By. Smt. Bindu. R, President:
The complaint is filed by Jose. A, S/o. Augustian alleging that during 2016, one Mr. Jyohi Prakash. N. G claimed to be the Sales Manager of Opposite Party No.2 approached the Complainant and canvassed to take a mediclaim insurance policy and the Complainant consented to avail the health insurance policy mainly on account of the promise that he could avail cashless treatment from the listed hospitals. The Complainant signed all the papers and paid the premium to the said Sales Manager on 26.12.2016 and subsequently policy certificate was issued. Assurance was also given to the Complainant that the renewal of the policy will be intimated and they will be approaching the Complainant for renewal. But the Opposite Party had not intimated the reminder for renewal and hence the same became lapsed. In February 2018, the said Sales Manager approached the Complainant requesting him to renew the policy assuring blameless service and the Complainant again signed all the papers and paid the premium on 28.02.2018. Subsequently policy certificate was also issued to the Complainant.
2. On 18.09.2018 the Complainant was admitted in Shanthi Ayurveda Hospital, Ayikkarapadi with symptoms of skin disease. Immediately the matter was informed to the Opposite Party and the Complainant was issued claim intimation number and no positive response was received from Opposite Party regarding the availability of cashless treatment on the basis of policy. Hence the Complainant forced to pay the bill amount in the hospital. The said Sales Manager assured the Complainant that he will take up the matter with the Company and would see that the matter will be settled in favour of the Complainant and accordingly Complainant was directed to send the claim form with bills, discharge summary etc.. In the meanwhile the Complainant received a letter from Opposite Party No.2 on 04.01.2019 stating that the claim had been repudiated since the Complainant had history of psoriasis since 2014. According to the Complainant he is not a psoriasis patient never treated for the same and he had not suppressed any material facts at the time of taking policy. On 15.02.2019 the Opposite Party No.2 sent a DD for Rs.2,962/- with covering letter stating that “due to non-disclosure of material fact (ie about existing of pre-existing disease) the current policy is cancelled and premium is refunded herewith)”.
3. The Complainant further alleged that the repudiation of the claim is improper and they have ignored the fact about the earlier policy taken by the Opposite Party which was not renewed due to the fault of the Opposite Party. According to the Complainant since the Complainant is entitled to have cashless treatment as per the policy, the Opposite Parties ought to have given the treatment expenses first and then to repudiate the claim to recover the same from the Complainant. The Complainant further stated that mediclaim policies as part of the social security scheme of the Government, pay and recovery is the rule and not to the exception. Thus there is breach of duty on the part of the Opposite Party and hence the Complainant prays for the reliefs claimed in the complaint.
4. On getting notice the Opposite Party appeared and filed their version stating that the Complainant had took a Medi Classic Insurance Policy (Individual) commencing from 28.02.2018 to 27.02.2019 for a sum insured of Rs.1,50,000/- and the terms and conditions of the policy are supplied to the Complainant and the policy is issued on the basis of proposal form. It is stated by the Opposite Party that the Complainant was admitted in the Shanthi Ayurveda Skin Speciality Hospital for the treatment of psoriasis and as per the discharge summary the Complainant is suffering from psoriasis. As per the hospital records of DM Wayanad Institute of Medical Sciences the Complainant had history of Chronic Plaque Psoriasis as on 16.09.2014. Since as per the policy conditions, the pre-existing diseases are excluded and also for the reason that at the time of inception of the policy, the Complainant has not disclosed the medical history/health details in the proposal form, the details are not given by the Complainant. It is stated by the Opposite Party that as per condition of the policy notice dated 07.01.2019 was issued to the Complainant informing the cancellation of policy w.e.f 16.02.2019 and also the premium is returned as per DD dated 14.012.2019.
5. It is stated by the Opposite Parties that the contract of insurance is an uberimafide contract and it is the duty of the insured to state the details correctly in the proposal form. It is also stated that the insurer is obliged to disclose the details which are under knowledge of the insurer. It is admitted by the Opposite Party that the Complainant had a Medi Classic Policy for a period commencing from 26.12.2016 to 25.12.2017 for a sum insured of Rs.1,50,000/- but the same was not renewed by the Complainant for getting the continuity benefit even though it is advised by the Opposite Party. The non-renewal of the policy is only because of the negligence and carelessness from the part of the Complainant. The agent of the policy had intimated the Complainant about the renewal of the policy. Moreover Opposite Parties had intimated about the renewal to the Complainant in time but the Complainant was not interested. Thus the policy had become lapsed and Complainant lost its continuity. On 28.02.2018, the Complainant approached the agent and the Opposite Parties with request to renew the policy which was not possible. Then the Complainant submitted a new proposal forma nd on that basis the new policy was issued to the Complainant, in which it is not stated anything about the pre-existing diseases. It is contented by the Opposite Party that since the hospital where the Complainant was admitted and undergone treatment was a non-network hospital and no cashless facility will be made available in a non-network hospital and the same was intimated to the Complainant before the date of discharge. It is contented that the Opposite Party that from the hospital records, it is clear that the Complainant had history of Chronic Psoriasis as on 16.09.2014. Which means, the Complainant had given a false statement in the proposal form. The Claim was repudiated on the terms and conditions of the policy and the reason is clearly mentioned in the repudiation letter forwarded to the Complainant and as per condition 13 of the policy, the Opposite Party had returned the premium amount of Rs.2,962/- as per DD dated 14.02.2019. It is also stated in the version that there is deficiency of service on the part of the Opposite Party and since the previous policy was lapsed as not renewed due to the carelessness and negligence of the Complainant itself, the Complainant cannot take advantage of the lapsed policy. It is stated by the Opposite Parties that since the Opposite Party is functioning under the guideline of IRDA controlled by Government of India and dealing public money the Company must exercise abundant caution in dealing with claims and the Commission considered the matter in detail.
6. It is the case of Complainant that on the assurance made by the Sales Manager of 2nd Opposite Party that the Complainant could avail cashless treatment from the listed hospital without worry about the cash requirement for the treatment, the Complainant signed all the papers and paid the premium to the said Sales Manager on 26.12.2016 and subsequently a policy certificate was issued and since no reminder received regarding renewal, the policy was not renewed in time and the same was elapsed. The Complainant again took the policy from the same Sales Manager in 2018 and subsequently the Policy Certificate is issued to the Complainant. Therefore prayed for dismissal of the complaint with costs to the Opposite Parties.
7. The evidence consists of the oral evidence of PW1 and Ext.A1 to A7 from the side of the Complainant and documentary evidence Ext.B1 and B2 from the side of Opposite Parties.
8. The following questions are coming up for consideration:-
- Whether the Complainant had sustained to any deficiency of service from the Opposite Parties?
- Whether the Complainant is entitled to get any compensation from the Opposite party. If so, the quantum of compensation
- Whether the Complainant is entitled to get cost of the proceedings.
9. Point No.1:- From this it is very clear that the Complainant had no case that the Opposite Party or the Sales Manager of Opposite Party is cheated the Complainant. It is thereafter in 18.09.2018 the Complainant is hospitalised with symptoms of skin disease and claim application was filed. Which is repudiated by the Opposite Parties without even considering earlier policy which is lapsed and hence there is deficiency of service on the part of the Opposite Parties. It is deposed by PW1 that the earlier policy was not renewed since he is not interested and the second policy was taken in 2018. According to the PW1, he was admitted in the hospital for soothing and not for treatment. It is admitted in the box that psoriasis was detected in the hospital. Ext.B2 in which it is marked that history of Chronic Plaque Psoriasis. Ext.B2 is the General OP Card of the Complainant from DM WIMS Hospital in which it is marked as History of Chronic Plaque Psoriasis scalp Psoriasis and the date mentioned is 16.09.2014. On the other hand the evidence of the Opposite Party shows medical check up was not conducted since the Complainant was 43 years on that time. According to OPW1, the medical check up is needed only in the case of above 50 years of age. It is deposed by the OPW1 that the records of DM WIMS Hospital of the year 2014 was collected by the investigation team of the Company and it is deposed by PW1, that it is not correct to say that the medical check up was not done for the reason that the second policy is in continuation of the first policy. According to OPW1, the valid policy was of the year 2018-19 and the claim was repudiated and thereafter policy was later cancelled by the Opposite Party.
10. Considering the entire evidences on record this Commission came to the conclusion that the Complainant has not proved the deficiency of service on the part of the Opposite Party. Hence Point No.1 found against the Complainant.
11. Since Point No.1 is found against the Complainant, Point No.2 & 3 need not be considered by the Commission.
In the above circumstances, the complaint is dismissed without costs.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 5th day of June 2023.
Date of Filing:-29.02.2020.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the Complainant:-
PW1. Jose. A. Driver.
Witness for the Opposite Parties:-
OPW1. Balu. M. Assistant Manager, Legal.
Exhibits for the Complainant:
A1. Medi classic Insurance Policy (Individual) Schedule for the period
of 26.12.2016 to 25.12.2017.
A2. Customer Identity Card.
A3. Medi classic Insurance Policy (Individual) Schedule for the period
of 28.02.2018 to 27.02.2019.
A4. Repudiation of Claim Letter. Dt:04.01.2019.
A5(a). Demand Draft.
A5(b). Letter. Dt:15.02.2019.
A5(c ). Endorsement Schedule.
A6. Lawyer Notice. Dt:06.03.2019.
A7. Reply Notice. Dt:14.05.2019.
Exhibits for the Opposite Parties:-
B1. Copy of Common Proposal Form.
B2. Copy of General OP Case Sheet.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
ASSISTANT REGISTRAR
CDRC, WAYANAD.
Kv/-
