THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.

C.C. 117/2011

Dated this the 3^rd day of December 2016

                     (Smt. Rose Jose, B.Sc, LLB.                         :  President)

                          Smt.Beena Joseph, M.A                           : Member

                          Sri. Joseph Mathew, MA, LLB                : Member

ORDER

Present: Rose Jose President:

            This petition is filed under section 12 of Consumer Protection Act 1986 for getting an order directing the Opposite Party to pay the entire claim amount of Rs.3,01,440/- with 12% interest per annum and a compensation of Rs.25,000/- for his sufferings and cost of the proceedings to the petitioner.

            The case of the petitioner is that, he is a Medi classic Insurance policy holder of the opposite parties  under Medi Family Package Plan having policy No. P/181311/61/2008/000162 valid from 08.06.2007 to 07.06.2008.  This policy covers all expenses incurred for treatment of diseases and hospitalization benefits of the insured and his family members.  The premium amount for the said period was Rs.3,820/-.

            On 27.02.2008 unexpectedly he felt giddiness while returning from his office in his own vehicle and was admitted at PVS hospital, Calicut, where he was diagnosed to have Anterior valve Myocardial Infarction and transferred to CCU and then referred to MIMS hospital Kozhikode.  There he underwent major procedure OFFPUMP CORONORY ARTERY BYPASS GRAFTING.  As  per the advice of the Doctor he had underwent surgical procedure including Mitral valve replacement on 04.03.2008 and consequent hospitalization at MIMS Hospital, which had cost him more than Rs.3,00,000/-.

            There after the claim made before the Opposite parties along with all relevant documents was rejected on the ground that “Pre-existing disease and suppression of Material facts.”  The petitioner alleged that the reasons stated by the Ops in rejecting the claim are totally untrue and baseless.  It is stated that in his entire life till the date of admission at PVS hospital on 27.02.2008, he had ever undergone any treatment what so ever for any type of heart ailment.  The statement that he had suppressed material facts while taking the policy was also false.  There was no pre-condition of a medical examination and as such he had only stated the truth and nothing has been suppressed in this regard.

            He further stated that even after repeated requests and remainders the OPs have not settled his claim and as a result he is facing acute financial stringency and loss.  The unilateral and arbitrary rejection of his bonafide claim amounts to deficiency in service on their part and that caused much mental agony, financial loss and other untold sufferings to him.  Hence this petition.

            The opposite parties filed a combined version contending that the petition is not maintainable and is bereft of bonafides and filed experimentally to extract money from them dishonestly. It is admitted that the petitioner had a policy of them as stated in the petition, but stated that he had earlier taken a similar policy with M/s. Oriental Insurance Company for the period from 09.06.2006 to 08.06.2007.  The petitioner was admitted at MIMS Hospital on 28.02.2008 for treatment of Rheumatic Heart Disease (RHD) Moderate Mitral Regurgitation, CAD and Triple Vessel Disease and had undergone off pump coronary Artery By-pass and Mitral valve replacement.  After the treatment he made the claim for Rs.3,01,440/- with relevant documents.

            But it is submitted that, on perusal of the discharge summary it was noticed that the petitioner was referred from PVS Hospital with the diagnosis of evolved AWMI Rheumatic Heart Disease on treatment.  In order to ascertain the duration of RHD, they have sent a registered letter to the petitioner on 18.08.2008 calling upon him to submit the treatment details of RHD, but he had replied in his letter dtd.02.09.2008 that he had never consulted any cardiologist for RHD and has not furnished any details of previous consultation or treatment for RHD.  As per 5^th policy condition the insured shall furnish all information as the Company may require in dealing with the claim.  On investigation they found that the petitioner was hospitalized on 14.01.2004 for fistulactomy  treatment at PVS hospital Calicut and the discharge summary clearly indicated that he was suffering from RHD.  The case sheet also revealed him as a known case of RHD, on regular treatment and under medication.  It was also brought out that the petitioner had cerebral embolism and was on oral anticoagulants for the same,  All these proves that the petitioner had pre-existing disease of RHD even before 2004.   Hiding all these ailments he had taken policy with the oriental Insurance Company and of them.

            They further contended that the insured has to disclose all the material facts related with his health condition at present and also past history in the proposal form.  Here to the relevant question whether he had suffered any ‘High blood pressure, heart disease including Ischemic heart disease(IHD) Rheumatic Heart Disease’ in the proposal form, the answer of the petitioner was “No”.  To another question “Had he been treated as in-patient or out-patient for surgery” the answer was also ‘No’.  All these shows that the petitioner had intentionally suppressed the material facts and obtained policy fraudulently.  This is violation of the principal of ‘utmost good faith’ and the said  act therefore renders the contract viod-ab-intio. As the insurance  contract itself is void there is no obligation on their part to compensate the petitioner in any way and the petitioner is not entitled for any of the reliefs sought for in the petition and there is no deficiency in service on their part and hence prayed to dismiss the petition with compensatory cost.

The points for determinations are:-

1. Whether there is any deficiency in service on the part of the Opposite Parties?
2. Reliefs and costs if any.

     Evidence consists of the affidavits filed by both the parties, Ext.A1 to A7, B1 to B12 and depositions of PW1, RW1 & RW2.

Point No.1:- There is no dispute with regard to the policy or its validity.  According to the OP the only reason for the rejection of the claim is pre-existing disease and suppression of material facts. The Insurance contract is based on “utmost good faith” The insured is supposed to discloses all the material facts related with his health conditions including past history of diseases in the proposal forum.  Here the petitioner had taken the policy suppressing his past history of disease in the proposal form and this is violation of policy conditions and it render the insurance contract “void-ab-intio”. They produced the proposal form of the petitioner and marked as Ext.B12.  In Ext. B12 proposal form under caption “Medical history and other details of the insured person the answer to the question No.b’ whether the insured is having “High Blood Pressure, heart disease including IWD, RHD” the answer is ‘NO.’  They also produced the copy of discharge summary and consultation sheet of the petitioner issued from the PVS hospital and was marked as Exts.B9 & B10. Ext.B9 is the case history of the petitioner issued by Department of general surgery PVS hospital.  This shows that the petitioner has been admitted at PVS Hospital on14.01.2004 and  underwent surgery on 16.01.2004 and he was discharged on 20.01.2004.  In this document it is clearly written that I and D(Incision and Drainage) surgery was done on 07.08.2002 and a known case of rheumatic heart disease on regular treatment. Ext.B10 is the copy of consultation sheet of the petitioner from the PVS Hospital issued by Dr.Easaw dtd.14.01.2004.  Here the doctor written that”  Mr.Biju is known to have RHD and had a cerebral embolisms .  He is on oral anticoagulant. Recently he had a respiratory infection”Dr.Easaw was examined as RW2.  He deposed that “ I have examined this person Bijunath.  It had (Ext.B10) written by my assistant in the presence of me and I am aware of this document.  This patient was suffering from RHD on the day when this sheet was issued.  He was suffering from RHD(Page 2^nd RW2).

           Thus the deposition of RW2 confirmed that the petitioner was suffering from RHD during the period 14.01.2004 itself.  So also Ext.B5 is the discharge summary issued from MMS Hospital.  In Ext.B5 under the heading HISTORY it is written that” Mr. Bijunath aged 34 years was referred from PVS Hospital with a diagnosis of evolved AWMI Rheumatic heart diseases on treatment” Ext.B7 is the copy of registered letter dtd.18.08.2008 calling upon the petitioner by the Ops to submit the treatment details of RHD.  Ext.B8 is the reply sent by the petitioner to Ext.A7 letter dtd.02.09.2008.  In that letter the petitioner had stated that he had never consulted any cardiologist for RHD.  This shows that even after request by the Ops the petitioner was reluctant to reveal his past history of ailment.  Thus Exts. B9 & B10 clearly proved that the petitioner was suffering from RHD and an (1andD) surgery has been done on 07.08.2002.  A perusal of Ext.B12, the proposal form shows that, the petitioner has not disclose these facts in that form while taking the policy.  In his deposition RW1 would say that “All the medical re-imbursement claims are managed by a medical Team skilled in this field.  After going through the terms and conditions of the policy they are deciding whether to allow a claim or not” (Page 5 RW1) It is further stated by him that as it is found by the medical team that there is nexus between the RHD and the surgical procedure conducted on the petitioner on 04.03.2008 which leads to this claim and based on their advise they have rejected the claim. Clause 13 of the policy conditions reads” The Company may cancel this policy on grounds of misrepresentation, fraud, moral hazard,  non-disclosure of material facts as declared in proposal form at the time of claim. Considering all the facts stated and perusal of documents on record it is found that the petitioner has not disclosed or had suppressed the material facts related with his health conditions in the proposal form and thereby violated the policy conditions.  Hence the rejection of the claim by the Opposite parties based on the policy conditions cannot be considered as a deficiency in services on their part and hence we cannot attribute any deficiency in service on them, in this regard.Point No.1 found against the petitioner.

Point No.2 In view of the finding in point No.1.  This petition is liable to be dismissed and the petitioner is not entitled to get any relief sought for in the petition.

           In the result this petition is dismissed. Parties will bear their cost.

Dated this 3^rd day of December 2016.

Date of filing:18.03.2011

SD/-MEMBER                                    SD/- PRESIDENT               SD/-MEMBER

                                                                                 APPENDIX

Documents exhibited for the complainant:

A1. Endorsement schedule of Star Health and Allied Insurance Company Ltd.

       Along with medi classic Insurance policy schedule-medi family package plan(4

      sheets) dtd.12.06.2007.

A2. Letter addressed to M/s. Star Health and Allied  Insurance Company Ltd, 

      Thampanoor dtd.02.09.08.

A3. Brochure published by the opposite parties regarding the features of medi-

      classic Insurance policy(2 sheets)

A4. Operation record from dept. of Cardio Thoracic and Vascular surgery MIMS

       Hospital, Calicut dtd.28.02.08.

A5. Coronory Angiogram report from dept of Cardiology MIMS Hospital Calicut

      Dtd.29.02.08.

A6. Discharge Summary from the dept. Cardio Thoracic and Vascular surgery

       MIMS Hospital Calicut, dtd.12.03.08.

A7. Claim rejection letter issued by Star Health Allied Insurance Company Ltd

      dtd. 06.12.08.

Documents exhibited for the opposite party:

B1. Authorisation Letter issued by Star Health  and allied Insurance Co.Ltd

     dtd. 12.08.15

B2. The Medi-classic Insurance policy (individual) and policy condition.

B3. Endorsement  Schedule of Star Health and Allied Insurance Co.Ltd

      Dtd.12.06.2007.

B4. Policy schedule of Oriental Insurance co.Ltd  period from 09.06.2006 to

      08.06.2007.

B5.Discharge summary of Dept of Cardio Thoracic & Vascular surgery.

B6. Claim Form for Medical Insurance  of Star Health and Allied Insurance Co.Ltd.

B7. Regd. letter with Ack.Due dtd.18.08.2008 requirement of documents for

     Hospitalization claim

B8. Reply letter dtd.02.09.2008.

B9. Admission slip of Department of General surgery of the complainant

B10. Consultation sheet of PVS Hospital, Calicut.

B11. Claim Rejection letter of Star Health and Allied Insurance Co.Ltd.

B12. Medi-Classic Proposal Form –Family Package  of Star Health and Allied

        Insurance Co.Ltd.

Witness examined for the complainant:

PW1. Bijunath (Complainant)

Witness examined for the opposite party:

RW1. Manu Mohan( Executive in claims of Star Health Insurance Co.Ltd)

RW2. Dr.Easaw ( Physicion of PVS Hospital)

                                                                                                                        Sd/-President

//True copy//

(Forwarded/By Order)

SENIOR SUPERINTENDENT