By Sri. A.S. Subhagan, Member:

            This is a complaint preferred under section 35 of the Consumer Protection Act 2019.

            2.  Facts of the case in brief:-

            The Complainant is a policy holder in Opposite Party Insurance Company for the period from 09.04.2012 to 08.04.2013 with Policy No.P/181315/01/2018/000199.  He was used to renew the policy year after year.  The Opposite Party company had convinced the Complainant that a claim upto Rs.3,00,000/- should be paid to the Complainant and family for admission and treatment for more than 24 hours in hospital.  As the Complainant was not familiar in English language, the policy was taken by the Complainant, believing the words of the Opposite Parties.  The Proposal Form was got signed by the third Opposite Party from the Complainant after filing it by the third Opposite Party himself.  Once the Complainant had got giddiness and about this was discussed to the third Opposite Party but he had told that it was not needed to be stated in the Proposal Form.  The Complainant had no other diseases.  But on 26.10.2014, the Complainant got treatment for giddiness from Vinayaka Hospital, Sulthan Bathery which was intimated to the third Opposite Party.  But the Opposite Party had told that no benefits shall be available to the Complainant as he was not admitted in hospital.  Upto January 2017 Complainant was treated there as outpatient and afterwards was admitted in Sree Chithra Institute of Medical Science and Technology.  They advised surgery and on 26.02.2018, he was admitted in R. Madhavan Nair Centre for Comprehensive Epilepsy Care, underwent treatment and surgery and was discharged from there on 21.02.2018.  For getting reimbursement, the Complainant submitted, Bills, Medical Reports, Discharge Summary etc through the third Opposite Party, in the Office of the second Opposite Party.  But instead of admitting the claim, the Opposite Parties repudiated the claim stating “Non-disclosure of pre-existing disease” on 28.07.2018, terminating the existing policy arbitrarily.  This is deficiency in service/unfair trade practice resulting in the mental agony of the Complainant and he has been cheated by the Opposite Parties.  The termination of the policy of the Complainant and his family is against law.  Stating all this, the Complainant had forwarded and Advocate’s Notice for which the Opposite Parties had sent a reply notice stating unsustainable facts.  Hence this complaint with the following prayers.

1. To direct the Opposite Parties to reimburse Rs.84,363/- being the treatment expenses together with interest @ 12%
2. To direct the Opposite Parties to pay Rs.50,000/- towards compensation
3. To direct the Opposite Parties to pay Rs.10,000/- towards cost of this complaint and
4. To direct the Opposite Parties to renew the terminated policy of the Complainant with retrospective effect.           

3.  On receipt of notice, the Opposite Parties appeared before the Commission and filed version, the contents of which in brief are as follows:-  The policy of the Complainant is admitted.  The terms and conditions of the policy were given and explained to the Complainant at the time of issuing the policy.  In the Proposal Form the Complainant had specifically declared that he was not suffering from any disease or ailment.  The Opposite Party submitted that the Complainant was admitted in Sree Chithra Tirinunal Institute of Medical Sciences and Technology, Thiruvananthapuram on 16.02.2018.  As per the discharge summary, the Complainant had history of “seizures” for the past ‘6’ years.  This means that he was suffering from illness from 16.02.2012, ie before inception of the policy.  But the same was not disclosed in the Proposal form which is willful suppression of material facts and on this basis, the claim of the Complainant was repudiated.  As per condition No.15 of the policy, the Company informed the Complainant as per notice dated 28.07.2018 that the coverage in the name of his policy was cancelled with effect from 06.09.2018.  The Opposite Parties admitted that the Complainant had sent an Advocate’s Notice which was duly replied on 23.01.2019.  The Complainant had taken the policy through the agent but not through the third Opposite Party.  The Third Opposite Party had not filled the Proposal Form.  The Complainant on his own free will had taken the policy.  The consultation of the Complainant in Vinayaka Hospital was not informed to the Opposite Parties.  The Opposite Parties had not arbitrarily terminated the policy of the Complainant and his family.  The Opposite Parties had only deleted the Complainant from the policy with effect from 06.09.2018 as per condition No.15 of the policy on the ground of non-disclosure of pre-existing condition ‘seizure’ at the time of taking the policy.  The whole policy was not cancelled.  The policy is continued to the rest of the Members of the policy ie, wife and children of the Complainant.  The Complainant, for the reasons only known to him, had decided not to renew the policy in the name of his family.  So, there has been no deficiency in service from the part of the Opposite Parties.  Hence it is submitted to dismiss the complaint and allow cost and compensation to the Opposite Parties.

            4.  Complainant filed Chief Affidavit, Exts.A1 and A2 were marked from his side and he was examined as PW1.   Chief Affidavit was also filed for the Opposite Parties by the Assistant Manager (Legal) of the Opposite Party Company, Exts.B1 to B6 were marked from their side and he was examined as OPW1.

            5.  Considering the complaint, version, affidavits of both the parties, documents marked from both the sides, the oral evidence adduced by the Parties and the arguments of the Counsels for the Complainant and the Opposite Parties, Commission raised the following points for consideration:-

1. Whether there has been any deficiency in service/unfair trade practice from the part of the Opposite Parties…?
2. Whether the Complainant has the right to get his health insurance policy renewed with retrospective effect…?
3. If so, whether the Complainant has the right to get reimbursement of insurance claim of Rs.84,363/- with 12% interest
4. If so, whether the Complainant has the eligibility to get compensation as prayed for….?
5. If so, whether the Complainant has the right to get cost of this complaint as prayed for..?

6.  Point No.1:-  The case of the Complainant is that the Complainant and his family had a Family Health Optima Policy with the Opposite Parties and when he submitted the claim application for reimbursement of hospital expenses, after undergoing treatment and surgery, his claim was repudiated by the Opposite Parties stating “non-disclosure of pre-existing disease” and his existing policy was arbitrarily cancelled by the Opposite Parties.    The policy of the Complainant and his family is admitted by the Opposite Parties.  They also admitted that the claim of the Complainant was repudiated on account of Non-disclosure of material facts.  For this, the Opposite Party relies on Ext.B3 which is the case summary and discharge record of the Complainant from R. Madhavan Nair Centre for Comprehensive Epilepsy Care in which it is stated by the doctor that the Complainant had ‘seizures’ from past ‘6’years.  The policy was primarily effected from 09.04.2012 covering the Complainant, his wife and two children and thereafter had renewed up to 27.04.2018.  The contention of the Opposite Parties is that the Complainant had suppressed the material facts regarding previous illness in the Proposal Form.  The Complainant has stated that the Proposal Form was not filled by him but it was filled by the third Opposite Party and had got his signature on it.  The Complainant also stated that he had no other illness except once happening giddiness which was disclosed to the third Opposite Party at the time of taking the policy.  Anyway it is observed that in oral examination of OPW1, he has deposed that “proposal form     (Ext.B2)  c­mas¯ t]Pn “seizure”   F¶ AkpJw Dt­m F¶   question CÃ, any other problem Dt­m F¶ question D­v”.  So in our opinion here, the Complainant need not disclose the “seizure” in the Proposal Form as there was no specific question as to “seizure” in the Proposal Form.  Moreover, the Opposite Party has failed to prove that the Complainant was aware of “seizure” and underwent treatment previously for the disease even though he had “seizure” at the time of taking the policy.  In the discharge form it is stated that the Complainant had “seizure” from past 6 years but the date or month from which he had this disease is not at all stated.  Moreover, the treated doctor was not examined by the Opposite Parties to prove their allegation in this regard to import evidence as to the fact that the Complainant had “seizure” and he was aware about “seizure” at the time of taking the health insurance policy.  Therefore, the contention of the Opposite Parties that the Complainant had pre-existing disease named “seizure” since last six years which was known to the Complainant at the time of taking the policy and willfully suppressed that material fact in the Proposal Form cannot be accepted, as there is no proper material evidence to prove the contention of the Opposite Parties beyond doubt.  So, the repudiation of the claim of the Opposite Party without valid and sustaining ground is deficiency in service/unfair trade practice from the part of the Opposite Parties.  Hence, Point No.1 is proved against the Opposite Parties for which they are liable to compensate the Complainant.

7.  Point No.2:-  It is stated by the Complainant that the policy of the Complainant and his family was cancelled arbitrarily by the Opposite Parties and thereby curtailed the benefits under the policy to the Complainant and his family.  On the other hand, the Opposite Parties in version has contented that coverage in the name of his policy was cancelled with effect from 06.09.2018 as per condition No.15 of the terms and conditions of the policy intimating it by sending a notice dated 28.07.2018.  it is also contented by the Opposite Parties in version that they had only deleted the Complainant from the policy, the whole policy was not cancelled, the policy is continued to the rest of the members of the policy etc.  But in letter dated 28.07.2018 (Ext.A2) the Opposite Party has stated that “this letter shall be taken as the notice of cancellation as per the above mentioned policy condition”.  From this it is evident that the policy of the Complainant and his family is cancelled, and hence the contention of Opposite Parties in version that they had only deleted the name of the Complainant and the whole policy was not cancelled is seen untrue.  It is also seen that the Opposite Party has cancelled the existing policy of the Complainant and his family without being given the Complainant an opportunity of being heard.  This is against the principles of natural justice, which is also deficiency in service/unfair trade practice from the part of the Opposite Parties.  So Point No.2 is also proved against the Opposite Parties and the Complainant has the right to get his policy renewed with retrospective effect, if he chooses so.

8.  Point No.3:-  As Point No.1 and 2 are proved against the Opposite Parties, the Complainant has the right to get the amount of the claim reimbursed.

9. Point No.4:-  As deficiency in service/unfair trade practice is proved on the part of the Opposite Parties, the Complainant has the right to get compensation.

10. Point No.5:-  As all the four points above are against the Opposite Parties, the Complainant has the right to get cost of this complaint.

In the result, the complaint is partly allowed and the Opposite Party No.1 and 2 are directed to

1. Pay Rs.84,363/- (Rupees Eighty Four Thousand Three Hundred and Sixty Three Only) towards reimbursement of the insurance claim of the Complainant with 8% interest per annum from the date of this complaint
2. Renew the Family Health Insurance Policy of the Complainant and his family with retrospective effect from the date of cancellation of the policy, if he chooses so,
3. Pay Rs.25,000/- (Rupees Twenty Five Thousand Only) towards compensation for deficiency in service/unfair trade practice, mental agony etc.. and
4. Pay Rs.10,000/- (Rupees Ten Thousand Only) as cost of this complaint.

The above amounts shall be paid jointly and severally by the Opposite Parties No.1 and 2 within one month from the date of this Order, failing which the amount will carry interest @8% per annum from the date of this Order.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 2^nd day of June 2023.

Date of Filing:-08.12.2020.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Shine Abraham.                                          Agriculture.

Witness for the Opposite Partes:-

OPW1.          Balu. M.                                                                    Assistant Manager.

Exhibits for the Complainant:

A1.                  Lawyer Notice.                                                        Dt:15.10.2018.

A2.                  Letter.                                                                        Dt:28.07.2018.

Exhibits for the Opposite Partes:-

B1.                  Copy of Family Health Optima Insurance Policy Schedule.           

B2.                  Copy of Proposal Form.

B3.                  Copy of Case Summary and Discharge Record.

B4.                  Copy of Admission Record.

B5.                  Copy of Repudiation of Claim Letter.               Dt:23.07.2018.

B6.                  Copy of Acknowledgment Letter.                     Dt:19.07.2018.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-