Sri Devakumar.M.C.

Member

1.     The complainant has filed the complaint under section 12 of the C.P.Act 1986, against the opposite party, seeking a direction to continue the health policy and to pay `3,00,000/- as damages, `88,000/- towards the cost of dialysis, `2,00,000/- towards mental agony and other reliefs.
2.     The complainant subscribed to the senior citizen’s policy with opposite party on 29.03.2012 by submitting a duly filled in proposal form with a sum of `4,908/- towards premium.  The policy was renewed on 29.03.2013 on payment of `5,000/-.  The complainant was informed that, the policy covers the risk of renal failure from the 2^nd year of the policy i.e., from 29.03.2013.  The complainant submitted a mediclaim bill for a sum of `20,000/-.  The claim was repudiated and also cancelled the policy.  Thereby, the complainant alleging the deficiency in service on the part of opposite party, filed this complaint seeking reliefs.
3.     At the outset, the opposite party denied the allegations and submits, the complainant is not a consumer.  Hence, the complaint is not maintainable and liable to be dismissed.  The opposite party admits the issuance of policy on 29.03.2012 and also the renewal of the policy for the period 29.03.2013 to 28.03.2014.  The opposite party contends the repudiation of the mediclaim bill was on the ground of suppression of existing diseases.  As such there is no deficiency in service and hence, prays for dismissal of the complaint.
4.     Both parties to prove their contentions lead their evidence by filing affidavit along with documents.  The complainant counsel submitted oral arguments.  The opposite party counsel filed written arguments.  On perusal of the material on board, posted for orders.
5.     The points arise for consideration of this Forum are as follows:-

1. Whether the complaint is maintainable?
2. Whether the complainant proves the deficiency in service on the part of opposite party, in not honouring the claim and cancellation of the policy and thereby he is entitled for the relief sought?
3. What order?

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

Point No.1 :- In the affirmative.

Point No.2 :- Partly in the affirmative.

Point No.3:- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant being a senior citizen subscribed to the senior citizen’s Red Carpet Insurance policy on 29.03.2012, by paying a sum of `4,908/- towards premium for the period 29.03.2012 to 28.03.2013, without concealing the material facts about his health. Thereby the complainant becomes a consumer under section 2(1)(d) of C.P.Act is maintainable.  Accordingly, Point No.1 is answered in the affirmative.
8.    Point No.2:- The complainant was informed by the opposite party authorities, the policy covers the renal failure mediclaim after the 12 month of the policy.  Accordingly a mediclaim bill for a sum of `20,000/- was submitted for having availed the treatment at Columbia Asia Hospital, Mysore for renal problems.  But, the complainant received an intimation from opposite party’s office, stating repudiation of the claim and cancellation of the policy.  The complainant undergone dialysis twice a week by spending a sum of `1,100/- for each dialysis and has undergone dialysis continuously for a period of 10 months i.e. 80 times by spending `88,000/-.  The repudiation of claim and cancellation of the policy has caused loss, hardship and mental agony to the complainant.  Thereby, the complainant alleges the deficiency in service and sought for the reliefs.
9.    The opposite party contended that the complainant had suppressed the material facts in his proposal form by stating he is suffering from B.P. and diabetes only.  Though the complainant had renal problem, the same was not disclosed and concealed the fact by applying whitener intentionally in the proposal form.  Further, the medical team attached to the opposite party has ascertained the facts from the treating doctor that the complainant is a case of end stage renal disease and on dialysis since December 2011 i.e. prior to the issuance of the policy.  Hence, it is contended that suppression of material facts, which lead to repudiation of the claim.  Accordingly, condition No.7 of the policy, the opposite party is not liable to pay any compensation and prays for dismissal of the complaint.  As such, there is no deficiency in service and prays for dismissal of the complaint.
10.    On perusal of the material on board, the proposal form reveals that the complainant was suffering from B.P. and diabetes.  It is also noticed that a disease mentioned apart from B.P. and diabetes has been covered with whitener or eraser fluid.  So the insurance policy issued by opposite party indicates BP and diabetes only.  Anticipating benefits for the ailments suffered, the complainant had subscribed to the policy.  So there was no need for him to conceal any existing ailments.  Further, the complainant was well aware that he can claim benefits under policy from the 2^nd year for renal problem.  As such, there was no need to conceal the material facts by the complainant.  Further, once the proposal form submitted to opposite party, it is impossible for the complainant to put whitener on the disease mentioned already.  The photo copy taken by complainant, prior to submission of the proposal form, shows that the renal failure problem was clearly mentioned in the proposal form by complainant.  Further, in absence of the evidence on board, that the complainant was suffering from renal failure since December 2011, the contention of the opposite party is not justified.  In view of the above, it is concluded that the complainant not concealed any material facts relating to his ailments, as such the complainant needs to be compensated for mental agony and loss.  Accordingly, point No.2 is answered partly in the affirmative.
11. Point No.3:- In view of the above discussions, we hereby proceed to pass the following  

:: O R D E R ::

1. The complaint is partly allowed.
2. The opposite party is hereby directed to pay a sum of `88,000/- towards the cost of dialysis, to the complainant, within 45 days of this order.
3. The opposite party shall pay a sum `10,000/- towards mental agony, loss suffered and `2,000/- towards the cost of the proceedings, to the complainant, within 45 days of this order. 
4. In default, the opposite party shall pay a sum of `100/- per day as penalty, to the complainant until compliance is made.
5. In case of default to comply this order, the O.P. shall undergo imprisonment and also liable for fine under section 27 of the C.P.Act, 1986.
6. Give the copies of this order to the parties, as per Rules.