IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 19th day of July 2023
Present: Sri.Manulal.V.S, President
Smt.Bindhu.R, Member
Sri.K.M.Anto, Member
CC No.188/2022 (Filed on 31/08/2022)
Complainant : Jain.P. George,
Pulimoottil House,
S.H Mount P.O,
Kottayam – 686 006.
(By Adv: Mathew Philip) Vs.
Opposite parties : 1. Star Health and Allied Insurance
Company Limited,
Registered & Corporate Office,
1, New Tank Street,
Valluvarkottam High Road,
Nungambakkam, Chennai – 600 034.
2. The Branch Manager,
Star Health and Allied Insurance
Company Limited,
2nd Floor, Puthenpurackal Complex,
M.C Road, Kodimatha,
Kottayam – 686 013.
(Both by Adv: Avaneesh V.N)
O R D E R
Sri.Manulal.V.S, President
Case of the complainant is that he has taken a health insurance policy by name “Medi-Classic Insurance Policy (Individual) from the opposite parties for the period from 31-07-2021 to 30-07-2022 for a sum insured of Rs.4 lakhs.
Complainant suffered a twisting injury to the left knee during a slip and fall in the kitchen in March 2022 and consequently sustained injury to the left knee. Complainant consulted an Orthopaedic Surgeon of Caritas Hospital and as per medical advice complainant underwent an MRI scanning of left knee. Scanning report revealed complex tear in posterior horn of medial meniscus. The complainant was admitted at Caritas hospital on 14-06-2022 for further management and treated there as inpatient for 3 days and underwent for a surgical procedure for correcting the same on 15-06-2022. The total medical expenses at hospital was Rs.72,554/-. The application for cashless treatment was rejected by the opposite party stating that “the insured patient has ALD since 2018 and ACL injury from 2018’’. The insured has not disclosed this medical history in the proposal form and other portability forms at the time of porting the policy with us. This amounts to concealment of material facts and hence the policy was void abinitio.
It is submitted in the version that the complainant never suffered Alcoholic Liver Disease and ACL injury. The opposite party also sent a notice of cancellation dated 16-06-2022 proposed to cancel the policy with effect from 26-07-2022. So the complainant was forced to raise funds for his treatment contrary to the assurance of the opposite parties on cashless treatment. Hence this complaint is filed by the complainant praying for an order to set aside the notice issued by the opposite parties on 16-06-2022 and direct the opposite parties not to cancel the policy and further direct the opposite parties to pay Rs.72,554/- along with interest and Rs.25,000/- as compensation for the mental agony caused to him on the unjust denial of claim.
Notice was duly served to the opposite parties and the opposite parties filed version contending as follows:
The complainant took a Medi-Classic Insurance Policy (Individual) from the opposite parties for the period from 31-07-2021 to 30-07-2022 vide Policy No. P/181113/01/2022/004639 for a sum insured of Rs.4 lakhs. At the time of issuing the policy the complainant was supplied with the terms and conditions of the policy. The opposite party issued the policy to the complainant based on the proposal form submitted by him. In this case, the complainant has disclosed only Diabetes Mellitus and Hyper tension & cholesterol as pre-existing disease in the proposal form. As per the terms and conditions of the policy, benefits will not be available for pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first policy.
The opposite party received a request for cashless hospitalization from Caritas hospital stating that the complainant was admitted at the hospital on 14-06-2022 and was provisionally diagnosed with tear in the Posterior Horn on Medial Meniscus.
As per the “OP follow up record” of the hospital dated 27-03-2018, the complainant had undergone treatment for Osteoarthritis left knee (OA Knee LT) and on 23-06-2018, the complainant was again consulted and treated for Medial Meniscus tear left Knee. Moreover as per the OP record dated 21-12-2018, the complainant also underwent treatment for ALD and he was prescribed with medicines like Librax.
At the time of taking the policy, the complainant was well aware about this health condition and he has wilfully suppressed the disease in the proposal form, which is the basis of contract at the time of taking the policy. The complainant had answered in negative to the specific question in the medical history column 2 of the proposal form. As per condition No. V(1) of the policy, the policy shall become void in the event of mis- representation, mis-description or non-disclosure of any material fact by the policy holder. Hence the opposite parties had rejected the authorization for cashless treatment and communicated to the hospital and complainant. As per Condition No. V(7) of the policy, the company may cancel the policy at any time on the grounds of mis- representation, mis-description or non-disclosure of any material fact, fraud by the insured person by giving 15 days written notice. Hence as per the condition, a notice dated 16-06-2022 was issued to the complainant and informed that the coverage in the name of his policy was cancelled with effect from 26-07-2022 and Rs.24,201/- being the premium has been refunded to the complainant. It is submitted in the version that the complainant has only availed cashless facility and after discharge from the hospital no bills/documents were submitted before the opposite parties for reimbursement. The opposite parties had acted as per the terms and conditions of the policy. There has been no arbitrary decision from the opposite parties. As the complainant had not disclosed the material facts to the opposite parties, the policy became void and the opposite parties are not liable to pay any claim.
Complainant is examined as PW1 and Exhibits A1 to A8 were marked from his side. Padma Prabha.P who is the General Manager (Legal) of the opposite parties filed proof affidavit in lieu of chief examination and marked` Exhibits B1 to B3.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
(1) Whether there is any deficiency in service or unfair trade practice on the part of the opposite party?
(2) If so what are the reliefs and costs?
POINTS 1 & 2 :-
For the sake of convenience we would like to consider the point number 1 and 2 together.
There is no dispute on the fact that the complainant had availed Exhibit A2 Medi-Classic Insurance Policy (Individual) from the opposite parties for the period from 31-07-2021 to 30-07-2022 vide Policy No. P/181113/01/2022/ 004639 for a sum insured of Rs.4 lakhs.
It is proved by Exhibit A5 that the complainant was treated at Caritas Hospital, the diagnosis was ‘complex tear of posterior horn of medial and lateral menisci left knee, systemic hypertension, dyslipidemia, type 2 diabetics mellitus and lipoma left foot’ and he underwent for Arthroscopic medial meniscus balancing-left knee, excision of left foot swelling under SA on 15-06-2022. Exhibit A5 proves that the complainant was admitted at Caritas hospital on 14-06-2022 and discharged on 16-06-2022 .
It is proved by Exhibit A6 that the complainant had spent Rs.72,554/- for the treatment and for various tests.
The claim of the complaint was repudiated and policy was cancelled by the opposite party vide Exhibit A7 on the ground that “the insured patient has ALD since 2018 and ACL injury from 2018. The insured has not disclosed this medical history in the proposal form and other portability forms at the time of porting the policy with us. This amounts to concealment of material facts”.
On perusal of Exhibit A8 which is “OP follow up record” of the complainant at Caritas hospital we can see that there was an endorsement on the same on 27-03-2018 as OA(L) knee and (L) knee dislocation. Further there is another entry on 23-06-2018 as “? Medial meniscus tear (L) Knee”
The question is not whether the complainant was suffering any pain or not, but the question is that the factum regarding injury to the right knee suffered by the complainant in the year 2018, was not disclosed by him at the time of obtaining the mediclaim policy. The claim of the complainant was repudiated under two clauses of the insurance policy, namely, clause Nos. V(1) and V(7) of the insurance policy. As per clause V(1) of the policy provides that the policy shall become 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. Clause V(7) of the policy condition empowers the insurer to cancel the policy at any time on grounds of mis-representation, mis-description or non-disclosure of any material fact, fraud by the policy holder by giving 15 days written notice.
Exhibit A1 which is the proposal form contained questions pertaining to the health and medical history of the proposer and required a specific disclosure on whether any ailment, hospitalization or treatment had been undergone by the proposer. The proposer answered the queries in the negative, indicating thereby that he had not undergone any medical treatment or hospitalization and was not suffering from any ailment or disease except hypertension, cholesterol and diabetics. The declaration under Item 4(f) of the proposal form was in regard to whether any disease bones/joints, slipped disc, spinal disorder, injury to ligaments were involved. This query was also responded to in the negative. Acting on the basis of the proposal submitted by the proposer, a policy of insurance was issued by the opposite parties.
The complainant relied on decision of Hon’ble high Court of Kerala reported in 2019 (4) KLT 785(Star Health Insurance Co Vs. Satheesh Menon). In that case insured went to hospital for consultation on the basis of a throat pain. In this case the Hon’ble High Court has held that “ the disease may have many symptoms and mere swelling of the neck cannot invariably mean that a patient is suffering from Palpillary Carcinoma Thyroid. A disease can be said to be contracted for the purpose of insurance claim only when after diagnosis it is clinically found that the patient is suffering from the disease.” Here in this case on hand it is proved by Exhibit A8 that the complainant had consultation with the Orthopaedic Surgeon of Caritas hospital on 27-03-2018 and the diagnosis was as OA(L) knee and (L) knee dislocation. Further there is another entry in Exhibit A8 on 23-06-2018 as “? medial meniscus tear (L) Knee” Thus we are of the opinion that the said decision is not helpful to the complainant.
Evenif it is taken that the complainant did not feel any pain and had not undergone for the treatment between March 2022, it is proved from the documentary evidence available on record that the complainant – patient was suffering from OA(L) knee and (L) knee dislocation and medial meniscus tear (L) Knee in his right knee since 2018, hence the claim was not payable. On the evaluation of evidence on record we are of the opinion that complainant failed to prove any deficiency in service or unfair trade practice on the side of the opposite parties and the complaint is liable to be dismissed.
In the result the complaint is dismissed.
Pronounced in the Open Commission on this the 19th day of July, 2023
Sri.Manulal.V.S, President Sd/-
Smt.Bindhu.R, Member Sd/-
Sri.K.M.Anto, Member Sd/-
APPENDIX :
Witness from the side of the Complainant:
PW1 - Jain.P.George
Witness from the side of Opposite Parties :
Nil
Exhibits from the side of the Complainant :
A1 - Copy of Proposal Form
A2 - True copy of Medi-Classic Insurance policy
A3 - True copy of Collection receipt dated 02/08/2021
for Rs.24,406/- issued by the 2nd opposite party
A4 - Copy of MRI Scanning Report
A5 - True copy of Discharge Summary issued by Caritas Hospital
dated 16/06/2022
A6 - Original Medical Bills(8 Nos.) for Rs.72,554/- issued by
Caritas Hospital
A7 - Copy of notice of cancellation of insurance policy
A8 - Copies of OP follow up record of the complainant
at Caritas hospital
Exhibits from the side of Opposite parties :
B1 - Copy of Policy Schedule
B2 - Copy of Policy Conditions
B3 - Copy of Request for cashless hospitalization from
Caritas Hospital. Kottayam
By Order,
Sd/-
Assistant Registrar
