O R D E R.

By Sri.  A.S. Subhagan,  Member:-

          This is a complaint filed under section 12 of the Consumer Protection Act 1986.

          2. Facts of the complaint in brief:-  The Opposite Parties  are engaged in the service of Medical Insurance and the Complainant is the wife of  deceased  John M.C who was a Health Insurance Policy Holder of the Opposite Party in Policy No.10643599.  The deceased had joined in the policy in the year 2016 through  the scheme for  Kosamattam Finance  customer,  which was subsequently renewed in the year 2017  with the coverage from 31.05.2017  to 30.05.2018.  During the validity period of the policy,  on 15.06.2017,  the deceased had been admitted  DM WIMS,  Wayanad  since he was suffering from  upper back pain from the last seven days and on 18.06.2017  he was referred to Aster MIMS,  Kozhikode for  further  management and discharged from there on 23.06.2017  and considering the seriousness of the illness he was sent back to WIMS Hospital, Wayanad for supportive care from where he was succumbed to death on 26.06.2017.  Approximately an amount of Rs.2,40,000/- had been  incurred for treatment expenses and the claim forwarded by the Complainant was repudiated by the Opposite Party on the grounds (1)  Non disclosure of Hypertension (2) Non disclosure of Material Facts/ Pre-Existing Ailment at the time of proposal with its letter dated 01.08.2017 and  that  too in the name of the deceased.  Since the repudiation was on baseless grounds,  the Complainant contacted the Opposite  Parties   but they repeated the same ground.  The Complainant says that the Opposite Parties have applied unfair trade practice and cheated the Complainant.  They,  willfully with a malafide motive not to discharge their liability to pay the amount under the policy,  repudiated the claim  which is against the terms and conditions of the policy.  The Complainant is entitled to get the amount of Rs.2,40,000/-  being the treatment expenses along with cost and compensation for the mental and physical hardships undergone by the Complainant.  Hence,  the Complainant has approached this commission with this complaint with the following prayers:-

1.  To direct the Opposite Parties to pay  Rs.2,40,000/-  to the Complainant being the medical expenses incurred.
2. To direct the Opposite Parties to pay Rs.50,000/-  as compensation for physical and mental agony caused to the Complainant due to the deficiency of service of  both the Opposite Parties.
3. To direct the Opposite Parties to pay the cost of the this complaint and
4. To grant such other or further relief to which the petitioner may pray for and this commission deems fit to grant.

3. The Commission registered a case in respect of the complaint and notices

were issued   on the Opposite Parties.  The Opposite Parties entered appearance and independent versions were filed.  Chief affidavit was filed by the Complainant and Exts.A1 to A5 and X1 series  were marked  from his side and he was examined  as PW1.  The Medical Records Officer  of WIMS Hospital was examined as PW2 and Exts.X2 and X3 series were marked from his side.  Smt. Soumya John, the daughter of the deceased was examined as PW3 from the side of the Complainant.  1^st  Opposite Party had no evidence  and 2^nd  Opposite Party  was examined as OPW1. 

          4.  Brief  contents of version filed  by the Opposite Party No.1:-    The insured was covered  under a Group Insurance Policy No.10496361 issued to Kosamattam Finance Limited  to  its eligible customers.  For that a certificate of insurance bearing  No.10643599 was issued with effect from 05.05.2016  to 04.05.2017 subject to policy terms and conditions for a sum assured for Rs.2,00,000/-.  The said policy was further renewed till 30.05.2018.  On the ground  of this policy the insured  approached the Opposite Party with a cashless facility request for an expected amount of Rs.30,000/-.  As per the Physicians Progress Record of Aster Malabar Institute of Medical Science dated 20.06.2017  and 22.06.2017,  the Complainant is mentioned to be a known case of Diabetes and Hypertension and Chronic Liver Disease with Portal Hypertension with spontaneous  bacterial peritonitis.  As per the discharge summary of the  DM WIMS  dated 18.06.2017  the insured  is mentioned to have Chronic Liver Disease with Portal Hypertension,  Jaundice, Moderate Ascitis with SBP and as per  the discharge summary of Aster Malabar Institute of Medical Science dated 23.06.2017,   the insured is mentioned to be diagnosed with chronic liver disease,  cirrhosis of Liver, Diabetic Millets  and Hypertension.  As per the consultation follow up reference note of DM WIMS dated 16.06.2017  the insured  is duly mentioned to have a history  of Alcohol  Related Chronic Liver Disease since ‘2’ years,  that is before the inception of the  policy period and is on the medication of tab Rifagut  and Udiliv  for the same.  It is  also mentioned  that the insured  has stopped consuming  Alcohol, only  one and a half year back.  As per the statement by the daughter of the insured,  Soumya John,  dated 23.06.2017   it is mentioned that the insured had  high BP before ‘3’ years  that is before the inception of the policy period.  According to her the insured was previously admitted in DM WIMS for the same  ailment and was referred to Aster WIMS.  As per the statement by the Chief Consultant,  Dr. Anish Kumar,  dated 23.06.2017,  the patient is duly mentioned to be a known case of Hypertension and Diabetic  and Chronic Liver Disease.  Therefore,  in the light of the fact that the insured is a known case of Hypertension  since three years and has alcohol related chronic liver disease, both the periods are before the inception of the policy period and the same was  not disclosed to the Opposite Party by the insured at the time of proposal and hence the cashless claim of the Complainant was duly denied  by the Opposite Party for non-disclosure of material facts vide clause 5.2 of the  policy terms and conditions and the same was  intimated to the  insured vide letter dated 23.06.2017.  On the basis of the same ground the claim of the insured for a billed  amount  of Rs.1,30,142/- for  treatment  in Aster MIMS with effect from 18.06.2017  to 23.06.2017  was also rejected.  On the ground of the non disclosure of  material facts at the time of submitting  the proposal form,  the Opposite Party had forwarded a copy of the notice of cancellation of the policy to the insured.   Opposite party denied all other allegations of the Complainant.   The Opposite Party submits that the complaint is not legally maintainable and hence to be dismissed with heavy cost.

          5.  Brief contents of version filed by  2^nd  Opposite Party:-  The Complainant is not coming under the purview  of the Consumer Protection Act 1986.  The 2^nd  Opposite Party is not a necessary party to the complaint.  The 2^nd  Opposite party has not played any unfair trade practice towards the Complainant.  The 2^nd  Opposite party is only an agent of the 1^st  Opposite Party and has no knowledge as to the payment or non-payment of insurance claim to the consumers.  If the Complainant has  any eligibility to get insurance claim it is to be paid by the  1^st  Opposite Party and the 2^nd  Opposite Party is not liable to pay the amount.  Hence it is prayed to dismiss the complaint with compensatory cost of the  2^nd   Opposite party.   

          6. Considering the complaint,  versions, affidavit, documents marked and the oral evidence adduced by the parties,  the Commission raised  the following points for consideration.

1.  Whether there has been any deficiency in service or unfair trade  practice from the side of the Opposite parties?
2. If so whether the Opposite parties are liable to pay compensation to the Complainant?
3. If so whether the Opposite Party is liable to pay cost of the complaint and any other relief  as prayed for?

7. Point No.1:-   It is  the admitted fact  that  the  insured was covered under a

Group Insurance Policy  No.10496361 issued to Kosamattam  Finance  Ltd.  To  its eligible customers.  It was further renewed  up to  30.05.2018.  The main allegation of the Complainant is that the insured was expired on 26.06.2017,  but the insurance claim preferred by the Complainant was repudiated by the  2^nd  Opposite Party on the following grounds (1)  non disclosure of  Hypertension (2) non disclosure of Material Facts/ Pre-Existing Ailment at the time of proposal of the insurance policy which is deficiency in service and unfair trade practice.  The contention of the 1^st  Opposite Party is that the Complainant violated the policy terms and conditions by non disclosure of material facts as to Pre-Existing Diseases such as hypertension,  high blood  pressure ,  liver disease etc.  On  an intensive perusal of the documents marked as X1 series (consultation/ Follow up reference-Clinical Notes) it is recorded by DM WIMS that the patient had alcohol related liver disease since two years.  X3 series of  documents marked  reveals the final diagnosis as LRTI,  Thrombocytopenia, Alcohol withdrawal etc., On going  through  the online proposal form it is  seen that these Pre-Existing Diseases were not disclosed by the insured at the time of  submission of online proposal form of insurance which is against the terms and conditions of the policy.  Therefore we find that 1^st  Opposite Party has repudiated the claim of the Complainant on the  basis of the non-disclosure of the Pre-Existing  Disease which was a condition precedent  for being a member of the Group Insurance Policy.  Here,  the insured had not disclosed the Pre-Existing Diseases. So there has been no deficiency  in service or unfair trade practice  from the part of the Opposite Parties and therefore point No.1 is proved  against the Complainant.

8. Point No.2:-  As  point No.1 is  proved against the Complainant,  he has

no right to get compensation.

9. Point No.3:-  As point No.1 and 2 are proved against the Complainant she

has no right to get cost of the complaint.

In the result,  the complaint is dismissed without cost.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the  30^th  day of April 2022.

Date of filing:31.10.2017.

                                                                    PRESIDENT:  Sd/-

                                                                    MEMBER   :   Sd/-

                                                                    MEMBER    :  Sd/-

APPENDIX.

Witness for the complainant:

PW1.           Gracy.                             Complainant.

PW2.          Shivaprakash.                 M.R.O,  WIMS Hospital, Meppadi.

PW3.          Soumya John.                Nurse.

Witness for the Opposite Parties:

OPW1.        Regal Baby.                    Manager,  Kosamattam Finance.

Exhibits for the complainant:

A1.             Copy of Policy.                       

A2.             Copy of Discharge Summary.  

A3.             Copy of Claim Rejection Letter.              dt:01.08.2017.

A4.             Death Summary.                               

A5.             Copy of Family Membership Certificate. dt:27.09.2017.

X1 series.    Documents  produced by 1^st  Opposite Party.

X2 Series.   In-Patient Record

X3 series.    In-Patient Record

Exhibits for the Opposite Parties:

Nil.