THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.

C.C.315/2014

Dated this the 3^rd day of May, 2018

(Smt. Rose Jose, B.Sc, LLB.               :  President)

                                                                        Smt.Beena Joseph, M.A                      :  Member

                                                                        Sri. Joseph Mathew, M.A., L.L.B.     :  Member

​

ORDER

Present: Rose Jose, President:       

This petition is filed by the petitioner under Section 12 of Consumer Protection Act, 1986 for directing the opposite parties to allow his medi claim and reimburse his hospitalization expenses of Rs.47,183/- and also for compensation and cost.

Petitioner is a senior citizen. His case is that, he is the holder of a Health Policy of opposite parties having Policy No. P/181311/01/2014/0050153. He took the policy believing the words of the insurance agent that the said policy will cover all his medical needs in future. He was suffering from Bi-lateral Inguinal Hernia and in connection with this ailment he had admitted at MIMS Hospital on 17/11/2013 and had undergone a surgery and was discharged on 19/11/2013. The total expenses incurred for the treatment was Rs.47,183/-. The facts of the admission at the hospital was informed to the 1^st opposite party on the very same day itself. Thereafter he made claim before the 1^st opposite party on the same day itself but the claim was repudiated due to the reason that he had a history of stroke ten years back, CAD and IWMI on 2003 and he had suppressed this facts while joining the policy. The petitioner stated that the policy certificate issued by the 1^st opposite party reveals that the disease like Hernia etc. will come under the ambit of the insurance coverage if it is claimed for the continuous period of preceding 12 months of the 1^st year insurance coverage without any break. So he is entitled to get the claim amount since he had obtained the policy abiding the terms and conditions of the policy and the opposite parties are bound to honour his claim also. The repudiation of his claim without any valid ground amounts to deficiency in service and this caused much mental pain, financial loss and other difficulties to him. Hence this petition seeking reliefs.

The opposite parties in their version admitted that the petitioner was their policy holder under the scheme “Senior Citizen Red Carpet Insurance Policy” with policy No, P/181311/01/2014/0050153. Petitioner’s 1^st policy with them commenced from 31/10/2012 and the present policy was valid from 31/10/2013 to 30/10/2014. It is contended that the petitioner got admitted on 17/11/2013 with complaints of B/L Inguinal Hernia and had undergone laparoscopic B/L Hernia Mesh Repair under G.A. on 18/11/2013 and was discharged on 19/11/2013 and the claim for Rs.47,183 was repudiated due to the reason suppression of material facts pre-existing disease and this was informed to the petitioner through a letter dated 07/03/2014. The treatment records at MIMS revealed that he had a history of stroke 10 years back, CAD and IWMI in the year 2003. But while taking the policy in 2012, he had suppressed this facts. When a health policy is taken by a party, the proposer is expected to reveal all his previous medical history to insurer through the proposal form. But the petitioner has not done so. Before surgery he had consulted the cardiologist also.

It is further contended that in the additional questionnaire annexed to the proposal form specific disease like cancer, chronic kidney disease (CKD), CVA/Brain stroke, Alzheimer disease and Parkinson’s disease required an open disclosure, but the petitioner answered ‘No’ to the questions in the additional questionnaire. Since the petitioner had obtained the policy by suppressing material facts, he is not eligible to get the reimbursement of medical expenses from them under the policy. Concealment of a fact which was exclusively in the knowledge of the insured and could not have been detected by insurance company by way of reasonable and practicable inquiry is a sufficient reason for repudiating a claim. Hence they have rightly and legally repudiated the claim of the petitioner for the suppression of existing illness while taking policy and so no deficiency in service can be attributed against them as alleged. The petitioner is not entitled to get the benefit of the policy or any other reliefs and they are not liable to pay the hospitalization charges or any compensation or cost to the petitioner. All other allegations of the petitioner was denied as false and not true. Hence prayed to dismiss the petition with their cost.

The points for determinations are:

1. Whether there is any deficiency in service on the part of the opposite parties?
2. Reliefs and cost if any?

Evidence consists of the affidavit filed by both the parties. Ext.s A1 to A6 series, B1 to B5 and testimonies of PW1 and RW1.

Point No. 1:  The policy and its coverage was admitted by the opposite parties. According to them they have repudiated the claim on valid grounds.

As per Ext. B2 discharge summary from MIMS Hospital, the petitioner had stroke 10 years back, CAD and IWMI in the year 2003. But in the proposal form Ext. B1 against the column for providing the details about the previous illness the petitioner had entered ‘No’. So it is clear that the petitioner had obtained the policy by suppressing material facts. The petitioner was examined as PW1. In cross, he admitted that while taking policy the opposite party had provided him the terms and conditions of the policy. It was also admitted that he has been taking medicines for heart disease and BP for the last 12 years. The opposite party contended that in the policy it is clearly mentioned that the insurance under the policy is subject to terms and conditions, clauses, exclusions etc. attached. The petitioner could not bring out anything to show that the opposite parties have violated the terms and conditions of the policy in repudiating his claim by cross examination of the opposite party-PW1. Insurance is a contract and hence the insurer and insured are governed by the terms and conditions of the said contract and the insured cannot claim and not eligible to claim anything more than what is legally eligible to him as per the terms of the policy.

The opposite parties further contended that, the present policy is available only to persons above the age of 60 years and as per this policy 50% of the medical expenses will be deducted in the case of pre-existing diseases and 30% in other cases and that too if such diseases are disclosed in the proposal form and hence he is not eligible for any amount towards his medical expenses.

The petitioner has not denied the suppression of his pre-existing illness in the proposal form. But it is to be considered whether he had suppressed this fact deliberately or intentionally with ulterior motive to extract money illegally from the opposite parties. In cross examination, the petitioner stated that he had studied only upto 5^th standard. It is further stated that suppression was only because of ignorance and not with any interior motive to cheat the opposite parties or grab any amount. In his complaint it is stated that he had taken the policy fully believing the assurance of the insurance agent that since he had above 60 years, the policy will cover all his medical needs in future even if there is existing illness. He produced the brochure Ext. A6 issued to him by the insurance agent. In Ext. A6 it is written that “Senior Citizen Red Carpet Insurance – a special insurance policy covering the pre-existing diseases for those who are between the age of 60 to 69 years.” According to the petitioner believing the assurance given by the agent of the opposite parties and based on Ext. A6 brochure he had taken the policy.

In Paramjith Kaur Vs. Life Insurance Corporation of India and Ans. IV(2014)CPJ132(NC), the Hon’ble National Commission held that “Suppression of pre-existing - disease when there is deliberate suppression of material facts pertaining to health on part of life assured contract of insurance which is based on principle of utmost good faith gets vitiated and cause of death becomes irrelevant – repudiation justified”. From this decision it is clear that where there is deliberate suppression of material facts, repudiation of claim is justified. Here in this case, it is seen that the suppression of his pre-existing illness in the proposal form by the petitioner was not deliberate, willful or intentional. In his petition, the petitioner clearly stated that the suppression was merely because of ignorance. Since he was not in a position to read or understand the terms and conditions of the policy, he blindly believed the assurance of the agent of the opposite parties and he knows nothing more. In this circumstance considering the age of the petitioner and his educational qualification one cannot attribute any willful suppression of facts on the petitioner.

So considering the facts that the suppression of pre-existing illness in the proposal form by the petitioner was not deliberate, intentional or with any ulterior motive but merely because of the ignorance, we are of the view that the repudiation of the claim of the petitioner is not justifiable and the opposite parties are liable to allow the claim and to reimburse the medical expenses of the petitioner.

In the result, the following order is passed.

Opposite parties are ordered to allow the claim of the petitioner and to pay him the permissible amount as per the petitioner’s policy conditions and also to pay Rs.3,000/- (Rupees three thousand only) as cost of the proceedings within 45 days from the date of receipt of this order.

Dated this the  3^rd day of May, 2018

Date of filing: 17/06/2014

SD/-MEMBER                           SD/-PRESIDENT                 SD/-MEMBER

 APPENDIX

Documents exhibited for the complainant:

A1. Senior Citizen Red Carpet Insurance policy Schedule

A2. Advance premium receipt

A3. Discharge summary

A4. Repudiation letter

A5. Cash bill (17 in number series)

A6. Brochure

Documents exhibited for the opposite party:

B1. Proposal form submitted by the complainant

B2. Copy of Senior Citizen Red Carpet Insurance policy Schedule

B3. Copy of discharge summary

B4. Copy of repudiation letter issued to the complainant

B5. Authorization letter

Witness examined for the complainant:

PW1. Balakrishnan (Complainant)

Witness examined for the opposite party:

RW1. Balu M. (Opposite party)                                                              

Sd/-President

//True copy//

(Forwarded/By Order)

SENIOR SUPERINTENDENT