O R D E R.
By Smt. Beena. M, President (In charge):
This is a complaint preferred under Section 12 of the Consumer Protection Act 1986.
2. Brief facts of the case are as follows:- The Complainant had availed a Medi Classic Insurance Policy (Individual) from first Opposite Party on 21/07/2015. The policy was to be renewed annually as such the Complainant renewed the policy from 2016 to 2019. During the last Policy period the insured Smt. Mary, the wife of the Complainant was admitted in Baby Memorial Hospital, Kozhikode on 11-02-2019 for an ailment MNG, Auto Immune Thrombocytopenia, Sero +ve RA. The Complainant spent an amount of Rs.78,687/- for treatment and submitted the claim form to the First Opposite Party, but the claim was repudiated by the First Opposite Party stating that ‘’Suppression of material fact- the medical records of the insured patient revealed that she had history of active Hemopoiesis, increase in Megakaryocytes suggestive of Peripheral Platelet Destruction since 2013. Based on these findings, the medical team of the Opposite Party is of the opinion that the insured person had above disease prior to the inception of the medical insurance policy and it is non-disclosed pre-existing disease.’’ As per condition No. 7 of the policy issued to the Complainant, it has stated that if there is any misrepresentation or non-disclosure of material facts whether by the insured or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim’’. Hence, the Opposite party cancelled the policy. The Complainant further averred that the earlier aliment was completely cured and so the disease was not existing at the time of taking the insurance policy. Moreover, the Panel doctor examined the Complainant’s wife and found that the health condition was normal. The Doctor conducted general Physical examination and blood Test like fasting blood sugar, Serum Creatinine ECG, USG whole abdomen, Urine Routine, on 22-07-15, the Certificate of the panel doctor enclosed along with proposal form. The proposal form was filled by the agent and obtained the signature of the insured. The wife of the Complainant was admitted in Baby Memorial Hospital for the illness “Grade 3 MNG for Thyroidectomy with no history of DM/HT, no history of Hyperthyroidism, no former history of goiter, no Pallor, Jaundice/ Pedal edema. After the treatment the wife of the Complainant was discharged on 14-02-19. The earlier aliment of the wife of the Complainant was treated properly and cured during 2013. The Complainant stated that the earlier illness had no connection with present treatment and claim. The arbitrary decision of the Opposite Party in repudiating the claim and cancelation of policy amounts to unfair trade practice and exploitation. Hence this Complaint.
3. After the admission of the Complaint, the Commission issued summons to the Opposite Parties. The Opposite Parties entered appearance and filed version stating the following contentions.
4. It is admitted that the Complainant obtained Medi Classic Insurance Policy from the Opposite Party for the period commencing from 21-07-2015 which has been renewed up to 20-07-2019 for an amount of Rs. 2,00,000/-. At the time of issuing the policy, the Complainant was issued the Terms and Conditions of the Policy and the terms and conditions of the Policy were explained to the Complainant at the time of proposing policy. They further submitted that Proposal form is the basis of insurance contract, on that basis the policy is issued. In the proposal from, the Complainant has specifically declared that his wife was not suffering from any disease or ailment at the time of submitting the proposal form or any point of time earlier and her health condition was good in all respects. In the proposal form, the Complainant further declared that if after the insurance policy effected, any particulars stated in the proposal form are found incorrect, the insurance company would incur “no liability” under the policy. The Opposite Parties further submitted that the Opposite Parties received a pre-authorization request for cashless hospitalization from Baby Memorial Hospital, Calicut which states that the wife of the Complainant was admitted at the hospital and was provisionally diagnosed with Multi Nodular Goiter and the history is shown as 2 years. Based on the available documents/records, Opposite Parties had initially approved an amount of Rs. 10,000/- and the same was informed to the hospital vide letter dated 12-02-2019. Thereafter, the hospital had forwarded the bills and the discharge summary to the Opposite Party and on perusal of the discharge summary, in the history column it is noted that the patient is under treatment for Auto Immune thrombocytopenia and Sero +ve Rheumatoid Arthritis. Hence the Opposite Parties had issued a query to the hospital on 14-02-2019, directing to forward the copy of first consultation details when sero positive rheumatoid arthritis, auto immune thrombocytopenia was diagnosed and previous treatment details/copies of consultation exact duration. As reply to the said query letter, the hospital had forwarded the consultation record dated 07-11-2018 which shows that the wife of the Complainant had history of Active Hemopoiesis, increase in Megakaryocytes (a large bone marrow cell with a lobated nucleus responsible for the production of blood thrombocytes (platelets), which are necessary for normal blood clotting) suggestive of Peripheral Platelet Destruction since 2013. Based on the available records, it is clear that the wife of the complainant had history of Active Hemopoiesis, increase in Megakaryocytic suggestive of Peripheral Platelet Destruction since 2013. Neither the hospital nor the Complainant has provided the consultation details from 2013. Hence, the Opposite Parties with no other option than to withdraw the initial approval, informed the matter to the hospital and the Complainant vide letter dated 14-02-2019. After the treatment, the wife of the Complainant was discharged on 14-02-2019 and thereafter, the Complainant had submitted claim form, discharge summary, bills of Rs. 84,474/- (Rupees Eighty -Four Thousand Four Hundred and Seventy- Four only) and report for the reimbursement of the claim. As per the consultation paper dated 7-11-2018 from Baby Memorial Hospital, the patient had history of active Hemopoiesis, increase in Megakaryocytic suggestive of Peripheral Platelet Destruction since 2013. Based on the available medical records as stated above, it is clearly evident that the Complainant’s wife had history of Active Hemopoiesis, increase in Megakaryocytic suggestive of Peripheral Platelet destruction since 2013, which was before the inception of the policy and was not revealed in the proposal form of the policy. At the time of taking the policy, the Complainant was well aware about the health condition of his wife and he has willfully suppressed the pre-existing disease of his wife in the proposal form, which is the basis of contract at the time of taking the policy. Hence the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false and such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf. Hence, company has repudiated the claim and the same was communicated to the Complainant vide letter dated 26-04-2019. There is no deficiency in service, unfair trade practice from the part of Opposite Parties, whereas the Complainant is guilty of suppression of material facts and caused to obtain a policy by suppressing the existing aliments and past treatments for the same. The Complainant has not suffered any loss and damages due to the act of the Opposite Party. The Complainant has filed this Complaint frivolously for the sole purpose of harassing the Opposite Parties with intention for getting unlawful enrichment from the Opposite Parties who are dealing with public money and functioning under the guideline of IRDA controlled by the Government of India. As public money is held in trust, the company must exercise abundant caution in dealing with claims by applying all conditions correctly. The Complainant has no cause of action for the Complaint and no cause of action has arisen against the Opposite Parties. Therefore, it is prayed for dismissal of the Complaint.
5. On perusal of Complaint, Version and Documents, the Commission raised the following points for consideration:-
1. Whether there is any unfair trade practice from the part of Opposite
Parties?
2. Whether the Complainant is entitled to get any relieves as prayed for?
6. Point No. 1 and 2:- For the sake of convenience and brevity all points are considered together.
7. The Complainant had adduced oral evidence. He was examined as PW1 and the documents produced were marked as Ext. A1 to A15. On the side of Opposite Party, The Assistant Manager-Legal of Opposite Party company was examined as OPW1, and the document produced were marked as Ext. B1 to B13.
8. The case of the Complainant is that the claim amount was not paid to the Complainant as per the policy. The main contention of the learned counsel for the Opposite Party is that the Complainant’s wife had history of active Hemopoiesis, increase in megakaryocytes suggestive of peripheral Platelet Destruction since 2013, prior to taking the policy since these facts were not disclosed by him. Therefore, it was a case of suppression of material facts regarding health on the part of the Complainant, thus the claim of the Complainant was rightly repudiated by the Opposite Party under the terms and conditions of the policy. The main issue to be discussed in this case is whether the Complainant had suppressed details of his wife’s pre-existing deceases at the time of joining the policy. From the availing records it is found that wife of the Complainant had history of Active Hemopoiesis, increase in Megakaryocytic suggestive of Peripheral Platelet Destruction since 2013 and she was treated. But the case of the Complainant that there is no connection or relation with the present ailment. Before approval of proposal, the doctor of the Opposite Party company had examined the wife of the Complainant. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition, which was not disclosed by the insured in the proposal form. It is well settled that the insurance claim cannot be denied on simple reasons. There is no evidence available to satisfy the Commission that previous disease had any relation directly or indirectly to the present disease. Every disease cannot be termed as pre-existing disease. Pre-existing disease would mean the one which was in the knowledge of the insured at the time of taking the policy. It is the duty of the Insurance Company to prove by adducing medical evidence that insured had suffered the disease immediately preceding the inception of policy and the insured was well aware of it also. The Complainant has placed the file of the medical records of hospital. There is nothing on the record to disbelieve the treatment record of the Complainant. Here, the Opposite Party has not produced even a piece of evidence to show that the Complainant’s wife was undergoing treatment for the prior disease at the time of taking the policy. So, Active Hemopoiesis increase in Megakaryocytes suggestive of peripheral Platelet Destruction since 2013 seen in Ext. B7 is not sufficient for denying the Complainant’s claim. Therefore, the repudiation of claim based on Ext.B7 cannot be justified. Moreover, the doctor, who issued Ext B7, was not examined by the Opposite Party. It is mentioned that the patient is suffering from this disease since 2013, it is not clear under what circumstances the doctor has given such an opinion. After receiving the premium and making attractive offers, usually the Insurance Companies are rejecting the benefits under the policy on unreasonable grounds, It is not fair. In view of the aforesaid discussion, we hold that repudiation of the claim and the cancellation of the policy of the Complainant by the Opposite Party company was illegal and not in accordance with the law and is against the principles of natural justice. Considering the evidence and arguments submitted by the parties, we reached to the conclusion that the Opposite Party No. 1 and 2 are guilty of deficiency in service and hence the Complainant is entitled to the relief.
In the result, the Complaint is allowed, and the Opposite Party No. 1 and 2 are directed jointly and severally to pay Rs. 78,657/- (Rupees Seventy Eight thousand Six hundred and Fifty Seven only) to the Complainant with 8% interest from 11/02/2019 towards treatment expenses and to pay Rs.25,000/- (Rupees Twenty Five thousand only) towards compensation and also to pay Rs.8,000/- (Rupees Eight thousand only) towards cost of this proceedings. The Opposite Party No.1 and 2 shall comply the above order within one month from the date of receipt of this order, failing which the Opposite Party 1 and 2 are liable to pay interest at the rate of 9% per annum till realization.
Dictated to the Confidential Assistant, transcribed by him and corrected by me
and Pronounced in the Open Commission on this the 7th day of July 2023.
Dated of filing:12.03.2020.
PRESIDENT (I/C) : Sd/-
MEMBER : Sd/-
APPENDIX.
Witness for the Complainant:
PW1. George. P. K. Complainant.
Witness for the Opposite Parties:
OPW1. Balu. M. Assistant Manager- Legal
Exhibits for the Complainant:
A1. Medi- Classic Insurance Policy (Individual).
A2. Letter. dt:26.04.2019.
A3. Copy of Letter. dt:21.07.2015.
A4. Copy of Lab Report. dt:22.07.2015.
A5. Copy of Sonography Report. dt:22.07.2015.
A6. Insurance Policy Schedule. dt:21.07.2015.
A7. Insurance Policy Schedule. dt:21.07.2015.
A8. Insurance Policy Schedule. dt:21.07.2015.
A9. Discharge Summary.
A10. Final IP Bill Summary. dt:14.02.2019.
A11. IP Medication Bill.
A12. IP Receipt Voucher. dt:15.02.2019.
A13(a) Bill. dt:14.02.2019.
A13(b) Bill. dt:14.02.2019.
A13(c ) Cash Voucher. dt:14.02.2019.
A13 (d) Receipt Voucher. dt:15.02.2019.
A14. Copy Letter. dt:26.04.2019.
A15. Letter. dt:18.02.2019.
Exhibits for the Opposite Parties:
B1 Insurance Policy Schedule.
B2. Copy of Medi- Classic Insurance Policy (Individual).
B3. Copy of Proposal Form.
B4. Copy of Request for Cashless Hospitalisation for Medical Insurance
Policy.
B5. Copy of Discharge Summary.
B6. Copy of Query Letter for Enhancement Authorization. dt:14.02.2019.
B7. Copy of Treatment Plan and Doctor’s Instruction.
B8. Copy of Withdrawal of Preauthorisation Request. dt:14.02.2019.
B9. Copy of Letter. dt:26.04.2019.
B10. Copy of Letter. dt:18.02.2019.
B11. Copy of Letter. dt:22.03.2019.
B12. Copy of Letter. dt:02.05.2019.
B13. Copy of Letter. dt:07.05.2019.
PRESIDENT (I/C): Sd/-
MEMBER : Sd/-
