BEFORE THE ADDITIONAL BENCH DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT MYSURU.

Consumer Complaint (C.C.)No. 1188/2016

Complaint filed on 18.04.2016

Date of Judgement.18.02.2017

PRESENT                                : 1. Shri Ramachandra  M.S.,  B.A., LL.B.,

                                                     PRESIDENT

                                2. Shri  Thammanna,Y.S., B.Sc., LL.B., 

                                   MEMBER

Complainant/s               :              1.Doctor M.N. Manajappa

S/o Late N.Ningappa

 # ATD No. 474, 2^nd main ,

 6^th  cross, 1^st Block ,

 Ramakrishna Nagar, Mysuru.

                                                   (Sri. Ram gopal ., Advocate)

                                                                  V/s

Opponent        /s                     :          1. Star Health and allied nsurance

                                                          company limited. Corporate and REG. Office:

                                                         1, New Tabj street , Valluvr, Kottam High Road,  

                                                          Nungamabakkam, Chennai-600004, Rep.

                                                            By its Chairman & Managing Director

                                                        2. The Branch Manager Stat

                                                          Health and allied Insurance

                                                         Company Limited. Office: Lakshmi Arcade,

                                                          1^st Floor No. 14, 8^th cross, 4^th Main

                                                            Kamakshi Hospital Raod , Saraswathi Puram,

                                                            Mysuru-09.

3. Sri C. Ramesh Representative

of Stat Health and allied Insurance

Company Limited Officer: Lakshmi Arcade,

1^st Floor No.14, 8^th cross, 4^th Main

Kamakshi Hospital Road, Saraswathi Puram,

Mysuru-09.

(Sri  B.N.Shashidhar. , Advocate)

SHRI RAMACHANDRA . M.S.,

PRESIDENT

JUDGEMENT

The complainant has filed the complaint under section 12 of the C.P.Act 1986. against the opposite party pray for the refund of amount and compensation other reliefs as prayed in the complaint.

2. The brief facts complainant a senior citizen aged about 71 years and by profession he is a retired physician. The complainant submits that in the year 2011 the 3^rd opponents who being a good friend of this complainant approached and induced the complainant and gave explanation stating that the 1^st and 2^nd opponents announced their new policy for “SENIOR CITIZENS’’  Under the head of senior citizens red carpet health insurance policy stating that without pre-medical test the 1^st and 2^nd opponents will accept the premium and directly, issue insurance policy and also the said insurance policy will cover insured spouse. The 3^rd opponents also declared and stated that the 1 and 2^nd opponents have annualized regarding normal life of an Indian is in between 45 to 60 years. Every person after attaining 60 years of age, they will suffer one or other health problem and they are deprived of their medical benefits. The insurance policy companies are not issuing any such medical health policy to senior citizens after attaining the age of 60 years. Therefore, the 1^st and 2^nd opponents applied their broad mind and to help the poor, aged such senior citizen and to get medical cash less treatment they have come up with a great such policy under the name of senior citizens red carpet health insurance policy and induced the complainant to get such insurance policy through him. Believing the words of the 3^rd opponents, the complainant obtained the said policy of land 2^nd opponents through 3^rd opponents first on 13.10.2011 under the scheme of senior citizen red carpet insurance policy for sum inured of rs. 2 Lacks by paying its premium of Rs  9326/- under vide receipts no 1043001475 and its policy bearing no P/141116/2012/0001854 the copy of the policy is herewith produced for the kind perusal of this hon’ble court on 13.10.2011 and executed his signature to certain blank forms and handed over to the 3^rd opponent. The complainant also continued the policy by renew on all such due dates and well within the stipulated period up to the year 13.10.2015 to 12.10.2016.

3. Later on each and every year the 3^rd opponents use to approach the complainant house and induced to get it renewal of the said policy. The 1 and 2^nd opponent after collections of premium had continued the said new scheme of for senior citizen star health policies for the year 2012-13, 2013-14, 2014-15 and 2015-16. The total premium paid from 2011-16 is in a sum of Rs. 83,116. The complainant hereby produce the copies of the medical health insurance policy issued by the opponents for the kind perusal of this Hon’ble court.

4. The complainant submits that in the year 2015 due to knee pain the complainant all of a sudden started getting heavy pain in his both knees. There was no such trauma, fever, swelling or there was no such history of involvement of any other joints in the body etc., there was only one problem is that the complainant use to get pain in both of his knees and could not climb stair case, could not able to walk for a longer distances, and was not able to sit in crossed leg. Therefore, the complainant got admitted to Ganga medical centre and hospital (P) Ltd., Coimbatore on 10.10.2015 for the purposes of treatment and replacement of both the knees. Doctor prof. S.Rajasekaran and Dr. Rajkumar N. Have replaced both the knees of the complainant and discharged on 24.010.2015 at a cost of Rs. 3,62,730/- The complainant was discharged on 24.10.2015.

5. The complainant submits that the opponents have their own officer desk put up at Ganga medical centre and Hospital (P) Ltd., Coimbatore and they are suppose to issue authorization letter to hospital. The complainant further submits that at the time admitting to Coimbatore Ganga medical centre and hospital the complainant had informed the opponent to issue of a letter for pre-authorization for the utilization of cashless treatment under the vide  Insurance policy bearing no P/141116/2015/002654 to the said Ganga hospital . After knee replacement and on the day of discharge the opponents with their ulterior motives that on 24.10.2015 have withdrawn the authorization letter to Ganga medical centre and hospital on the grounds that as per the discharge summery the complainant under went angioplasty on 03.05.2011 prior to policy inception and the complainant failed to disclose the said facts at the time of obtaining insurance policy with them. The complainant submits that the opponents  kept mum from the day one of admission and on the day of discharge the opponents with ill will and with ulterior intention have withdrawn the authorization letter and breached the terms and conditions of he their policy. It is because of such breach of conditions the complainant was forced to raise loan of Rs. 3,00,000/-from his own friends and clear the medical bills of Rs. 3,62,730/- and un necessary interest at rate of 18% p.a. The complainant was put to great hardship and suffered mental agony.

6. The notice to the opposite party is duly served counsel is engaged and filed version and chief affidavit in his version the opposite party has admitted the issuance of policy to the complainant and it was also admitted that premium were paid regular and it is a valid policy till it is terminated  by opposite party.

7. Further opposite party contended that opposite party is not liable to pay the claim of complainant for the reason that the complainant has suppressed the fact that he was suffering from  pre existing decease much prior to obtaining  health policy further when complainant has intentionally not disclosed pre existing decease  at the time of obtaining policy it amounts to violation of conditions of policy for which complainant is not entitle  to claim insured amount and opposite party is not liable to pay the claim,  on account of this opposite party has also terminated the health policy by assigning the same reason.  On all these counts the opposite party prays for the dismissal of complaint.

8. To prove the facts, both complainant and opposite party filed  their evidence by filing affidavit along with documents. On perusal of the documents placed on board, and on hearing oral arguments and perused written arguments, matter posted for orders.

9. The points that arise for our consideration are;-

1. Whether the complainant proves that there is deficiency in service and unfair trade practice on the part of opposite party by not paying the claim amount to the complainant and thereby he is entitled for the reliefs sought?

2. What order?

10. Our answer to the above points is as follows;

1. Point No.1: In the negative

2. Point No.2: As per final order for the following;

REASONS

11 . Point No.1:- That it is an admitted fact that complainant has obtained health insurance policy under scheme  senior citizens red carpet health insurance policy from opposite party on 13.10.2011 for sum insured of Rs. 2,00,000/- by paying its premium of Rs. 9,326 and policy no P/141116/2012/0001854 thereafter  complainant also continued the policy by renewing on all such dates and well within the stipulated period up to year 13.10.2015 to 12.10.2016 all these facts is proved by complainant with material documents in support of his contention the opposite party has also admitted these facts.

12. Further in the year 2015 due to knee pain the complainant all of a sudden started getting heavy pain in his both knees he could not climb stair case could not able to walk for a long distance and was not able to sit in crossed leg. Therefore complainant admitted to Ganga medical centre and hospital (P)Ltd., coimbatore on 10.10.2015 the doctors have replaced both knees of complainant at a cost of Rs. 3,62,730/- when complainant approached the opposite party for pre authorization for the utilization of cashless treatment on 24.10.2015 the opposite party have withdrawn the authorization letter from hospital on the grounds that as per discharge summary the complainant underwent angioplasty on 03.05.2011 prior to policy inception and complainant failed to disclose the said facts at the  time of obtaining insurance policy with them. It is because of such breach of conditions they refused to settle the claim and further they have also terminated policy by refunding  the last premium amount of Rs. 23,940/-.

13. Further the claim of complainant is repudiated by opposite party  for above reasons. Here very important fact is that when complainant obtained policy from opposite party it is a contract between complainant and opposite party when opposite party has issued health policy it was on certain  terms and conditions , which were laid down by opposite party same was agreed, accepted by complainant and obtained policy. When such being the case any violation of policy conditions by the complainant amounts to  violation of policy terms and conditions for which opposite party is not liable to pay. Here in this complaint when there is condition that at the time of obtaining policy complainant is bound disclose all pre existing decease matter.  When complainant has knowingly does not disclose angioplasty when it realts to heart decease it is a pre existing decease and thereafter if the policy is obtained it amounts to violation of conditions of policy, for which the opposite party company has rightly repudiated the claim of complainant.

14. When opposite party became aware of these facts opposite party has terminated the policy of complainant by assigning the  above reasons and they have also refunded the last insurance premium amount this act of opposite party is expected by a prudent  insurance company and their action can be termed as justified and it is in accordance with terms and conditions of policy and company guidelines and the company policy also supports such procedure of opposite party .

15. Further an important and clinching point is   complainant is a doctor  being a medical practioner he is a well versed in the medical filed we expect that his act and action to be very fair , he is highly educated prudent  man in society when he obtained health policy from opposite party he is bound to give all particulars and whatever information, details which is required to be furnished by him. The complainant has knowingly and wilfully did not disclose the material fact that he had under gone angioplasty Procedure prior to obtain the said policy when this fact came to the knowledge of opposite party it resulted in termination of policy complainant is not entitle for the relief claimed for the reason that since when complainant violated the conditions of policy and for the breach of contract he is not entitle for any relief claimed. The opposite party has established his defence with cogent and convincing evidence it can be held that the repudiation of complainant claim is justified. Further the words used in repudiation as per conditions no .7 of policy the repudiation is not done by opposite party under medical grounds it is stated by opposite party that though the claim of complainant is medically pay able legally it is not pay able from these sentences it can be understood that even though the claim of complainant is medical payable for the violation of policy terms and condition.  The opposite party is estopped from settling lawful claim of complainant.

16. This opposite party submits that the complainant has not come to this Honourable forum with clean hands and his case is doubtful the opposite party has not denied the claim by whims and fancies and the opposite party has denied the claim only after the perusal of the claim records of the complainant. In fact the policy issued is subject to certain conditions clauses, warranties, exclusion etc., and this is a contract of at most good faith and this opposite party believes the complainant. But unfortunately, there is a non-disclouser of material facts which disentitles the complainant as per condition no.7. of the policy. If there is any mis representations/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to made any payment in respect of any claim and therefore the claim of the complainant is rightly rejected by the opposite party.

17. In view of the above, the complainant is not entitled to any relief at the hands of this Honourable Forum as there is absolutely no deficiency of service on the part of this opposite party at any point of time.

The complainant has relied   the below mentioned rulings of Hon’ble State Commission in support of his contention:

1. State Consumer commission West Bengal PA/166/2014

1.  Star Health and allied insurance Ltd and other V/s Bijay Kumar Bhattacharjee

2. State Commission Delhi Appeal no 931/05

 National Insurance co ltd,, V/s Sri Chandan Jain

3. State Commissioner Chandigarh F/A 86 of 2011

Star Health V/s Sanjeev Kumar Saini

4. National commission Delhi R/P No 3816/2012

Arun Kumar V/s New India insurance Com Ltd., and other

These ruling is not applicable to the case on hand.

18. Complainant has miserable failed to prove the deficiency of service on the part of opposite party .

The opposite party has relied on rulings in support of his contention

1.  Ramatti V/s LIC of India before N.D.C. IC of India which is reported in CPJ(1)2015-121.

2. In a case before National Commission between ICICI Bank Ltd V/s Pushpa Chordra and others which is reported in CPJ(1) 2015 62 NC.

3. In a case before National Commission between LIC of India Ltd., V/s Rammani Patra and reported  in CPJ IV 2015 529 NC

4. Before National Commission between chimni bai  Sohanla mehtha V/s New India Assurance company Ltd., and  reported 14 CPJ 2015II  654.

5. Before National Commission between LIC of India V/s Bimala Devi in CPJ 2016 57(NC).

6. Before National Commission LIC of India Ltd V/s Maya Devi reported in CPJ II 2016, 396 NC.

7. Before National Commission between LTC of India Ltd V/s Fathima Anthoniamma and others reported in CPJ II 2016,  49, NC.

19. The gist and principal of the above ruling in totality is suppression of pre-existing decease violation of policy conditions claim repudiated contract between parties falls in category of contract “uberrimae fidei “ it is not for proposer to determine whether information sought for is material for  the purpose of policy or not it was bounded duty of assured to disclose facts nexus  point has to be eschewed out of consideration otherwise the “uberrimae fidei “  shall stand violated repudiation justified.

20. The principal of these rulings is aptly applicable to the defence of opposite party. The opposite party has successfully supported his defence by way of material evidence and the ruling of national commission and thereby  he has proved that the repudiation of complainant claim is justified.

21. In view of these facts we are of our definite view that there is no deficiency in service on the part of opposite party they not liable to pay compensation to complaint. When such being the case the complainant is liable to be dismissed.

22. According to this forum we answered Point no.1 in the negative  and pass the following:

23. Point no.2:- For the above discussion we here by proceed to pass the following:

ORDER

1. The complaint is hereby dismissed.

2. Give the copies of this order to the parties, as per Rules.

(Dictated to the stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on the 18^th   February  2017)  

Shri Thammanna Y.S.,                                 Shri Ramachandra M.S.,    

          Member.                                                           President.                

LIST OF WITNESSES EXAMINED AND DOCUMENTS MARKED ON BEHALF OF COMPLAINANT

Evidence by way of affidavit on behalf of complainant:

CW-1           :   Dr. MANJAPPA

List of Documents Produced on behalf of complainant:

1        :         Insurance policy  

2        :         Pervious years policy     

3        :         Discharge summary of Hospital       

4        :         Insurance withdrawal and rejection of authorisation letter

5        :         Start health insurance company repudiations of claims

6        :         Insurance policy cancellation letter

LIST OF WITNESSES EXAMINED AND DOCUMENTS MARKED ON BEHALF OF OP.

Evidence by way of affidavit on behalf of OP :

RW-1 :         UPENDRA KUMAR NAIK

List of Documents Produced on behalf of OP :

1        :         Xerox copy of the star Senior citizens red carpet insurance form

                   duly singed by the  complainant dated 13.10.2011 agreeing to

                   the terms and conditions mentioned therin specifically.

2        :         Xerox copy of he authorisation for cashless treatment of the

                   insured patient.   

3        :         Xerox coy of the inputs given by the opposite party to their 

                   Advocate to prepare the objection statement containing two

                   pages.

4        :         Xerox copy of the discharge summary issued by Ganga Medical

                   centre and Hospital (P) limited pertaining to the treatment given

                    by them to the complainant herein.

5        :         Xerox copy of the coronary angioplasty report dated 03.05.2011

                   issued by Sri Jayadeva institute of cardiovascular sciences and

                   Research centre, Mysore Branch , KR Hospital premises.

Shri Thammanna Y.S.,                                 Shri Ramachandra M.S.,    

          Member.                                                            President.