Complaint filed on:02-06-2023.

                                                      Disposed on:24-04-2024

BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, TUMAKURU

DATED THIS THE 24^th DAY OF APRIL, 2024

PRESENT

SMT.G.T.VIJAYALAKSHMI, B.Com., LLM., PRESIDENT

SRI.KUMARA.N, B.Sc. (Agri), LLB., MBA., MEMBER

SMT.NIVEDITA RAVISH, B.A., LLB. (Spl)., LADY MEMBER

CC.No.63/2023

Smt.Mumthaz.S W/o Nazeer Sab,

A/a 42 years, 3^rd cross, Shaktinagara,

Turuvekere town, Turuvekere,

Tumakuru District-572 227.

……………….Complainant/s

(By Sri.Kishor.R, Advocate)

                                                V/s

STAR Health and Allied Insurance Co, Ltd.,

#221, 1^st floor, 9^th main road, 5^th block,

Jayanagar, Bengaluru - 560 041.

……………….Opposite Party/s

(By Smt.Mamatha K.P – Advocate)

: O R D E R :

BY SMT.NIVEDITA RAVISH –  LADY MEMBER

This complaint is filed by the complainant Under Section 35 of Consumer Protection Act, 2019 against the Opposite Party (hereinafter called as OP) to direct the OP to grant compensation of Rs.12,00,000-00 with 12 % interest from the date of filing of the complaint till realization.

2.       The case of the complainant that, the complainant has availed the insurance policy No.P/141125/01/2020/015972 in Family Health Optima Insurance Plan in the year 2019 and the said policy renewed every year. The said policy was obtained by the son of the complainant. In the month of March 2022, the complainant had severe chest pain and the complainant was firstly took to Fortis Hospital at Tumkur there it was found that the complainant was with severe cardiac issues and the complainant was taken to Kasturaba Hospital at Manipal for further treatment. The complainant admitted in Kasturaba Hospital, Manipal from 05-03-2022 to 17-03-2022 and underwent several surgeries and spent more than Rs.8,00,000-00 towards treatment, medicine, hospital charges among other expenses. The OP has offered cashless treatment in the insurance policy, when the said disease contracted by the complainant was intimated to OP and the OP repudiated the complainant’s claim for treatment expenses with a baseless and malafide reason stating “the complainant was with previous history of ill-health”. Though the doctor at Kasturaba Hospital has given an opposite opinion to the same the OP has rejected the cashless treatment and repudiated the claim for reimbursement of medical expenses. Hence, this complaint.

3.        After issuing the notice by this commission, the OP has appeared before this commission with their counsel and filed version.  

4.        The OP has admitted that, the son of the complainant took said Family Health Optima Policy for sum assured of Rs.5,00,000-00 and the above policy renewed from 2019-2020 to 2021-2022. Further OP has admitted that, the complainant reported claim during the 2^nd year of the Policy in claim No.CIR/2022/141145/3944738. For reimbursement of medical expenses of Rs.5,06,000-00. The OP has submitted that, the complainant raised their authorization request to avail cashless facility and on perusal of the claim documents, the OP give reason in rejection of authorization for cashless treatment dated 07-03-2022 by giving reason that, the complainant failed to disclosed pre-existing disease in the time of inception of the 1^st policy. Further the complainant has filed claim form along with medical document on 18-03-2022 and after scrutinizing the documents, it is observed from the medical records that, the insured person has MVP prior to inception of medical insurance policy, which is the pre existing diseases and which is not disclosed by the insured person in the proposal form, which amount to misrepresentation / non disclosure of material facts. Further the OP has submitted that, the OP has not liable to make any payment in respect of any claim while there is misrepresentation on behalf of insured person. Therefore the OP has submitted that, there is no any deficiency on service on the part of the OP and prayed for the dismissal of the complaint against the OP.    

5.       The complainant filed her affidavit evidence with documents? One shri. Manjunath.T.L. Branch Manager of OP filed his affidavit evidence on behalf of OP with Nine documents, which are marked as Ex.R1 to R9.

6. .  We have heard the arguments from both counsels and on perusal of pleadings, evidence and documents, written arguments filed by complainant, the points that would arises for our determination as follows:

1. Whether the complainant proves the deficiency in service on the part of OP?

2. Is complainant entitled to the reliefs sought for?

7.       Our findings on the aforesaid points are as follows:

Point No.1: Negative

Point No.2: As per below order

:R E A S O N S:

Point Nos.(1) & (2):-

08.     Counsel for the complainant has argued that, the complainant has availed the insurance coverage vide policy No.P/141125/01/2020/015972 in Family Health Optima Insurance Plan in the year 2019 and said policy was renewed every year and the said policy was obtained by the son of the complainant. The OP has admitted the same. Copies of the policy schedule produced by the complainant establish the same. Further counsel for the complainant has contended that, in the month of March 2022, the complainant had severe chest pain and she was firstly took to Fortis hospital at Tumkur there it was found that the complainant was with severe cardiac issues and then she was taken to Kasturaba Hospital at Manipal for further treatment. Copy of discharge summary of Kasturaba Hospital, Manipal produced by the complainant is establishes that, the complainant has admitted in the Kasturba Hospital, Manipal from 5-3-2022 to 17-3-2022 and same document is reflecting as, Therapeutic Procedures “MV repair Annuloplasty with SJM26 mm saddle ring done on 11-3-2022”. But in the same time the complainant produced the document of History, Examination, Treatment, progress and operation, the same document reflecting number 17 and reflecting as “New” and the registered date is 22-01-2022. The same document is establishing that the complainant has went for the treatment in month of January 2022 to the Kasturba Hospital, Manipal. Further same document showing reflecting that, the treating doctor of Kasturba Hospital, Manipal has referred for MV repair for the complainant.

09.     Further counsel for the complainant has argued that the OP has rejected the cashless treatment and also repudiated the claim of the complainant on the basis of the non-disclosing of the pre-existing disease of the complainant. The OP has also admitted that the above argument of the complaint. Copy of the “Rejection of Authorization for Cashless Treatment dated 07-03-2022” reveals the same. Further, counsel for complainant has argued that, the complainant has no history of particular disease and produced the copy of opinion given by the treating doctor at Kasturba Hospital, Manipal. Which is reflecting that, the treating doctor has given opinion that, the complainant has no previous history of any pre-existing cardiac disease. Further, counsel for the complainant has argued that the complainant has spent more than Rs.8,00,000-00 towards treatment, medicine, hospital charges, ambulance charges etc., by availing loan from her friends, relatives etc., The complainant has not produced any evidence to show that, she availed loan from her friends relatives etc., But the complainant produced the total impatient bill of cash Kasturba Hospital, Manipal, which is reflecting “No.IP/21-22/64621CS, date 17-03-2022 and total amount of Rs.5,07,600-00”. Further, counsel for the complainant relied on the judgment rendered by the Hon’ble Supreme Court in Manmohan Nanda V/s United India Insurance Co. Ltd., and in Om Prakash Ahuja V/s Reliance General Insurance Co. Ltd., etc.

10.     Per contra, the counsel for the OP has argued that, though there is valid policy in force in favour of the complainant and the complainant has failed to disclose the pre-existing disease while taking 1^st policy and which has direct nexus to the treatment taken by the complainant on 05-03-2022 to 17-03-2022 in the Kasturba Hospital Manipal. Further the counsel for OP has contended that, the complainant have the heart disease since before inception of the 1^st policy. To prove the same the OP has produced the Ex.R1/ copy of the proposal form of policy and Ex.R3/copy of medical document of Fortis Adarsha Heart Hospital dated 21-08-2019. Ex.R1 establishes that, the son of the complainant has taken the 1^st policy on 18-11-2019 and Ex.R3 reflecting that, the complainant took the treatment on 21-08-2019. Which is before 3 months of the inception of the 1^st policy. Further on perusing the Ex.R1 the son of the complainant has filled as a “No” in the column pertaining to his mother, in column No.4(c) which is for health history regarding “Heart Disease”. Further on perusing the Ex.R3, Final Impression given by the consultant cardiologist of Fortis Adarsha Heart Hospital, it is mentioned

as-Final Impression:

MITRAL VALVE PROLAPSE, MODERATE MR.

MILD TR WITH MODERAT PAH (PASP-54MMHG)

DILATER LA,

NO RWMA

No RML LV SYSTOLIC FUNCTION LVEF 60%

No CLOT/VEG/PE

(TACHYCARDIA NOTED DURING STUDY)

We examine / verify the word “MITRAL VALVF PROLAPSE, MODERATE MR and it is found that, “Mitral valve proplapse (MVP), also known as floppy mitral valve syndrome, systolic click-murmur syndrome, and billowing mitral leaflets, is valve heart disease. It is generally considered a benign condition, however, at times, it may present with sudden cardiac death, endocarditis or cerebrovasular accident”. Hence we have considered that MVP is a heart disease

11.     Further counsel for the OP has argued that, the OP is not liable to make a payment on the claim of the complainant as per condition No.1 of the Policy and Policy is also liable to be cancelled and necessary action will be taken as per condition No.7 of the policy. To prove the same the OP has produced Ex.R9/ copy of terms and conditions of Family Health Optima Insurance Plan. On perusing the standard conditions in Ex.R9 point No.1 is explaining as “1) Disclosure of Information. The Policy shall be void and all premium paid thereon shall be forfeited to the company, in the event of mis-representation, mis description or non-disclosure of any material fact by the policy holder”. Point No.7 (ii) of standard conditions in Ex.R9 is explaining as “(ii) The company may cancel the policy at any time on grounds of misrepresentation, non-disclosure of material facts, fraud by the insured person by giving 15 days written notice. There would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure of material facts or fraud”. Further it is defined the “pre-existing Disease in the clause of Definitions in Ex.R9 as, “Pre-existing Disease means any condition, aliment, injury or disease:

           a) That is / are diagnosed by a physician within 48 months     prior to the effective date of the policy issued by the insurer or its reinstatement or

           b) For which medical advice or treatment was recommended by, or received from a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.                                                    

12.     In the present case the son of the complainant availed the 1^st policy on 18-11-2019 and as per Ex.R3, the complainant has diagnosed with “MITRAL VALVE PROLAPSE-MODERATE” on 21-08-2019, which is prior to 3 months before availing the 1^st policy by the complainant’s son and same Ex.R3 is not objected by the complainant. Further, though knowing there is heart disease to the complainant the son of the complainant has not disclosed the pre-existing disease in the proposal form. The Ex.R1 is signed by the insured person, who is the son of the complainant. When the proposal accepted insured should be bound by the terms and conditions of the policy. The counsel for the complainant has relied upon the citation / decisions of the Hon’ble Supreme Court in Manmohan Nada V/s United India Insurance Co. Ltd., and in Om Prakash Ahuja V/s Reliance General Insurance Co. Ltd., etc., But these decisions are not came to help / rescue to the complainant in the present case. Because facts and circumstances are different in the instant case. In the present case the complainant has took treatment for Mirtal Valve replacement on 05-03-2022 to 17-03-2022 in Kasturba Hospital, Manipal. Which is the direct nexus with the diagnosed as MVP on 21-08-2019 in Fortis Adarsh Hospital, Tumkur as per Ex.R3. Hence we have not found any deficiency in service on the part of the OP in rejecting cashless treatment and repudiating the insurance claim of the complainant and complaint is liable to be dismissed. Accordingly we proceed to pass the following;

:O R D E R:

Complaint filed by the complainant is dismissed without any cost.