BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.141/2017

DATED ON THIS THE 25^th May 2018

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT  

                     2) Sri. Devakumar.M.C.                  

                                                B.E., LLB., PGDCLP   - MEMBER

Sri. Devakumar,M.C.

Member

1.     The complainant filed the complaint under section 12 of the C.P.Act 1986, against the opposite parties, alleging deficiency in service and unfair trade practice and seeking a direction to pay the medical expenditure incurred for the treatment of her left eye with such other reliefs.
2.     The complainant submits that, she obtained a Health Insurance policy from opposite party insurance company and paid Rs.5,027/- towards the premium amount.  The policy provided a cashless medical expenses coverage of Rs.3,00,000/- and valid between 30.07.2016 to 29.07.2017.  She submitted a cashless request for cataract operation for her left eye, at Shekar Eye Hospital at Bangalore, under the policy.  The opposite party repudiated the claims under clause 6.1 of the policy terms and conditions. Hence, the aggrieved filed the complaint seeking reliefs.
3.     The opposite parties filed the version and denied the allegations as false.  The insurance policy was issued based on the information furnished in the proposal form and with utmost good faith.  On receipt of the cashless facility request for the planned hospitalization on 18.10.2016, at Shekar Hospital, Bangalroe for cataract operation for an estimation of Rs.44,000/-, with documents, on verification found that, the complainant was suffering from decreased vision prior to inception of the policy. Hence, cashless request for hospitalization has been repudiated as per policy terms and conditions, for non-disclosure of the pre-existing diseases. Further, the removal of cataract was excluded for a specific period of 24 months from the date of inception of the policy.  The complainant sought for cashless request within 3 months from the date of issuance of the policy.  Thereby, the cashless request is denied and pleads there is not deficiency in service on their part.  As such, prays for dismissal of the complaint.
4.     To prove the facts, both side parties led evidence by filing affidavit and relied on several documents.  The opposite party relied on several judgements rendered by Hon’ble Supreme Court and Hon’ble National Commission.  The opposite party filed written arguments and heard the respective counsels.  Perused the material on record and posted the matter for orders.
5.       The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service and unfair trade practice for not providing the cashless request for hospitalization expenses under the health insurance policy obtained by her, thereby she is entitled for the reliefs claimed?
2. What Order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :-  In the negative

Point No.2:- As per final order

:: R E A S O N S ::

7.    Point No.1:- The complainant took an health insurance policy from opposite party No.1 company through its branch office at Mysuru (opposite party No.2), by submitting a duly filled proposal form with a declaration and premium amount of Rs.5,027/-.  The insurance policy was valid between 30.07.2016 to 29.07.2017 (i.e. for one year) and provides coverage for a sum of Rs.3,00,000/-.
8.    The complainant requested for a cashless hospitalization facility for the cataract operation of her left eye on 13.10.2016, by submitting the doctor’s estimation of Rs.44,000/- for the operation at Shekar’s Eye Hospital, at Bangalore.
9.    The opposite party, on verification of the documents submitted by the complainant found that, she was suffering from decreased vision of her left eye, prior to inception of the policy, which was not disclosed in the proposal form.  Further, the cataract operation was excluded under clause 4.1 (b)(i)(iv) of the policy terms and conditions, for a period of 24 months, from the date of inception of the policy and informed the complainant that, the claim is not covered and the complainant is not entitled for the benefits under the policy.  Agitating the contention of the opposite party, the aggrieved complainant filed the complaint.  Later, the complainant undergone cataract operation at Shekar Eye Hospital, Bangalore and incurred a sum of Rs.1,39,215.50 and the same is claimed under policy by submitting all the documents.
10. The opposite party contended that, the complainant concealed the known material facts and obtained the insurance policy.  The opposite party issued the policy with utmost good faith on the basis of the information furnished in the proposal form.
11. The documents submitted, revealed that, the complainant was suffered with vision problems on her left eye, prior to inception of the policy and concealing the treatment availed, the policy has been obtained.  As per clause 4.1 (b)(i)(iv) of the “Exclusion” the cataract operation was not covered for a period of 24 months from the date of inception of the policy.  As such, intimated the rejection of the request vide letter dated 28.03.2017.
12. Further, contended that, under clause 6.1 of the policy terms and conditions, the policy holder is not entitled for any benefits under the policy for suppression of known material facts.  Even on that ground also the complainant is not entitled for any benefit under the policy.  The policy was issued with free look period option, in case the insured was not satisfied with the terms and conditions, then the same would have been returned to the insured, but the complainant remained silent without raising any objections. Therefore, the allegations are denied and prayed for dismissal of the complaint with costs.
13. The opposite party relied on several decision rendered by the Hon’ble Supreme Court and Hon’ble National Commission, wherein it is held that, any suppression of all known material facts, leads the contract of insurance as void abinitio. In view of the same, the opposite party’s contention of repudiation of claim under the provision of health insurance policy for suppression, is justified.  Thereby, the complainant is not entitled for any reliefs sought.  Therefore, we opine that the complaint is liable to be dismissed.  Accordingly, the point No.1 is answered in the negative.    
14. Point No.2:- With the above discussion in point No.1, the complaint filed by the complainant is hereby liable to be dismissed, without cost. Hence, the following order:-

:: O R D E R ::

1. The complaint is hereby dismissed.
2. Give the copies of this order to the parties, as per Rules.