IN THE CONSUMER DISPUTES REDRESSAL FORUM KOTTAYAM
Present:
Hon’ble Mr. Bose Augustine, President
Hon’ble Mr. K.N. Radhakrishnan, Member
Hon’ble Mrs. Renu P. Gopalan, Member
C.C. No. 203/12
Monday the 27th day of February, 2017
Complainant : Joseph V.C
Vellookunnel,
Chakkampuzha,
Pala-686 575
(By Adv.RajaGopal Padippurackal)
Vs
Opposite parties : 1) M/s. Star Health & Allied Insurance
Co.Ltd. KRM Centre, VI Floor, No.2,
Harrington Road, Chetpet Chennai-
600 031 Rep.by its General Manager.
2) N. Natarajan,
M/s. Star Health & Allied Insurance
Co.Ltd, Vinayaka Building, M.C.Road
Perumbavoor, 683 542 Rep.by its
Branch Manager.
3) M/s. M/s. Star Health & Allied Insurance
Co.Ltd,1st Floor Kannapuram Building,
Opp.CTO, M.C Road, Kottayam 686 001
Rep.by its Branch Manager.
(OPs Adv.T.J. Lakshmanan)
O R D E R
Hon’ble Mr. Bose Augustine, President
The case of the complainant filed on 8-7-12 is as follows.
The complainant is a holder of Senior Red Carpet Insurance policy vide No.P/181211/01/2012/005424 of the 1st opposite party. The above policy is a Health Insurance Policy for the senior citizens having the age groups of 60-69 years. As per the terms of the policy no pre-insurance medical test is required and all pre-existing deceases are covered from the 1st year except those for which treatment or advice was recommended by or received during the immediately preceding 12 months from the date of proposal. The complainant insured with the 1st opposite party for the sum of Rs.1,00,000/- through the 2nd opposite party. As per the proposal form of the policy it is required to inform to the company that whether the proposer have ever suffered from or suffering following diseases named cancer, chronic, kidney disease, CVA Brain Stroke, Alzhemier disease and Parkinson’s disease. Since the complainant is not suffering from any such disease at the time of the proposal he has answer the same accordingly in the questionnaire attached with the proposal form. Thereafter the complainant was admitted with the department of Cardio Thoracic Surgery of the Little Flower Heart Care Centre attached to the Little Flower Hospital Angamaly on 11-2-2012 due to severe chest pain. As the complainant was suffering from severe Triple Vessel Coronary Artery Disease, the surgery was conducted on 16-2-12 and he was discharged on 23-2-12. And he has paid Rs.1,50,699/- for treatment expenditure on 23-2-2012. Thereafter he made a claim with the 1st opposite party through the 2nd opposite party and it was repudiated by letter dated 2-4-12 stating that various existing illness suppressed while taking policy. According to the complainant the opposite party is duty bound to give all the benefits under the coverage of the insurance policy and they are liable to pay the treatment expenditure including the expenditure for the medical bills, surgery etc as per the terms of the policy. The 1st opposite party is liable to pay Rs.1,30,060/- and the act of opposite parties, the repudiation of the claim, amounts to deficiency in service and unfair trade practice. Hence this complaint.
Opposite parties filed version contenting that the complaint is not maintainable. The policy was issued based on the proposal form submitted by the complainant and on utmost good faith, subject to terms and conditions of the policy. According to the opposite parties they had received a preauthorization request form from the hospital duly signed by the doctor in connection with the treatment of the insured for the cashless benefit. In the said request form the doctor has stated that the insured is having diabetics for 15 years. Since the insured had suppressed the existence of the illness in the proposal form the opposite parties denied the cash less benefit on the ground that suppression of material facts. Thereafter the complainant submitted a claim from for the reimbursement of the medical expenses along with the medical records. The opposite party had perused the medical records and repudiated the claim vide letter dated 2-4-12 due to suppression of material facts regarding the existing illness. According to the opposite parties from the discharge summary it reveals that the complainant is having diabetes, normotensive, had C/o DOE 5 years. It means that he was suffering from the symptoms of illness prior to policy. It is also reveals from the discharge summary and the risk factor for the said illness is diabetic. The proximate cause for the treated illness is diabetic and since the complainant is having the said diabetic for last 15 years even before the commencement of the policy. The suppression of the said existing illness in the proposal form before availing the insurance coverage makes the insurance contract void. So the complainant is not entitled for any claim. According to the opposite parties they had repudiated the claim of the complainant only in accordance with law relying on the policy conditions and the complainant is not entitled to get any amount. And there is deficiency in service or unfair trade practice on the part of them. They prayed for dismissed of the complaint with cost.
Points for considerations are:
- Whether there is any deficiency in service or unfair trade practice on the part of opposite parties?
- Relief and costs?
Evidence in this case consists of the proof affidavit of both sides and Ext.A1 to A6 documents from the side of the complainant and Ext.B1 and B2 documents from the side of opposite parties.
Point No.1
Complainant’s case is that the opposite party repudiated the genuine medical claim of the complainant. Policy is admitted and the treatment for the illness of Cardio Thoracic Surgery is also admitted. Copy of the repudiation letter issued by the 1st opposite party is produced and the same is marked as Ext.A4. In Ext.A4 the reason for repudiation is showed as complainant is having various illness and it is suppressed by the complainant at the time of taking the policy. Since the material facts are suppressed the complainant is not entitled for any amount. Complainant produced the discharge summary and the same is marked as Ext.A3. In Ext.A3 it is stated that the complainant underwent CABG x 5 Graft on 16-2-12. In Ext.A3 it is also stated that complainant is having diabetes mellitus. Opposite party in their version stated that since the complainant is having a history of diabetes mellitus and the same was suppressed at the time of submitting the proposal, the contract of insurance become void. In our view the said contention is not sustainable became nothing has been broughtout by the opposite party that due to the subsisting illness caused the Coronary Artery disease. Furthermore diabetes cannot be considered as an illness because now a days it can be considered only as daily ease of life. So in our view, act of opposite parties in repudiating the claim of the complainant, amounts to deficiency in service. Point No.1 is found accordingly.
Point No.2
In view of the findings in Point No.1 complaint is allowed.
In the result,
- The opposite parties are ordered to pay Rs.1,30,060/-, the claim amount to the complainant.
- The opposite parties are ordered to pay Rs.5000/- as compensation and Rs.5000/- as cost of the litigation cost to the complainant.
The Order shall be complied with within 30 days from the date of receipt of copy of the order. If not complied as directed, the award amount will carry 15% interest from the date of order till realization.
Pronounced in the Open Forum on this the 28th day of February,2017.
Hon’ble Mr. Bose Augustine, President Sd/-
Hon’ble Mr. K.N. Radhakrishnan, Member Sd/-
Hon’ble Mrs. Renu P. Gopalan, Member Sd/-
Appendix
Documents of complainant
Ext.A1-Senior Citizens Red Carpet Insurance Policy
Ext.A2-Policy Brochure
Ext.A3-Discharge Summary
Ext.A4-Copy of letter dtd 2/4/12 issued by OP1
Ext.A5-Photocopy of series of bill cum receipt(6 Nos)
Ext.A6-Star Senior Citizens’ Red Carpet Insurance blank proposal form
Documents of opposite party
Ext.B1-Photocopy of star Senior Citizen’s Red Carpet Insurance Proposal
Ext.B2-Photocopy of Senior Citizens Red Carpet Insurance Policy-Schedule
By Order,
Senior Superintendent
