O R D E R
By Sri. C.T. Sabu, President :
The case of the complainant is that complainant taken policy of Senior Citizens Red Carpet Insurance from the opposite party for the period 30/10/2012 to 29/10/2013 covering one person sum insured Rs.5,00,000/- and the same was renewed up to 30/10/2013 to 29/10/2014 vide policy No.P/181213/01/2014/005303 for a sum of insured Rs.3,00,000/- for one person. Before the renewal, complainant submitted a claim for Rs.23,000/- related with first policy. But the complainant received a letter from the opposite party stating that the claim of the complainant is repudiated and the subsequent renewal of the policy also rejected and the non-renewal of the policy also intimated to the complainant. Then the complainant approached to get back the premium amount as the opposite party not renewed the policy. But the Officer in Charge of the opposite party behaved unpleasantly and reluctant to pay the amount. Hence this complaint preferred.
2) The notice issued properly. On receiving notice opposite party appeared through their counsel and filed detailed counter contending that the complaint is not maintainable either in law and facts. The averments in the version are mentioned as below :
a) The opposite party admitted the policy
b) Proposal form is the basis and integral part of the insurance contract, on that basis the policy issued. The policy is issued strictly according to the terms and conditions only and it is a settled law that the parties to the insurance contract are bound by the terms and conditions of the policy issued. The policy issued to the complainant being a health policy, the complainant is bound to give proper information regarding the present and past health status at the time of filing the proposal which is material for proper underwriting of the proposal.
c) The policy is issued after accepting the facts in the proposal form on utmost good faith. The complainant has not mentioned any disease in the proposal form in the medical history column to the specific question that “Has the proposed person/suffered from any disease/illness or sustained any injury or disability due to accident involving hospitalisation in the proceedings 12 months or beyond preceding 12 months ?The complainant has answered “No” in both columns.
d) Moreover in the additional questionnaire of the proposal form there is a specific question that “Have you ever suffered or suffering from CANCER. The complainant has answered as No eventhough he aware of CA Sigmoid. The complainant wilfully suppressed the material facts from the opposite party and fraudulently obtained the policy.
e) After the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the insurance company is not liable for any claim. The complainant was admitted on 09/05/2013 at PVS Hospital, Calicut for the treatment of Anastomotic Stricture, Ca Sigmoid Post OP, Schwannoma Rt. Lung-Post OP, Diabetes Mellitus and after treatment discharged on 11/05/2013. And after treatment discharged on 11/05/13. If the material facts regarding the proposals pre-existing diseases were known to the insurance company the policy would not have been issued.
f) In the Discharge Summary clinical finding/history columns shows “A case of Ca Sigmoid-Anterior Resection, end colostomy & Hartman’s procedure on 13/11/2011 Reversal of Hartman’s done on 22/12/2011. History of Lung mass-Rt. Thoracotomy and excision of mass done on 02/11/2011. Now admitted with complaints of abdominal pain. History of DM on treatment. Course in the hospital columns shows ‘advised colonoscopic stricture dilatation. He wants to get it done at later date” It clearly indicates that the disease was existed from 22/12/2011 and knowing the fact fully complainant had taken policy on 30/10/2012 in order to get unlawful gain.
g) It is a clear case of pre-existing disease. The opposite party repudiated the claim on that basis and it was duly intimated on 29/07/2013 to the complainant. But the policy again renewed on 30/10/13 to 29/10/2014. While renewing the policy on 2014-15, the company intimated the customer the reason for non- renewal of the policy vide letter dtd. 03/10/2014 as per policy condition. The policy holder obtained policy by suppressing the previous cancer treatment. There is no deficiency in service hence the complaint has to be dismissed.
3) The points for consideration are follows :
a) Whether there is any deficiency in service from the side of
opposite party ?
b) If yes, reliefs and costs ?
4) When the case was posted for evidence the complainant filed proof affidavit to the tune of averments made in the complaint. The documents produced are marked as Exts. P1 to P6. Ext. P1 is the Advance Premium Receipt dtd. 30/10/12; Ext. P2 is the Senior Citizens Red Carpet Insurance Policy – Schedule; Ext. P3 is the copy of Repudiation letter dtd. 03/10/2014; Ext. P4 is the Advance Premium Receipt dtd. 21/10/2013; Ext. P5 is the Star Senior Citizens’ Red Carpet Insurance – Proposal Form and Ext. P6 is the Senior Citizen’s Red Carpet Insurance – Proposal Form. The opposite party also filed detailed counter proof affidavit in which they affirmed and explained all the averments made in their version. The documents produced by them are marked as Exts. R1 to R6. Ext. R1 is the copy of Senior Citizens Red Carpet Insurance Policy; Ext. R2 is the Copy of Discharge summary from PVS Hospital; Ext. R3 the copy of Pre-Authorisation Request Form; Ext. R4 is the Senior Citizens Red Carpet Insurance Policy – Schedule; Ext. R5 is the Repudiation letter dtd. 29/07/213 and Ext. R6 is the Authorisation Letter dtd. 29/11/2016.
5) We have examined the affidavit and perused the documents produced by both parties. The opposite party’s case is that there is no deficiency in service. The claim of the complainant was repudiated only because of the pre-existing disease. If the material facts in the proposal form regarding the pre-existing disease were known to the opposite party the policy would not have been issued. All the contentions of the opposite party is with regard to the claim under the 1st policy. But the opposite party failed to give explanation with regard to issuance of the 2nd policy for the period of 2014 to 15. But they intimated non - renewal of the policy by Ext. P3 letter. Moreover in the Ext. P3 document specifically stated that cheque for refund of premium calculated on prorate basis will be send shortly. The opposite party have not taken any contentions on that aspect and no explanation is given by them to show that any refund is made. Therefore on that aspect there is deficiency in service and we are inclined to allow the complaint partly.
6) The complainant is entitled to get the refund of premium of the policy as stated in the Ext. P3 document. Both parties have no dispute with regard to other matters going through the complaint as well as version.
7) In the result, the opposite party is directed to pay the premium amount received from the complainant for the renewal of policy No.P/181213/01/2014/005303 along with interest @ 9% from the date of receipt of payment. The opposite party also directed to pay Rs.3,000/- (Rupees Three thousand only) towards cost of this complaint. The order should be complied within one month from the date of receipt of copy of this order.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Commission this the 30th day of October 2021.
Sd/- Sd/-
Sreeja S. C. T. Sabu
Member President
Appendix
Complainant’s Exhibits :
Ext. P1 Advance Premium Receipt dtd. 30/10/12
Ext. P2 Senior Citizens Red Carpet Insurance Policy – Schedule
Ext. P3 copy of Repudiation letter dtd. 03/10/2014
Ext. P4 Advance Premium Receipt dtd. 21/10/2013
Ext. P5 Star Senior Citizens’ Red Carpet Insurance – Proposal Form
Ext. P6 Senior Citizen’s Red Carpet Insurance – Proposal Form.
Opposite Party’s Exhibits :
Ext. R1 copy of Senior Citizens Red Carpet Insurance Policy
Ext. R2 Copy of Discharge summary from PVS Hospital
Ext. R3 copy of Pre-Authorisation Request Form
Ext. R4 Senior Citizens Red Carpet Insurance Policy – Schedule
Ext. R5 Repudiation letter dtd. 29/07/213
Ext. R6 Authorisation Letter dtd. 29/11/2016.
Id/-
President
