documents which are marked as exhibits in this case has proved to the satisfaction of this Forum that he is entitled to claim the amount of Rs.3,98,200/- along with future interest.
In the result, the opposite parties are directed to work out the claim of the complainant treating him eligible for the claim as per the terms of the policy and to pay the sum so arrived along with 9% interest per annum from the date of complaint till its realization and to pay an amount of Rs.2000/- (Rupees two thousand only) towards costs of this proceedings. The order shall be complied within complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected by me and
pronounced in open Forum on this the 31st day of December, 2015.
Sd/- Smt.Elizabeth George (President) :
Sd/- Sri. Antony Xavier (Member) :
Sd/- Smt.Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Thomas Mathew (Witness)
Ext.A1 - Copy of the advertisement of AEGON RELIGARE life insurance
Ext.A2 - True copy of the discharge summary
Ext.A3 - Copy of the bill details of Pushpagiri Hospital, Thiruvalla
Ext.A4 series - Copy of the bills (16 Nos.) of Pushpagiri Hospital, Thiruvalla
Ext.A5 - Copy of the Health Claim Form
Ext.A6 - Draft copy of Radiation Oncology Treatment Summary
Ext.A7 - Copy of the bill details of Amrutha Institute of Medical Science
Ext.A8 series - Copy of the bills (9 Nos.) of Amrutha Institute of Medical Science
Ext.A9 series - Copy of the Aegon Religare Policy details (43 pages)
Ext.A10 - Copy of the letter dated 24.9.2012 sent by complainant to OP1
Ext.A11 - Copy of the receipt dated 24.9.12 issued by Professional Couriers
Ext.A12 - Copy of the letter dated 14.12.12
Ext.A13 - Copy of the letter dated 26.12.12 from complainant to OP1
Ext.A14 - Copy of the letter dated 18.3.14 sent by complainant to OP1 with copy
to OP3
Ext.A15 - Copy of the letter dated 31.3.2014 sent by third opposite party to
Complainant
Ext.A16 - Copy of the letter dated 3.4.2014 sent by complainant to third OP
Ext.A17 - Copy of the postal receipt dated 3.4.14 issued to complainant
Ext.A18 - Original visiting card of Jijo Koshy, Asst. Manager of third opposite party
Ext.A19 - Original visiting card of Rajan P. Varghese, Manager of third OP
Ext.A20 - Copy of the representation sent by complainant to Ombudsman dated
24.1.2015
Ext.A21 - Copy of the postal acknowledgement dated 29.1.15 issued to complainant
Evidence of the opposite parties:-
RW1 - Santosh Nair (Witness)
Ext.B1 - Copy of the health claim form
Ext.B2 - Copy of the Standard policy
Ext.B3 - Copy of the discharge summary
Ext.B4 - Copy of the letter dated 26.12.12
Ext.B5 - Copy of the claim rejection letter dated 20.7.12
Ext.B6 - Copy of the proposal form
Ext.B7 - Authorization letter
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties/S.F.
Typed by:- pr/-
Compared by:-
