IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present:
Hon’ble Mr. Bose Augustine, President
Hon’ble Mr. K.N. Radhakrishnan, Member
C C No. 218/2013
Friday, the 31stday of July, 2015
Petitioners : Thomas Mathew,
Kumblamthanathu House,
Ayarkunnam P.O.
Kottayam – 686 564.
(Adv. Sathesh Mathew Zacharias and
Adv. Kalesh Kumar)
Vs.
Opposite Parties : Star Health and Allied Insurance Co. Ltd.
1st Floor, Kannampuram Bldg.
Opp. CTO, M.C. Road,
Kottayam – 1.
(Adv. M.C. Suresh and T.J. Lakshmanan)
O R D E R
Hon’ble Mr. Bose Augustine, President
The case of the complainant filed on 31/07/2013 is as follows.
Complainant is the policy holder of family health optima insurance policy of the opposite party as vide No. P/181113/01/2012/004032 from 05/03/2012 to 04/03/2013. The sum insured is Rs.3,00,000/-. According to the complainant, during the period of policy on 13/04/2012, the 4th insured Aron Mahtew Thomas was taken to Krupa Clinic for the treatment of vomiting. And he was referred to Mangalam Diagnostic Research Center for abdominal ultra soundgraphy and it was found that a large seized heterogeneous mars in the right lobe of liver of Aron Mathew Thomas. On 14/04/2012, CT scan of abdomen was done and suspected hepatoblastoma and suggested clinical pathological co-relation. On clinical pathological study of microscopic finding indicated the possibility of Hepeto blastoma and suggested aspiration biopsy repeated to get more tissue material specific from the tumor mass. Then, on 06/08/2012 the said Aron Mathew was admitted at Lakeshore Hospital and Research Center, Kochi and surgery was done on 09/08/2012. He was discharged on 20/08/12 and was spent Rs.1,66,000/- as medical expenses. The complainant had submitted the claim form with all documents to the opposite party. But, opposite party repudiated the claim of the complainant by the letter dtd.09/01/2013 stating that ‘pre-existing disease – ie. it falls under exclusion clause No.1 of the policy. According to the complainant, there was no disease diagnosed to the insured master Baby Aron Mathew Thomas till 13/04/12, when abdominal ultra sonography was done. And the illness was not been known to the insured at the time of taking policy and hence there is no suppression of material of facts. According to the complainant, the policy was expired on 04/03/2012 and is to be renewed for which a request letter and blank cheque was given to the opposite party, but it was not renewed. According to the complainant, the act of opposite party in repudiating the claim and non-renewal of the policy amounts to deficiency in service and unfair trade practice. Hence this complaint.
The opposite party filed version admitting the issuance of the Family Health Optima Insurance of the complainant and his family members for the first time from 05/03/12 to 04/03/13. According to the oppositeparty, the complainant had submitted four claims in connection with the treatment of his minor son Aron Mathew. The discharge summary of the patient related to the admission from 16/04/12 to 23/04/12, it is stated that the baby was evaluated in Kottayam in connection with the complaints of diagnosed illness with a duration of 2 months. The 1st discharge summary of the patient reveals that the insured is having the symptoms of diagnosed / treated illness since 2 months from the date of admission in the hospital. The insured was admitted in the hospital on 16/04/12 and as per the discharge summary, the duration of the treated illness is for 2 months ie, from 16/02/2012 onwards. But, the commencement of policy is from 05/03/12. So the claim clearly falls under exclusion clause no.1 of the policy conditions namely ‘pre-existing disease’. So, the opposite party is not liable to indemnify the insured. According to the opposite party, there is a suppression of material facts on the part of the complainant. The complainant had deliberately suppressed the health conditions of his minor son while submitting the proposal and without disclosing the health condition of his minor son, he had taken the policy. So the contract of insurance become void-ab-initio. So the opposite party is not in a position to renew the policy of the complainant. According to the opposite party, the repudiation of the claim of the complainant is only on valid grounds and there is no deficiency in service or unfair trade practice on the part of them. And the opposite party prayed for dismissal of the complaint with their cost.
Points for considerations are
- Whether there is any deficiency in service or unfair trade practice on the part of opposite party?
- Relief and costs?
Evidence in this case consists of the proof affidavit of the both sides and Ext.A1 to A11 documents from the side of complainant and Ext.B1 to B12 documents from the side of opposite party.
Point No.1
The crux of the complainant’s case is that opposite party repudiated the medi claim submitted by him amounts to deficiency in service. Copy of the repudiation letter dtd.09/01/2013 is produced and the same is marked as Ext.B4. In Ext.B4, it is stated that from medical documents submitted by the complainant, it was revealed that the minor son of the complainant is suffering from diseases prior to the date of inception of the policy. Opposite party produced copy of the policy and the same is marked as Ext.B1. From Ext.B1, it can be seen that period of insurance is from 05/03/12 to 04/03/13. Ext.B3 is the medical certificate issued by Dr. P.V. Gangadharan, H.O., Medical Oncology Department of Lakeshore Hospital. In Ext.B3, the date 1st consultation is shown as 16/04/2012. Moreover, the doctor noticed, the complaints told by the patient, that the patient is suffering from recurrent vomiting – 2 months, abdominal distension. So from Ext.B3 and B1 document, it can be inferred that the illness was commenced prior to the date of inception of the policy. In our view, a health insurance policy is issued in good faith based on the details stated in the proposal from. Suppression of material facts in the proposal form of a medi-claim policy and subsequent issuance of policy based on the said proposal, make the contract of insurancevoid-ab-initio. Based on the above findings, we do not find any deficiency in service on the part of opposite parties. Point No.1 found accordingly.
Point No.2
In view of finding in Point No.1, complaint dismissed. No cost ordered.
Pronounced in the Open Forum on this the 31st day of July, 2015.
Hon’ble Mr. Bose Augustine, President Sd/-
Hon’ble Mr. K.N. Radhakrishnan, Member Sd/-
Appendix
Documents of petitioner
Ext.A1 : Policy No.P/181113/01/2012/004032 issued by opposite party
Ext.A2 : Letter dtd.22/10/2012 issued by opposite party
Ext.A3 : Letter dtd.15/11/2012 issued by petitioner
Ext.A4 : Letter dtd. 09/01/13 issued by opposite party
Ext.A5 : Copy of lawyers notice dtd.14/03/13
Ext.A6 : Copy of lawyers notice dtd.16/04/13
Ext.A7 : Copy certificate dtd.14/11/12 from Dr.T.S. Zachariah
Ext.A8 : Copy of fitness certificate of Aaron from Bharath hospital
Ext.A9 : Copy of letter dtd.07/03/13 issued by petitioner
Ext.A10: Copy of cheque dtd.05/03/2013 from IndusInd bank.
Ext.A11 : Voucher from DTDC courier & cargo Ltd.
Ext.A12 : series of medical bill (76 Nos.)
Documents of opposite party
Ext.B1 : Copy of Policy No.P/181113/01/2012/004032 with policy conditions
Ext.B2 : Copy of discharge summary of Aaron Mathew Thomas dtd.16/04/12 –
23/04/12 from Lakeshore Hospital & Research Center Ltd.
Ext.B3 : Copy of medical certificate dtd.16/04/12 – 23/04/12 issued by
Dr. V.P. Gangadharan.
Ext.B4 : Copy of letter dtd.09/01/2013 issued by opposite party
Ext.B5 : Copy of discharge summary from Lakeshore Hospital
dtd.10/05/2012 –17/05/12
Ext.B6 : Copy of medical certificate issued by Dr. V. Gangadharan dtd.10/05/12
– 17/05/12
Ext.B7 : Copy of letter dtd.09/01/2013 issued by opposite party
Ext.B8 : Copy of discharge summary dtd.04-06-12 – 08/06/12 from Lakeshore
Hospital
Ext.B9 : Copy of letter dtd.09/01/13 issued by opposite party
Ext.B10 : Copy of discharge summary dtd.25/06/12 – 30/06/12 from Lakeshore
Hospital
Ext.B11 : Copy of letter dtd.09/01/13 issued by opposite party
Ext.B12 : Copy of proposal form
By Order
Senior Superintendent
