D.O.F: 03/05/2014
D.O.O: 24/01/2019
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.88/14
Dated this, the 24th day of January 2019
PRESENT:
SRI.ROY PAUL :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
K. Vishwavinoda Bhat. , : Complainant
Banari House,Panjikal P.O.
Mulleria. Via, Kasaragod District.
(Adv: Sathyashankara. M)
And
1. Star Health Allied Insurance Co. Ltd, No.1 : Opposite Parties
New tank street, Valluvar Kottam High Road,
Nungabakkam, Chennai.
2. Star Health Allied Insurance Co. Ltd,
No.14-2-104/24, TS No.26-01, City light building,
Balmatta Road, Mangalore-575001.
( Adv: Anil Kumar.K for OP 1 & 2.)
ORDER
SRI.ROY PAUL :PRESIDENT
This is a complaint filed under section 12 of Consumer Protection Act for an order directing the opposite parties to pay the insurance claim along with compensation and cost to the complainant.
The case of the complainant in brief:-
The complainant had availed the health insurance policy of the opposite parties, after much canvas from the agents and inducement of the opposite parties. They had assured that the medical expenses and hospitalisation charges will be covered under the policy. The policy was obtained as per the scheme Senior Citizen Red Carpet Insurance Policy. During the month June 2013 the complainant was admitted in K.S Hedge Hospital at Mangalore for Pre Septal Cellulities and he was treated there from 24/06/2013 to 06/07/2013. At that time the complaint lodged claim before the opposite parties availing benefit under the policy but opposite parties sent a reply dated 03/04/2014 intimating the complainant that the policy was cancelled. So there is deficiency of service and unfair trade practice on the part of the opposite parties and complaint has suffered much hardships, mental agony, inconvenience, loss of time and money. Hence the complaint.
The opposite parties entered appearance before the Fora and submitted their written version contending that the complainant has suppressed his previous health history while obtaining the subject policy and was obtained the policy by misrepresentation. Hence the opposite parties have cancelled the policy by invoking the condition No 10 of the policy, the opposite parties elaborately explained the said conditions in Para 5, and 6 in the version. According to the opposite parties so there is no deficiency of the service on the part and complaint may be dismissed with cost.
On the basis of the rival contentions in the pleadings the following issues were framed for consideration.
- Whether there is any deficiency service on the part of the opposite party?
- Whether the complaint is entitled for any reliefs?
- Reliefs and cost?
The evidence consist of the oral testimony of Pw1 and Ext A1 to A5 documents marked on his side. No oral evidence was adduced from the side of the opposite parties. Ext B1 to B3 documents weremarked.
ISSUE NO: 1
The complaisant adduced evidence by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. He was cross examined as Pw1 by the opposite party and he relied on Ext A1 to A5 document also to substantiate his case. According to him the repudiation of the claim by the opposite party is unjust and improper. The allegation made in the version are absolutely wrong and against the facts. There is deficiency of service on the part of the opposite parties. The cancelation of the policy after receipt of premium without any valid ground amounts to unfair trade practice. Due to the deficiency of service on the part of the opposite parties the complaint has suffered much hardship, mental agony, inconvenience loos of time and money. Hence the complaint may be allowed.
The learned counsel for the opposite parties vehemently argued that as per clause 11 of the policy there is suppression of material facts by the complainant. At the time of availing in the policy he was suffering from any ailments including hypertension. Ext B3 series medical records including the discharge summary bill reveal the said facts. Hence the cancellation of the policy as per the terms and condition is just and proper. There is no deficiency of service and unfair trade practice on the part of opposite parties and complaint may be dismissed with cost.
On perusal of the pleadings, documents and evaluation of the evidence tendered before the Fora we are of the view that admittedly the complainant is a senior citizen. The opposite parties have introduced a special policy with a motive to provide health insurance protection to senior citizen. The premium rate for the said policy is comparatively higher than the ordinary policies. As per the medical certificate dated 17/07/2013 it is certified that the complainant was admitted on 24/06/2013 at K.S Hegde Hospital and diagnosed that his left eye perceptual cellulites and after the admission he was ‘newly detected to have hypertension and diabetics’’. The Pw1 also deposed before the Fora that “F\n¡v _n.]n bpÅ Imcyw BZyambmWv tlmkv]näen sh¨v a\ÊnembXv” though the opposite party produced documents to show that the complaint was suffering from hypertension before availing the policy, no steps was taken by the opposite parties to prove the veracity of these documents before the Fora . No witnesses were also examined on their part. Apart to that we the Fora got a doubt whether the alleged BP of complainant can be treated as a pre existing disease in case of a senior citizen aged more than 65 years. There was no RTA complaint /disease for the complainant as alleged by the opposite parties. On perusal of Ext B1 policy pre-existing disease means any condition, ailment or injury or related condition (s) for which the insured had signs or symptoms and/or were diagnosed and/or, received medical advice/treatment within 48 months prior to the Insured’s first policy with any Indian insurer. There is no documents contrary to the above conditions before this Fora . From the foregoing discussions and findings we are of the considered view that there is no violation of policy condition No:7 or 11 of the policy as alleged by the opposite party. So the claim submitted by the complainant is liable to be allowed by the opposite party. We hold that the cancellation/repudiation of the claim of the complainant by the opposite party amounts to deficiency of service. Hence the issue No: 1 found against the opposite party and answered accordingly.
ISSUE NO: 2&3
As discussed above the complaint is entitled for the claim amount from the opposite parties. It is also in evident that the complaint has suffered much hardship, mental agony, inconvenience, loss of time and money. Due to the deficiency of service on the part of the opposite parties. So we hold that the opposite party is liable to pay the claim amount in claim No: C-11/2014 /141211/0056034 to the complainant along with Rs. 5000/- as compensation and Rs. 2000 as litigation cost. Thus the issue No 2 and 3 also accordingly answered.
In the result the complaint is allowed directing the opposite parties No: 1 and 2 jointly and severally to pay the insurance claim amount in claim No: C-11/2014/141211/0056034 to the complainant with interest @ 8% per annum from the date of complaint (03/05/2014) along with Rs. 5000/- as compensation and Rs. 2000/- as litigation cost within 30 days of the receipt of the order. Failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 1986.
Sd/- Sd/-
MEMBER PRESIDENT
Exhibits:
A1- Health Insurance Policy Dated: 25-02-2013.
A2- The renewed Policy Dated: 28-03-2014.
A3- Advance Premium paid receipt of Rs.5,000/-
A4- The Letter Dated: 03-04-2014..
A5- Clinical Laboratory Report Dated: 21-01-2013.
A6- Copy of the Cash bill for Rs.42,945/- Dated: 06-07-2013.
A7(Series)- Copy of the Pharmacy Bills- 16 in Number.
B1-Copy of the policy schedule dated: 25-02-2013.
B2- Prospectus about the Policy.
B3- Medical Records About the complainant availed from the Hospital..
Witness Examined :
PW1- Vishwavinoda Bhat
Sd/- Sd/-
MEMBER PRESIDENT
Forwarded by Order
Senior Superintendent
Ps/
