Kerala

StateCommission

A/13/411

STAR HEALTH & ALLIED INSURANCE COMPANY & OTHERS - Complainant(s)

Versus

PATHU K - Opp.Party(s)

LAKSHMANAN T.J

04 May 2016

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL

COMMISSION, VAZHUTHACAUD, THIRUVANANTHAPURAM

 

APPEAL NO.411/2013

JUDGMENT DATED 4/5/2016

  (Appeal filed against the order in CC No307/2011 dt 4/1/2013 on the file of CDRF, Malappuram)

  

PRESENT:

SMT. A. RADHA                                      :         MEMBER

SHRI. K. CHANDRADAS NADAR           :        JUDICIAL MEMBER

APPELLANTS:

1.  Star Health & Allied Insurance Co. Ltd.,

 KRM Centre, 6^th Floor No.2, Harrington Road,

 Chetpet, Chennai-600 031.

 

2.  Star Health & Allied Insurance Co. Ltd.,

Area Office, 1^st Floor, Simax Tower,

West Nadakavu, Calicut-673 011.

 

3.  Sherina, Rep: Star Health & Allied Insurance Co. Ltd.,

 Help Desk, Moulana Hospital,

Ootty Road Perunthalmana.

(By Adv:  Lakshmanan T.J)                    

                        Vs

RESPONDENT:

            Pathu.K., W/o. Muhammed, Polakunnan House,

Thiruvazhamkunne P.O., Mannarkkad, Palakkad District.

(By Adv:   M. Hashim Babu)  

                

JUDGMENT

SMT. A. RADHA  :  MEMBER

          This appeal arises against the order in C.C. No.307/11 on the file of CDRF, Malappuram.  The appellants are the opposite parties and respondent is the complainant.

          2.  The brief facts of the case are that the complainant who is having a Medi Claim Policy with the opposite parties renewed the policy continuously 3 times without break.  The complainant had undergone left knee surgery during the 2^nd renewal period at the Moulana Hospital, Perinthalmanna.  It is stated in the complaint that she had not claimed the expenses since there is no chance to claim insurance amount during the first two renewals of the policy.  On 30/10/2011 during the 3^rd renewal period the complainant had to undergo a knee transplantation surgery at the Moulana Hospital and incurred Rs.1,15,810/-.  The complainant approached for Medi Claim benefit for the expenses of knee surgery which was rejected by the opposite party on the ground of pre-existing disease.    As per the Medi Claim Policy the complainant is entitled for claiming     Rs.1 Lakh towards medical expenses from the opposite parties. This act of the opposite party resulted in financial loss and mental agony against which the complaint is filed to refund the Medi Claim and also for compensation of Rs.50,000/- and cost of proceedings.

          3.  The opposite parties admitted the policy of insurance which was renewed twice and claim was made by the complainant after the 2^nd renewal.    It is also an undisputed fact that the complainant underwent knee surgery at Moulana Hospital.  The complainant already received Rs.6,411/- as Medi Claim for viral fever  on 2/8/2010.  The complainant wilfully suppressed the material fact that she was suffering from knee pain even prior to her taking of the policy.  The complainant had undergone treatment at the Moulana Hospital earlier which was revealed on investigation conducted by the opposite party.  It is contended that Osteo Arthritis (OA) is not an acute    onset disease but a long progressive condition and in the case of the complainant she was well aware that she suffered knee joint pain and had undergone treatment for the same which was not revealed in the proposal form by which the contract of insurance became abinitio void.  There is no deficiency of service on the part of opposite party in rejecting the claim as the nature of disease itself is pre-existing in nature.  Hence the complaint is only to be dismissed.

          4.  The evidence consisted of the proof affidavit of both parties and documents marked as Exbts: A1 to A10 and B1 to B6.

          5.  It is the argument of the counsel for the appellant that the Medi Claim of the respondent was repudiated on the ground that the respondent had undergone a knee surgery in left knee during the 2^nd renewal period of the medi-claim which was suppressed while renewing the policy.      Exbt: B1, the proposal form, filed by the respondent had not disclosed the details of the person proposed for insurance.  In the medical history to the question whether the proposed person been treated “as in patient, mental or physical impairment wherein the respondent gave the answer as ‘Nil’.   The respondent is bound to reveal the status of her health condition at the time of filing the proposal form and in this case the respondent suppressed the material fact that she had pre-existing disease and claimed for the right knee transplantation expenses.  The contract of insurance is based on good faith.  The non-disclosure of ailment by the respondent amounts to wilfull suppression and the repudiation of claim cannot be considered as deficiency of service on the part of opposite parties.  The respondent did not disclose wilfully and fraudulently suppressed that fact vitiating the contract entered into void abinitio.  It is argued that the Osteo Arthritis Grade IV is not an acute onset disease but it is certainly a long progressive condition.  Hence the repudiation of the claim is as per law and the respondent failed to satisfy the requirement to reveal her health status in the proposal forum certainly amounts to suppression of material fact and the order of the forum below is to set-aside. 

          6.  It is submitted by the counsel for the respondent that the respondent was remitting the Medi Claim Insurance continuously from 2009-2010, 2010-2011 and 18/9/2011-17/9/2012 without any break.  It is admitted that during the 2^nd renewal period the respondent had undergone knee surgery at the Moulana Hospital during the policy period.  The counsel pointed out that the respondent had not claimed for that surgery as per the condition the first 2 years the medi claim cannot be availed.  During the 3^rd year the complainant had a knee pain within 1¹/₂ month after renewal of the policy.  The respondent had to undergo right knee transplantation at the Moulana Hospital.  The medical expenses came to Rs.1,20,810/- whereas the respondent claimed Rs.1 Lakh towards the Medi Claim Policy from the opposite parties.  The respondent is entitled for claiming expenses for the operation as the policy was renewing for the       3 years continuously without any break.  On submission of medical bills the appellant repudiated the claim on the ground of pre-existing disease.  The respondent had the knee pain within a short period and is not pre-existing and there had no symptom of knee pain while renewal of the policy or while taking the policy.  The respondent was not aware of the existence of knee pain and there is no suppression of pre-existing disease by the respondent.  Hence the respondent is entitled for the Medi Claim as per the conditions and for the repudiation of the claim respondent prayed for the compensation and cost from the appellants.

          7.  We have heard both the counsels in detail and perused the documents.  The undisputed fact is that the complainant availed Medi claim Policy of the appellants continuously without any break for 3 years.  It is only in the 3^rd slot of the renewal period the respondent claimed                re-imbursement of the medical expenses.  The respondent stated that she had left knee surgery during the 2^nd period.  On going through the documents produced by the appellant as Exbt: B1, the proposal form, does not reveal the details of the operation she had undergone for the left  knee.  The respondent had to reveal the medical details of her operation undergone prior to the right knee transplantation.  The suppression of the operation already undergone itself curtails the principle of contract of insurance.  It is mandatory to fill up the medical history in the proposal form stating the health details which was not done by the respondent.  Hence we are of the considered view that the respondent suppressed the details of operation conducted in her left knee during the 2^nd year of the policy period  and the respondent is not entitled for reimbursement of medical expenses.

          In the result, appeal is allowed setting-aside the order passed by the Forum Below.

The office is directed to send a copy of this order to the Forum Below along with LCR.

 

 

A. RADHA                :              MEMBER

 

 

K. CHANDRADAS NADAR  : JUDICIAL MEMBER

 

 

Sa.

 

 

 

 

 

KERALA STATE CONSUMER                                                                                       DISPUTES REDRESSAL 

COMMISSION,

VAZHUTHACAUD,

THIRUVANANTHAPURAM.

 

 

 

 

APPEAL NO.411/2013

JUDGMENT DATED 4/5/2016

 

 

 

 

Sa.