By Smt. Beena. M, Member:
This is a complaint filed under section 35 of the Consumer Protection Act 2019.
2. Brief facts of the case are as follows:- The Complainant had taken a Family Health Optima Insurance Policy from Star Health & Allied Insurance Company Ltd. in the year 2016 and it was renewed by paying premium amount periodically. While so, the Complainant’s wife Mrs. Laila was admitted on 30/09/2019 in Aster Mims Hospital, Calicut due to ventral hernia and underwent laparoscopic mesh repair. Subsequently, the Complainant submitted the claim form to Opposite Party for reimbursement of medical expenses incurred, but the Opposite Party repudiated the claim on the reason that at the time of submitting the proposal, the Complainant had suppressed the material facts regarding the pre-existing disease of the Complainant’s wife and was treated for renal diseases. The Complainant further stated that he had revealed to the agent of the Opposite Party about the renal disease. So the Opposite Party is bound to pay the claim amount. This act of the Opposite Party in denying claim is a deficiency in service. Hence the Complainant filed this Complaint seeking relief such as to direct the Opposite Party to pay an amount of Rs.1,86,990/- with 18% interest and further to pay compensation of Rs. 20,000/- and Rs. 10,000/- as cost of the Complaint.
3. The Opposite Party appeared before the Commission, filed version and contested the case. The Opposite Party averred that the Complainant had taken Family Health Optima Insurance Policy for himself and his family for Rs. 5,00,000/- on 11/10/2016. The Complainant had renewed the said policy up to 19/10/2020. The terms and conditions of the Policy were explained to the Complainant at the time of proposing the policy and the same was served to the Complainant along with the policy schedule. On the basis of the proposal form, the Opposite Party issued an insurance policy. In the proposal form, the Complainant has specifically declared that the proposers were not suffering from any diseases or ailment at the time of submitting the proposal form. In the proposal form, the Complainant had further declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the Insurance Company would incur ‘no liability’ under the policy. In the discharge summary issued by Aster MIMS, Calicut, the treated doctor had recorded in the secondary diagnosis column that ‘Chronic Kidney Disease- proteinuria -on medicines, Hypertensions, Diabetes Mellitus.’ Hence as a part of the claim proceedings protocol, the Opposite Party conducted investigation and collected records from Aster MIMS, Calicut. As per the records the Complainant’s wife was admitted at the same Hospital from 07-01-2010 to 08-01-2010 as was diagnosed with Type 2 diabetes mellitus, Acute glomerulonephritis with nephrotic range proteinuria and also in the past medical history column it was noted that the patient had undergone renal biopsy and as per treatment record dated 04-10-2011, the Complainant’s wife had history of Diabetic Mellitus, Hypertension and Protein uric Chronic Kidney Disease. Based on the medical records, Complainant’s wife had pre existing decease at the time of taking policy, the Complainant was well aware of the health condition of his wife and he has willfully suppressed the pre-existing disease of his wife in the proposal form. As per Condition No.6 of the policy, the Company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect/false. Hence Company has repudiated the claim and the same was communicated to the Complainant vide letter dated 05/12/2019, as the insured had willfully suppressed the pre-existing diseases in the proposal form, which is the basis of contract. The allegations made in the Complaint are false. No deficiency in service or unfair practice and any type of negligent attitude had been from the side of the Opposite Parties. So, the Opposite Party prayed for dismissal of the Complaint with compensatory costs.
4. On perusal of complaint, version, and documents, the Commission raised the following points for consideration:-
1. Whether the Complainant is entitled to get medical claim from the
Opposite Party?
2. Whether the Complainant is entitled to get compensation and what order
as to cost.
5. Point No. 1 and 2 :- For the sake of convenience and brevity all points are considered together.
6. The Complainant was examined as PW1 and the documents produced were marked as Ext. A1 to A6. OPW1, Mr. Balu, the Asst. Manager, Legal, M/s Star health and allied insurance company Ltd was examined from the side of the Opposite Parties and Ext. B1 to B8 were marked.
7. The case of the Complainant is that the claim amount was not paid to the Complainant as per the policy. The main issue to be discussed in this case is whether the Complainant suppressed details of his wife’s pre-existing diseases at the time of joining the policy. From the availing records it is found that Complainant’s wife had suffered Chronic Kidney Disease- proteinuria -on medicines, Hypertensions, Diabetes Mellitus and she was treated as an inpatient in Aster WIMS Hospital, Calicut. But in the proposal form all respected columns regarding previous health history were answered as “No” by the Complainant. Here, Hypertension existed for sometimes but it might be under control at the time of filling up of the proposal form. Moreover, It is well settled that the insurance claim cannot be denied on the ground of common lifestyle disorders such as diabetes or hypertension. The pre existing disease must have a length of 48 months prior to the inception of the first policy. On the other hand, it has to be proved by the insurer that the policy holder was suffering from pre existing disease for two years prior to the purchase of policy. As per the certificate Ext A6, Dr. Abhishek Rajan has opined that the current problem of the Complainant is unrelated to the previous renal disease. In the light of the opinion given by the doctor, in our considered view, the conditions in which the Complainant was hospitalized should not necessarily be the result of pre-existing disease. Apart from this, the Opposite Party has not brought any evidence to contradict the findings of Dr. Abhishek Rajan given in Ext. A6. In these circumstances, the repudiation of the claim on the ground that the diseases for which the Complainant has been treated, were pre existing cannot be justified. So the points are found in favour of the Complainant.
In the result Complaint is allowed partly and the Opposite Party is directed to pay Rs. 1,86,990/- (Rupees One Lakh Eighty Six thousand Nine hundred and Ninety only) to the Complainant with 6% interest towards the expenses of medical treatment from the date of filing the petition till date of payment. The Opposite Party is also directed to pay Rs.10,000/- (Rupees Ten thousand only) as compensation for loss and damages and also Rs. 5,000/- (Rupees Five thousand only) towards cost of proceedings.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 31st day of October 2022.
Date of filing:27.01.2020.
PRESIDENT: Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. Abdul Gafoor. Complainant.
Witness for the Opposite Party:
OPW1. Balu. M. Assistant Manager, Legal.
Exhibits for the Complainant:
A1. Policy Schedule.
A2. Advance Premium Receipt.
A3. Discharge Summary.
A4. U S G Abdomen Report. dt:17.05.2019.
A5(a). Bill No.UNG/2019-20/BILL/19416. dt:30.09.2019.
A5(b) Bill No.IPP/190953. dt:30.09.2019.
A5© Bill No.IPP/192196. dt:01.10.2019.
A5(d) Bill No.IPP/191334. dt:01.10.2019.
A5(e) Bill No.IPP/193217. dt:02.10.2019.
A5(f) Bill No.IPP/194052. dt:03.10.2019.
A5(g) Bill No.IPP/194052. dt:03.10.2019.
A5(h) Bill No.IPP/193217. dt:02.10.2019.
A5(i) Discharge Bill (Bill No.MT/2019-20/BILL/287). dt:04.10.2019.
A5(j) Bill No.RBI/2019-20/BILL/151004. dt:14.10.2019.
A6. To whom so ever concerned. dt:05.10.2019.
Exhibits for the Opposite Party:
B1. Copy of Proposal Form.
B2. Copy of Policy Schedule.
B3. Copy of Discharge Summary.
B4. Copy of Discharge Summary (Nephro 1st Visit).
B5. Copy of Letter. dt:05.12.2019.
B6. Copy of Letter. dt:03.10.2019.
B7. Coy of Letter. dt:19.12.2019.
B8. Copy of Letter. dt:21.12.2019.
PRESIDENT : Sd/-
MEMBER : Sd/-
