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
CC No. 226/14
Tuesday the 30th day of June, 2015
Petitioner : Joseph Chandy @ Chandy Joseph
Parambettu House,
Kummannoor PO
Kottayam Dist.
(Adv. Benny Joseph)
Vs
Opposite parties : 1) Star Health and Allied Insurance
Co.Ltd, K.R.M Centre VI Floor
No.2,Harrington Road, Chetpet
Chennai-600 031.
2) Star Health and Allied Insurance
Co.Ltd, First Floor, Vijay Plaza,
S.S Kovil Road,
Thiruvananthapuram.
3) Star Health and Allied Insurance
Co.Ltd, 1st Floor, Kannampuram
Buildings, OPP CTO, MC Road,
Kottayam.
(OP 1 to 3 Adv. Agi Joseph)
O R D E R
Hon’ble Mrs. Renu P. Gopalan, Member
- The complainant filed the complaint on 26/6/14. The averments in brief are as follows.
The complainant had insured himself through a mediclaim policy vide Policy No.P/181113/2012/004365 with the 1st opposite party for the period from 26-3-12 to 25-3-13. He had paid a premium amount of Rs.4908/-. The 2nd opposite party is the state level branch of the 1st opposite party in Kerala State and the 3rd opposite party is the District level branch of the 1st opposite party in Kottayam District. At the time of taking the policy, the complainant was 72 years old and there has no pre-existing diseases. But, on 3-1-13 the complainant fell ill and admitted in the Caritas Hospital, Kottayam. He had to undergo Coronary Angioplasty in Caritas Hospital on 7-1-13. The treatment expenses of the complainant amounted Rs.1,20,890/-. Accordingly the complainant preferred claims with the opposite parties vide No. CLI/2013/181113/015 7282. But the claim of the complainant was repudiated by the opposite parties on the ground that, the documents submitted by the complainant revealed that the complainant had undergone treatment for cardiac problem since 2008, H.T.N(Hyper tension) since 2009 and BPH (Benign Prostrate Hypertrophy) for 15 years. The opposite parties further stated that the complainant was having withheld material information regarding his health at the time of obtaining the policy. The complainant alleged that, the cardiac problems were commenced and diagnosed for the first time, only on 3-1-13. So, the allegations regarding HTN & BPH are not at all connected with cardiac problems. As such, the act of rejection of the claim of the complainant amounts to deficiency in service and unfair trade practice on the part of the opposite parties. Hence, the complainant has filed the complaint for reimbursement of Rs.1,20,890/- with compensation of Rs.25,000/- and Rs.5000/- as costs of litigation.
2. The opposite parties filed Vakalath on 8-10-2014. The Forum has given 4 posting dates for filing their version, but they failed to file version. Then, the case was posted for adducing evidence even after 7 posting dates, were over, the opposite parties have not filed version. The complainant filed chief and proof affidavit on 25/2/15. On 22/6/15, the complainant was represented and the opposite parties were absent and have no representation before the Forum. Exts. A1 to A8 were marked on the side of the complainant and heard the matter in detail in the absence of the opposite parties.
- Based on the pleadings and contentions, the following points arise for consideration are:
- Whether there is any deficiency in service or unfair trade practice on the part of the opposite parties?
- As to reliefs and costs?
Evidence in this case consists of the Chief and Proof affidavit filed by the complainant and Exts. A1 to A8 documents from his part.
3.Point No.1
It is not in dispute that the opposite parties have issued a policy vide No.P/181113/2012/004365 to the complainant for the period 26-3-12 to 25-3-13 and the premium amount of Rs. 4908/- we perused the documents on record. The copy of policy schedule was produced by the complainant and was marked as Ext.A1. Ext.A2 is the copy of claim form submitted by the complainant. Ext.A3 is the repudiation letter dtd 31-5-13 issued by the 1st opposite party. Ext.A4 is the copy of the reminder letter dtd 26/2/13 sent by the complainant to the opposite party. Ext.A5 is a certificate issued by Dr.Johny Joseph, Cardiologist, Caritas Hospital on 24-6-13. Ext.A6 is copy of the Lawyer’s notice sent through the counsel of the complainant to the opposite parties, Ext.A7, A7(a) & A7(b) are the postal receipts and Ext.A8 is the acknowledgement card.
On perusal of Ext.A3, it is stated that, the claim preferred by the complainant had been repudiated on the basis of the medical documents of the complainant submitted by him. Ext.A3 reads as under,
“The medical documents submitted by you reveal that the patient had undergone treatment for cardiac problems since 2008, HTN since 2009 and BPH since 15 years. The policy commences from 26-03-2012. Existing illness suppressed while taking policy. In the proposal form, you have not revealed the previous health related complaints. A health insurance policy is issued in good faith after assessing the health condition of a proposer based on the health related facts stated in proposal form. Obtaining a policy without disclosing the full facts on health of a person would make the insurance policy void ab initio”.
Ext.A5 is a certificate issued by Dr. Johny Joseph, Caritas Hospital Kottayam on 24/6/13 who had treated the complainant.
Ext.A5 reads under,
“Mr. Chandy Joseph, who has an acute coronary event, does not give any features to suggest Coronary events in past. I have evaluated him since 2008. His TMT was negative in 2008 and only age related aortic valve changes(mild aortic stenosis) were noted which not connected with present coronary problem. I strontly consider that his effort angina of recent onset (with one week of Myocardial Infarction) is new onset and he should not be denied of any insurance claims”.
Ext.A5 clearly shows that, the complainant had no cardiac problems in the past. We are of the view that, the report given by Dr. Johny Jospeh who had treated the complaint is quite genuine.
Pre-existing disease means any ailment/disease/injury that the person suffering from (known/not known, treated/untreated, declared or not declared in the proposal) whilst taking the policy.
The opposite parties had wrongly repudiated in the very first place on flimsy grounds without any substantial evidence. The opposite parties had settled the claim for an amount of Rs.52,943/- only when the complainant has filed this complaint before the Forum,
The reason for repudiation of the claim of the complainant is that, he had pre-existing disease and the complainant withheld the illness at the time of taking the policy. During the pendency of the case, the opposite parties processed the claim of the complainant and sanctioned a sum of Rs.52,943/- to the complainant. From this act of the opposite parties itself shows that, the contention raised by the opposite parties in repudiating the claim of complainant does not stand. So in our view, the complainant is entitled for the balance amount as claimed by the complainant.
In our view, considering the facts stated above, there was apparent negligence or deficiency in service on the part of the opposite parties. In this view of the matter it is apparent that for the negligence and deficiency in service, the opposite parties would be jointly and severally liable to pay the claim amount to the complainant.
Hence point No.1 is found in favour of the complainant.
Point No.2
In view of the findings in Point No.1, the complaint is allowed in part.
The counsel for the opposite party stated that the opposite parties have issued a cheque for Rs.52,943/- to the complainant after the filing of the complaint as part payment of the claim amount and the same was encashed on 14-7-14. The balance amount of Rs.67,947/- is to be paid by the opposite parties to the complainant.
From the discussions, it is found that there is negligence and deficiency in service on the part of the opposite parties. Therefore,
- The opposite parties are directed to pay the complainant the balance claim amount of Rs.67,947/-(Sixty seven thousand nine hundred and forty seven rupees only) out of 1,20,890/- with interest @ 9% from the date of repudiation.
- Since interest is allowed, no separate compensation is ordered.
- The opposite parties are directed to pay Rs.5000/- as costs of the proceedings.
The opposite parties are jointly and severally liable to pay the award amount and costs.
Order shall be complied with within 30 days of receipt of a copy of the order.
Pronounced in the Open Forum on this the 30th day of June, 2015.
Hon’ble Mrs. Renu P. Gopalan, Member Sd/-
Hon’ble Mr. Bose Augustine, President Sd/-
Hon’ble Mr. K.N. Radhakrishnan, Member Sd/-
Documents for the complainant
Ext.A1-Policy schedule
Ext.A2-Copy of Claim form for medical insurance
Ext.A3-Copy of repudiation letter dtd 31/5/13
Ext.A4-Copy of the reminder letter dtd 26/6/13
Ext.A5-Certificate issued by Dr. Johny Joseph, Caritas Hospital
Ext.A6-Copy of Lawyer’s notice dtd 31/1/14
Ext.A7-Series of postal receipts(3 Nos.)
Ext.A8-AD card
By Order,
Senior Superintendent
