BEFORE THE DISTRICT CONSUMER’S FORUM: KURNOOL
Present: Sri.Y.Reddappa Reddy, M.A., L.L.M., President,
And
Smt. S.Nazeerunnisa, B.A., B.L., Lady Member
Friday the 12th day of December, 2014
C.C.No.80/2012
Between:
S.A.Alam,
S/o. S.Abdul Sattar,
SI of Police,
R/o. Jagajjanani Nagar,
Nandyal. Kurnool District. …Complainant
-Vs-
- The Branch Manager,
Life Insurance Corporation of India,
Railway Station Road,
Nandyal-518 501.
- The Manager,
Life Insurance Corporation of India,
Divisional Office, College Road,
Post Box No.10,
KADAPA-516 004. …OPPOSITE PARTies
This complaint is coming on this day for orders in the presence of Sri.S.V.Krishna Reddy, Advocate for complainant and Sri.L.Hari Hara Natha Reddy, Advocate for opposite parties 1 and 2 and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri.Y.Reddappa Reddy, President,)
C.C. No.80/2012
1. This complaint is filed under section 12 of Consumer Protection Act, 1986 praying:-
(a)To directing the opposite parties to pay medical expenses bills incurred by the complainant of Rs.1,76,650/-.
(b)To award costs of the complaint.
(c)To award Rs.20,000/- for mental agony.
(d)To award interest @ 24% per annum from the date of submission of documents along with claim form from i.e., 06-04-2012 to till the date.
(e)To grant such other relief or reliefs as the Honourable Forum may deem fit and proper in the circumstances of the case.
2. Brief facts of the complainant are:- The complainant is working as S.I. of Police at Nandyal. He took a policy under Life Insurance Corporation of India Jeevan Arogya and paid a sum of Rs.7,839/- on 06-06-2011 towards premium. Opposite party herein issued policy bearing No.656291833 on 28-06-2011. As per the terms of the policy, if policy holder suffers any aliments or underwent treatment, expenses will be paid by the insurance company.
The complainant herein was deputed to Assembly security duty during the Assembly sessions which were held at Hyderabad in the month of March, 2012. On 13-03-2012 when the complainant was on duty, he got giddiness suddenly and fell down on the road. He was shifted to Yasoda Hospital initially and later on he was shifted to Medicity Hospital, Hyderabad on 15-03-2012 for better treatment. The complainant underwent treatment in Medicity Hospital and was discharged on 24-03-2012. The Hospital Authority charged a sum of Rs.1,78,228/- which the complainant was forced to pay then and their itself. The complainant informed the same to the opposite party and submitted claim form with all necessary documents and hospital bills with a request to clear the claim, as per the terms of the policy. But the opposite party repudiated the claim of the complainant by stating prior to taking policy the complainant was suffering with diabetes, he suppressed the same and obtained policy. They sent a repudiated letter with anti date by putting 18-07-2012, but the same was posted on 06-09-2012 and served on the complainant on 15-09-2012.
Prior to issuing of policy, panel doctor of the opposite party conducted medical tests to the complainant. After going through the reports and after satisfying that the complainant was fit for insurance policy, they have issued the policy by covering the health of complainant. Hence question of taking objection that the complainant was suffering with diabetes prior to taking policy does not arise. The conduct of the opposite party in refusing to settle the claim made by the complainant while subsistence of policy is not proper and correct. Sending of repudiation letter with anti date amounts to deficiency of service. Hence he prays to allow the complainant and
1.To direct the opposite parties to pay a sum of Rs.1,76,650/- and also a sum of Rs.20,000/- towards mental agony, with interest at 24% per annum and costs of this complaint.
3. After service of the notice the opposite party No.2 filed written version which run into 5 pages. The sum and substance of the written version filed on behalf of the opposite party No.2 in brief run as follows. They admitted with regard to issue of policy under Jeevan Arogya scheme and its subsistence on the date of ill health of the complainant. They expresses their ignorance with regard to deputation of the complainant to security duty at Hyderabad when Assembly Sessions were going on at Hyderabad, during the month of March, 2012. They denied that the complainant fell down on 13-03-2012 while he was on duty, first he was shifted to Yasoda Hospital and later on to Medicity Hospital on 15-03-2012, his discharge on 24-03-2012 and the quantum of amount charged by Hospital authorities at Hyderabad.
In para 5 of the written version they stated that the complainant declared himself to be quite healthy. As per his statement and replies to question No.7 (I) to (XIV), he signed in the declaration at the foot of the said proposal for health insurance that all his said statements regarding health as also other particulars, form the basis of the contract of insurance and agreed therein that if any untrue averments were to be found in his statements, the contract of Insurance shall be absolutely null and void, and that all the moneys paid in respect thereof shall stand forfeited to the corporation. Basing on his statements only policy was issued in favour of the complainant on 28-06-2011.
The complainant was not keeping good health at the time of taking health insurance policy. The fact of suffering from diabetes mellitus and Hyper tension has not been disclosed by the complainant insured in his proposal for health insurance dated 06-06-2011. As per the progress notes, dated 16-03-2012 of Medicity Hospital, Hyderabad, complainant had history of diabetes mellitus for 10 years and hyper tension since 3 years prior to the date of surgery and he was under regular medication. Had the complainant disclosed his preexisting deceases at the time of submission of the proposal for health insurance the decision of the corporation would have been different basing on his health conditions as on the date of proposal. The contract of insurance is a contract of utmost good faith and the complainant has to disclose all facts known to him relating to his past and present health condition, whether it is material or not to the contract. In the instant case there is a non discloser of material facts relating to the complainant i.e., preexisting diseases. The complainant misled insurer by suppressing the material facts. As such the policy was called on question under section 45 on Insurance Act, 1938 and the contract is declared as void abinitio. Therefore all amounts paid by the complainant were forfeited and no amount whatsoever is payable towards the policy contract. Hence they pray to dismiss the complaint with exemplary costs. Opposite party No.1 adopted the same written version of opposite party No.2.
4. In support of the contention of the complaint, complainant filed his sworn affidavit by narrating the facts which he mentioned in his complaint and marked Ex.A1 to Ex.A9. In support of the contention of the opposite parties, sworn affidavit of the Manager (Legal and HPF) LIC of India, Divisional Office, Kadapa filed and marked Ex.B1 to Ex.B11.
Ex.A1Policy bearing No.656291833, Ex.A2 Photo copy of Hospital Discharge Card dated 04-03-2012, Ex.A3 Photo copy of Claim Form dated 06-04-2012, Ex.A4 Letter of opposite party dated 18-07-2012, Ex.A5 Photo copy of Hospital Discharge Bill, Ex.A6 Renewal Premium Receipt dated 06-06-2012, Ex.A7 Photo copy of Renewal Premium Receipt dated 06-06-2012, Ex.A8 Medical Examiner’s Confidential Report dated 06-06-2011, Ex.A9 Photo copy of Emergency Certificate dated 28-03-2012. Ex.B1 Photo copy of Proposal for health Insurance Policy submitted by the complainant, Ex.B2 Photo copy of Policy Bond bearing No.656291833, Ex.B3 Photo copy of Policy Conditions and privileges of health insurance policy, Ex.B4 Claim intimation Form, dated 06-04-2012 submitted by the complainant, Ex.B5 Hospital Treatment Form, Ex.B6 Form for claiming HCB/MSB/OSB/Day Care benefits under LIC’s Health Insurance Policy, Ex.B7 Discharge Summary of Medicity Hospitals, Hyderabad from 15-03-2012 to 24-03-2012, Ex.B8 Photo copy of Progress Notes dated 16-03-2012 of Medicity Hospitals, Hyderabad, Ex.B9 Photo copy of Operation Notes dated 16-03-2012 of Medicity Hospital, Hyderabad, Ex.B10 Summary of the claim processing completed by the TPA dated 11-07-2012, Ex.B11 Claim Repudiation Letter dated 18-07-2012 by Divisional Health Unit, Divisional Office, Kadapa.
5. Now the points that arise for consideration are:
- Whether there is deficiency of service on the part of opposite parties 1 and 2?
- If so to what relief, the complainant is entitled?
6. POINT No.i:- The counsel for complainant submitted though the complainant was working as S.I. of Police at Nandyal, being attracted by the terms of the policy of L.I.C. of India relating Jeevan Arogya, he took it on 06-062011 by paying huge amount of Rs.7,839/- towards one year premium. He also renewed the same on 06-06-2012 for another one year. When the complainant took Jeevan Arogya policy for the first time, the panel medical officer of the L.I.C., examined the complainant. After thoroughly examining and satisfying with the health of the complainant he issued a confidential report on 06-06-2011. Basing on the report only the policy was issued by the opposite party in favour of complainant which is marked as Ex.A1. Hence he prays to direct the opposite parties to pay amount as claimed in the complaint by holding the repudiation letter sent by opposite parties which is marked as Ex.B11 is not proper and correct. The counsel for the opposite parties represented there is no doubt to true policy under Ex.A1 was issued by opposite parties and the same was in force on the date of ill health of the complainant. The treatment form maintained by Hospital Authority at Hyderabad i.e., Ex.B5 clearly shows the complainant was suffering with diabetes Mellitus since 10 years and with Hyper Tension since 3 years prior to his admission on Medicity Hospital at Hyderabad. If the complainant had revealed about his ill health with which he suffering prior to taking of policy under Ex.A1, there was no scope for the opposite parties to issue policy in favour of the complainant. Suppression of material fact i.e., ill health of the complainant prior to above Jeevan Arogya policy, non discloser of the same to the Medical Officer who examined the complainant prior to issue of confidential report under Ex.A8, makes the contract between the complainant and opposite parties as null and void. Hence the complainant is not entitled to claim any amount and repudiation letter sent by the opposite parties is proper and correct. There is no need to interfere with the same. Hence he prays to dismiss the complaint with costs.
7. After going through pleadings of the both parties, sworn affidavits, documentary evidence produced on behalf of the both parties, written arguments and after hearing oral arguments submitted by the both parties it is clear the policy issued by opposite parties under Jeevan Arogya scheme, by insuring the health of the complainant under Ex.A1 and its substance on the date of admission of the complainant in the Medicity Hospital at Hyderabad are true and correct. When the complainant submitted claim form along with documents the concern authorities of the opposite party, while scrutining those documents came across the Hospital treatment form which is marked as Ex.B5, in which they have observed that the complainant was suffering with diabetes Mellitus since 10 years and Hyper Tension since 3 years prior to his admission in that Hospital. According to the opposite parties this was suppression of the material fact about the diseases with which the complainant was suffering prior to obtaining the policy under Ex.A1. Hence the policy issued under Ex.A1 is void abinitio. Basing on that observation they have rejected the claim of the complainant and sent repudiation letter under Ex.B11 on 18-07-2012.
8. After expiry of the period under Ex.A1 the complainant renewed the same on 06-06-2012. After collecting the premium the opposite parties issued renewal receipt which is marked as Ex.A6 and also issued policy by covering the health of complainant for further period of one year which is marked as Ex.A7. As per Ex.A4 the complainant submitted claim forms to opposite parties on 25-04-2012 itself. If really suppression of diabetes Mellitus and Hyper Tension are the grounds for not issuing Jeevan Arogya policy in favour of the complainant, the opposite parties ought to have been rejected the request of the complainant for renewal of the policy under Jeevan Arogya for further period of one year and they ought not have been collected the premium under Ex.A5. The counsel for complainant relied on the decision reported in II (2004) CPJ Page 452. In that decision the Honourable Delhi State Consumer Disputes Redressal Commission, New Delhi, held Maladies like diabetes, Hyper Tensions being normal wear and tear of life, cannot be termed as concealment of preexisting disease. Insured not bound to disclose diseases easily detectable by basic tests like blood test, ECG etc. After at the time of the policy deceased suffering from disease likely to cause death shortly, doctors on panel of opposite party would have detected easily.
9. In Para 7 their lord ships made clear “Let us assume that he was having diabetes at the time of filling up the proposal form but he was thoroughly examined by the doctors on the panel of the appellant and they found the general health and physical condition of the deceased very good. We have taken a view that the maladies like diabetes, Hyper Tensions are normal wear and tear of the life and the heart trouble or other such kind of trouble can be easily detected by the doctors whenever the insured is medically examined.
10. In Para 9 (viii) of the same judgment it is further observed day to day history or history of several years of some or the other physical problem one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalized or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of preexisting disease while taking mediclaim policy as after being cured of the disease, he does not suffer from any “disease” much less the “preexisting disease”. The principle lay down in the above decision is directly applicable to the facts of the present case. The repudiation of the claim of the complainant by the opposite parties under Ex.A4 and Ex.B11 is not proper and correct and against the principles of natural justice. There is clear cut deficiency of service on the part of opposite parties in repudiating the claim of the complainant and sending repudiation letter under Ex.A4 and Ex.B11 respectively.
1. Thus we hold this point in favour of the complainant and against the opposite parties.
2. While answering point No.1 we have made clear repudiation of the claim of the complainant made by the opposite parties is not proper and correct and there is deficiency of service on the part of opposite parties. The next point that arises to what amount the complainant is entitled. The opposite parties are not disputing the bill amount issued by Medicity Hospital Authorities on 24-03-2012 at the time of discharge of the complainant. They are mainly disputing that the complainant suppressed the disease of diabetes Mellitus and Hyper Tension, at the time of the taking policy and basing on that fact only they have repudiated the claim. During the course of arguments, the counsel for the complainant fairly consider that as the complainant happened to be the Government employee he got 30% (out of the bill issued by Medicity Hospital Authorities at the time of his discharge) was reimbursed from his department. The remaining amount was not paid by the Government. Hence the complainant is entitled to get 70% of the amount covered under Ex.A5 after deducting the 30% which he got reimbursement from his employer earlier out of the total amount. As the opposite parties repudiated the claim of the complainant on flimsy and untenable grounds they are liable to pay interest also at 9% per annum on the claim amount allowed by us above.
11. Because of the repudiation of the claim of the complainant by the opposite parties without any reasonable cause and as they attributed that the complainant suppressed the fact of suffering with diabetes and Hyper Tension at the time when he took policy under Ex.A1, caused a lot of mental agony and sufferance to the complainant. Hence the complainant is entitled to get a sum of Rs.10,000/- towards mental agony with which he suffered and also a sum of Rs.1,000/- towards costs of this CC.
12. POINT No.ii:- Thus opposite parties 1 and 2 are jointly and severally liable to pay amounts due to the complainant and we direct both opposite parties 1 and 2
- To pay 70% out of the amount covered under Ex.A5 i.e., Rs.1,21,879/- with interest at 9% per annum from the date of repudiation till the date of payment or realization whichever is earlier
- To pay a sum of Rs.10,000/- towards mental agony cause to the complainant by repudiating the claim on flimsy and untenable grounds and a sum of Rs.1,000/- towards costs of this litigation.
We direct the opposite parties 1 and 2 to pay amount as directed above within one month from today failing which complainant is at liberty to execute this order and realize the fruits of the order according to law.
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 12th day of December, 2014.
Sd/- Sd/-
LADY MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant:- Nil For the opposite parties:- Nil
List of exhibits marked for the complainant:-
Ex.A1 Policy bearing No.656291833
Ex.A2 Photo copy of Hospital Discharge Card dated 04-03-2012
Ex.A3 Photo copy of Claim Form dated 06-04-2012.
Ex.A4 Letter of opposite party dated 18-07-2012.
Ex.A5 Photo copy of Hospital Discharge Bill.
Ex.A6 Renewal Premium Receipt dated 06-06-2012.
Ex.A7 Photo copy of Renewal Premium Receipt dated 06-06-2012.
Ex.A8 Medical Examiner’s Confidential Report dated 06-06-2011.
Ex.A9 Photo copy of Emergency Certificate dated 28-03-2012.
List of exhibits marked for the opposite parties:-
Ex.B1 Photo copy of Proposal for health Insurance Policy submitted by the complainant.
Ex.B2 Photo copy of Policy Bond bearing No.656291833.
Ex.B3 Photo copy of Policy Conditions and privileges of health insurance policy.
Ex.B4 Claim intimation Form, dated 06-04-2012 submitted by the complainant.
Ex.B5 Hospital Treatment Form.
Ex.B6 Form for claiming HCB/MSB/OSB/Day Care benefits under LIC’s Health Insurance Policy.
Ex.B7 Discharge Summary of Medicity Hospitals, Hyderabad from
15-03-2012 to 24-03-2012.
Ex.B8 Photo copy of Progress Notes dated 16-03-2012 of Medicity
Hospitals, Hyderabad.
Ex.B9 Photo copy of Operation Notes dated 16-03-2012 of Medicity
Hospital, Hyderabad.
Ex.B10 Summary of the claim processing completed by the TPA dated
11-07-2012.
Ex.B11 Claim Repudiation Letter dated 18-07-2012 by Divisional Health
Unit, Divisional Office, Kadapa.
Sd/- Sd/-
LADY MEMBER PRESIDENT
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties :
Copy was made ready on :
Copy was dispatched on :
