Kerala

StateCommission

A/15/610

MANAGER HEALTH INSURANCE LIC OF INDIA - Complainant(s)

Versus

SAROJINI V P - Opp.Party(s)

ANITHA AJI

31 Mar 2017

ORDER

KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION SISUVIHARLANE VAZHUTHACADU THIRUVANANTHAPURAM

 

APPEAL NO. 610/2015

JUDGMENT DATED: 31/03/2017

 

(Appeal filed against the order in CC.No.204/2 on the file of CDRF, Kannur order dated : 20.06.2015)

 

PRESENT

 

SRI.K.CHANDRADAS NADAR   : JUDICIAL MEMBER

SRI.V.V.JOSE                          : MEMBER

 

APPELLANT

 

The Manager,

Health Insurance , LIC of India,

Divisional Office, Kozhikkode – 673 001

Rep.by authorized Officer,

The Manager,

L& HPF LIC of India,

Divisional Office, Thiruvananthapuram

 

(By Adv.Smt.Anitha Aji)

 

Vs

 

 

RESPONDENT

 

V.P.Sarojini,

W/o.V.K.Gopalakrishnan,

Vannadil Puthiyaveettil

Thayaneri,

Payynnur, Kannur District

Pin – 670 307

 

 

JUDGMENT

 

SHRI.V.V. JOSE       : MEMBER

        This appeal is filed under section 15 of the Consumer Protection Act, 1986 by the opposite party in CC 204/2013 dated 20/06/2015 on the file of CDRF, Kannur, directing the appellant / opposite party to pay Rs.1,25,700/- along with a compensation of Rs.10,000/- and a cost of Rs.2,000/-

        2.     The facts of the case is as follows:

        3.     The complainant availed a health insurance policy from the opposite party on 31/03/2008 for a total sum of Rs.2,00,000/- and payed the premium regularly and an amount of Rs.30,000/- was paid by her.  Complainant has undergone a surgery in August, 2012 and applied for the benefit of the policy which was rejected which caused severe mental agony as it is a deficiency from the side of opposite party and hence this complaint.

4.     Opposite party filed version contending the policy was lapsed due to non - payment of premium on 31/03/2013.  The proposal form was submitted by the complainant with a negative answer to the question related to the health details and medical information.  The third party administrator has processed the admissibility of the claim and the claim was rejected after an enquiry for the reason of pre-existing illness.  Complainant was taking treatment for Diabetic Mellitus for last ten years and hypertension for last 6 – 8 years.  This was not disclosed in the proposal form, if it was disclosed the proposal would have been rejected at the initial stage itself.  Due to misrepresentation about the material facts, the claim was rejected and it will not be any deficiency in service as alleged in the complaint.  Hence prayed for a dismissal.

        5.     The lower forum raised the following issues for consideration:

        Is there any deficiency in service which entitle the complainant for any remedy, if so the relief and cost entitled.

        6.     The evidence in this case is the oral testimony of PW1, the husband of the complainant and DW1 the manager of the opposite party and DW2 the doctor and B1 – B6 are the documents marked by opposite party.  No dispute regarding the health insurance policy.  Even though the policy was lapsed, it was in existence at the time of applying the claim. Only after rejection of the claim the policy premium was not remitted that is why it was lapsed.  Rejected the claim due to false information and suppression of facts that complainant was having Diabetic Mellitus and Hypertension for the past several years.  Ext. B1 the proposal form was filled by the complainant as she deposed.  And she has answered “no” to the question in Column ‘E’ in the proposal form.  She further deposed that she furnished a fitness certificate as required by LIC and the same was confirmed by DW1 while cross examined and he further stated that the document was given by a doctor in their panel.  So it can be assumed that policy was issued after perusing the certificate.   But the said medical certificate was not produced before the forum.  So no justification in repudiating the claim stating complainant has suppressed her illness.  The counsel of the opposite party vehemently argued suppression of material facts makes the policy contract void and the doctor was also examined to prove the complainant was having past history of illness.  Production of fitness certificate issued by a doctor in the panel of the company gives the benefit to the case of the complainant, as it is given after medical checkup.  So the repudiation is not justified and it amounts deficiency of service from the part of opposite party.  The allegation of the opposite party of previous illness will not stand.  The Forum below found the issues of deficiency in favour of the complainant and against opposite party, so complainant is entitled for remedy.  The surgery undergone comes under the purview of major surgical benefits.  As per Ext.B2 complainant is eligible for 100% of the sum assured.  At the time of treatment the policy was alive and in force. So the allegation of policy lapse due to non - payment of premium has no locus standi.  The Forum found that the complainant is eligible for entitlement of the claim as per Ext. B5 Rs.1,25,700/- and ordered accordingly.

        7.     Aggrieved by the above order the opposite party preferred this appeal on various grounds.  They allege that the order of Lower Forum is against the fact and law and not perused the policy of insurance (Ext.B1).  To them the Lower Forum failed to appreciate the point of view of the appellant in version, affidavit and argument note.  The proposal form is prepared by PW1, the husband of the complainant.  She suppressed the fact, she was under treatment for high blood pressure and diabetics.  Deposition of DW2 states that the complainant is having the above illness of diabetics for last ten years and hypertension for 6 to 8 years.  The Lower Forum did not considered the above facts as per Ext.B1.  The assumption of the Forum that the medical certificate was issued after carrying out clinical and laboratory test is wrong.  The Lower Forum failed to see the correct legal position and allowed the complainant’s claim.  The contract will be null and void if the proposer is giving a false disclosure of facts regarding the health condition.  Here in this case the complainant did not produce any single paper to substantiate her claim which is highly irregular.

        8.     Heard.  The lower court records perused.

9.    It is admitted that the complainant is policy holder of LIC health plus plan (table 901).  The case of the complainant is that she is a policy holder since 31/3/2008 based on the proposal form dated 8/3/2008 given by her.  The policy is valid for 14 years and therefore expiring on 31/3/2022.  The instalment of premium is Rs.6,000/- and benefits under the policy includes initial daily cash benefits of Rs.1,000/- and major surgical benefits of Rs.2,00,000/-.  The case of the complainant is that she regularly remitted the instalment premium since the inception and during the month of August, 2012 she has undergone a surgery in the Kasthurba Medical College Hospital, Mangalore.  Her date of admission was 10/8/2012 and date of discharge was 21/08/2012.  She has claimed the major surgical benefits of Rs.2,00,000/- and same was repudiated by the insurer / opposite party on 11/01/2013 stating that the cause of surgery was due to the reason of pre-existing decease and the complainant suppressed the health status while taking the policy.  The complaint was allowed by the Lower Forum partly by granting a relief of Rs.1,25,700/- being the amount claimed by her and refused by insurer as per B5 document.

        10.   The complainant was assisted by her husband from the day on while issuing the insurance proposal form till the filing of complaint and adducing of evidence.  He was examined as PW1.  No documents were produced by complainant.  However all her statements regarding the policy were admitted by the opposite party (without admitting the claim), no burden is conferred on complainant to prove the admitted facts.

        11.   The main question for consideration for this complaint and appeal is whether the denial of major surgical benefits as per the policy by the opposite party is justifiable or not.

        12. Admittedly, the opposite party has produced the relevant documents and got marked as Exts. B1 to B6. The Manager of the opposite party was examined as DW1 and the doctor who treated and issued B3 and B4 documents was examined as DW2. The appellant is repeatedly trying to impress that the complainants claims are based on pre existing disease and suppression of health status mentioned in proposal form and medical reports are contradictory.

        13.   We have gone through the records and got classified from the counsel of the appellant. B1 is the proposal form. B2 is the policy.B3 & B4 are the medical records. B5 & B6 are the repudiation letters from the opposite party. From B5 & B6, it is observed that the denial of benefits under the policy is due to the reasons stated as above. The policy was taken on 31.03.2008. The installment premium was paid by the complainant upto the period ending on 31.03.2003 as the same is not disputed by the opposite party. Opposite party has no case that the complainant has availed of during 2012-2013 as the same is not disputed by the opposite party. Opposite party has no case that the complainant has availed of during 2012-2013 or during earlier period. It is not disputed that the policy was issued by the opposite party without any medical examination and certification by a doctor authorized or appointed by the opposite party insurance company. The nature of such examination or clinical tests are not brought to our consideration. The medical examination done at the time of issuing the policy by the doctor appointed by the opposite party is not seen by us though the opposite party would say that the said certificate is issued without any clinical examination. We are unable to accept this, as the medical check up before admitting the insurance scheme is intended with some purpose without any test. What is the scope of a medical examination and issuance of certificate is not answered by the appellant. It is not a mechanical process. The non production of certificate leads us to take adverse inference. On that score appellant fails.

        14.   There is another reason also supporting the claims of the complainant. As per the B2 policy clause 4 which reads as there shall be a waiting period of 180 days from the date of cover commencement and 90 days from the date of revival in respect of each insured during which no hospital cash benefit and no major surgical benefits shall be payable in the event of hospitalization and surgery, if the said hospitalization and surgery occurred due to sickness. Here in this case the policy was commenced on 31.03.2008. The same was not lapsed or reinstated. As per this clause, had the complainant undergone hospitalization or surgery occurred due to sickness, she is not entitled to the benefits of the policy. Here, the complainant was covered by the policy for last five years. So the clause above does not apply in the case of complainant to repudiate the claim as done by the opposite party/ appellant. Even assuming the complainant had the problem of hypertension and disbelieves prior to the commencement of the policy, any sickness arising out of it will disentitle the complaint for claim only for a period of 180 days and not there after. We are not impressed by the arguments or contentions of the appellant to interfere in the order of the Lower Forum and hence we don’t interfere. There are no factual or legal reasons to interfere in the order of the Lower Forum. Appeal lacks merits. Hence we are inclined to dismiss the appeal upholding the order of the Lower Forum.

        In the result, the appeal is dismissed and the order of the Lower Forum is upheld directing the appellants to pay Rs.1,25,700/- towards policy claim and compensation of Rs.10,0000/- and a cost of Rs.2000/- to the complainant within one month from the date of receipt of this order. In the circumstances no cost is ordered.

 

        V.V.JOSE : MEMBER

 

K.CHANDRADAS NADAR : JUDICIAL MEMBER

       

Be/

 

 

 

 

 

 

 

 

 

KERALA STATE

CONSUMER DISPUTES

REDRESSAL COMMISSION

 SISUVIHARLANE

VAZHUTHACADU

 THIRUVANANTHAPURAM

 

APPEAL NO. 610/2015

JUDGMENT DATED: 31/03/2017

 

                                                                             Be/