By. Smt. Bindu. R, President:

            This complaint is filed by Arunkumar. P. A, Punnakkal House, Karimkutty Post, Kalpetta, Wayanad against the Branch Manager, Star Health Insurance Allied Insurance Company Limited, Ammus Building, Kalpetta Post, Wayanad and another alleging deficiency of service and unfair trade practice under section 12 of the Consumer Protection Act 1986.

            2.  The Complainant states that had joined Star Health Insurance Policy on 25.11.2013 including his wife Gia Lukose and elder daughter Ayona Arun.  Thereafter on 03.06.2015 a male baby was born to him and the second son named Aron Arun was included in the policy on 15.12.2015.  The Complainant states that Opposite Party had given insurance claim earlier for the Complainant and his elder daughter.  While so the children were affected urinary infection and were admitted in Government Hospital, Mananthavady.  The claim for both children were forwarded to the Opposite Party Company with claim numbers 0466601 and 0497991.  The Complainant states that the children had no other difficulties than fever and urinary infection and had taken no other treatments except that mentioned above and as per the advice of the doctor blood and urine test were conducted as doctor doubted kidney stone and ARPKD and the result were also submitted to the Opposite Party Company.  The Complainant states that, according to the doctor if the child is affected by ARPKD, they will be having slow growth, weight loss and disability which were not seen in the children.  The claim was rejected to the second child and according to the Opposite Party Company the matter is to be verified in the case of first child also on the ground of pre-existing disease.  According to the Complainant no medical checkup was conducted by the Company at the time of taking the policy and hence there is deficiency of service and unfair trade practice from the side of Opposite Party and hence the complaint for a direction to disburse the claim amounts along with other reliefs.

            3.  Upon notice Opposite Party No.1 and 2 entered into appearance and filed their joint version contenting that the complaint is without any bonafides.  Family Health Policy issued to the family of Complainant for a period 25.11.2013 to 24.11.2014 which had been renewed up to 2019 covering the Complainant, his wife and his daughter is admitted by the Opposite Parties.  The Complainant added his son in the existing policy on 15.12.2015 and the same has been renewed up to 20.12.2019.  According to the Opposite Parties, the term and conditions of the policy were explained to the Complainant at the time of proposing the policy.  As per the policy conditions, any of the particulars stated in the proposal form are found incorrect the insurance Company would not incur liability under the policy.

            4.  According to the Opposite Parties, the Complainant had registered two claims under the policy. In claim No.CLI/2019/181314/0497991 the son of the Complainant Master Aron Arun was admitted on 27.11.2018 at District Hospital Mananthavady for treatment of known case of Autosomal Recessive polycystic Kidney Disease (ARPKD) and UTI (Urinary Tract Infection) and was in the hospital till 01.12.2018.  According to the Opposite Parties the discharge Summary reveals known case of “ARPKD”. As part of claim processing protocol the Company  conducted investigation and collected the hospital records from DM WIMS and Fatima Mata Mission Hospital, Wayanad.  The Opposite Parties contented that the inpatient records dated 23.07.2015 issued by DM Wayanad Institute of Medical Sciences Hospital reveals that the patient is a known case of polycystic Kidney Disease (PCKD) and it is also noted that USG taken on 09.07.2015 shows cyst in Lt Kidney (small) and Bilateral mildly enlarged kidneys.  According to the Opposite Parties, the case records dated 03.09.2015 issued by DM WIMS Wayanad Institute of Medical Sciences Hospital clearly reveals that Master Aron Arun is a known case of polycystic kidney disease on cephalexin prophylaxis.  The Complainant added his son in the policy on 15.12.2015 without disclosing his health condition and hence it is suppression of material fact.  The Opposite Party contented that for the specific questions regarding the illnesses which the insured is having the answer is ‘No’.

            5.  According to the Opposite Parties the insured has willfully suppressed the pre-existing disease in the proposal form which is the basis of contract the Opposite Parties rightly rejected the claim vide letter dated 05.03.2019.  As per policy condition No.12, the Company issued notice to the insured in the last known address on 04.03.2019 and Policy No.P/181314/01/2019/003544 in respect of Master Aron Arun was cancelled due to the non-disclosure of pre-existing diseases.

            6.  As far as second claim of the Complainant’s daughter Ayona Arun is concerned, she was admitted in District Hospital Mananthavady, Wayanad for the treatment of known case of Autosomal Recessive polycystic Kidney Disease (ARPKD) and UTI (Urinary Tract Infection) and after treatment, she was discharged on 17.11.2018. On getting the claim form, the Opposite Party forwarded a letter dated 23.01.2019 to the Complainant requesting some more documents for which the Complainant had submitted the Routine blood evaluation reports only and did not provide the scan reports and other details.  The Opposite Party sent another letter on 02.03.2019 and advised to submit “letter from treating doctor regarding the exact duration of (ARPKD) Autosomal Recessive Polycystic Kidney Disease and Birth Summary “which was not produced by the Complainant as requested even after the reminders”.  Thus the Opposite Party sent a rejection letter on 16.04.2019 to the Complainant stating that “you are not interested in preferring the claim”.

            7.  According to the Opposite Party, the claim with respect to the son of the Complainant was denied since it is a known case of polycystic kidney disease and was on cephalexin prophylaxis medication prior to policy and the Complainant conveniently denied the same at the time of proposal.  The claim of the daughter of the Complainant was denied only because of the non-co-operation of the Complainant in producing the details requested.  According to the Opposite Party there is no deficiency of service and unfair trade practice from the side of the Opposite Party and prayed for dismissal of the complaint with compensatory costs.

            8.  Evidence in this case consists of the oral evidence of PW1 and Exts.A1 to A3 from the side of the Complainant.  OPW1 was examined and Ext.B1 to B10 marked from the side of Opposite Party.  The discharge summary of Mr. Aron is marked as Ext.X1 series.

            9.  The Commission had made a thorough examination into the complaint, version and documents filed from both side and the deposition of both parties.

            10.  The following are the main points to be analyzed in this complaint to derive into an inference of the fact

1. Whether the Complainant had sustained to any deficiency of service or unfair trade practice from the side of the Opposite Party…?
2. If so, the quantum of compensation and other reliefs for which the complaint is eligible to get..?

11.  Heard both sides and perused the records in detail.

12.  Case of the Complainant is that the Complainant joined Star Health Insurance Policy on 25.11.2013 including his wife and his elder daughter.  Thereafter male child was born to him and he was also included in the policy on 15.12.2015.  According to the Complainant Opposite Party had given insurance claim earlier to the Complainant and his elder daughter.  Later the children affected urinary infection and were treated in the Government  Hospital, Mananthavady for which the claim was rejected by the Opposite Party on the ground of existing disease which amounts to deficiency of service and unfair trade practice from their part.  On the other hand the case of the Opposite Party is that the first child was admitted in District Hospital, Mananthavady for the treatment of known case of Autosomal Recessive Polycystic Kidney Disease (ARPKD) and UTI (Urinary Tract Infection) and on getting the claim the Opposite Party requested some more documents for which the Complainant submitted only Routine Blood Evaluation reports and did not provide the scan report and other details and hence the claim was rejected.  As far as the second child is concerned he was admitted in the District Hospital, Mananthavady for treatment of known case of Autosomal Recessive Polycystic Kidney Disease (ARPKD) and UTI (Urinary Tract Infection).  On 27.11.2018 as part of claim processing protocol the Company conducted investigation and collected the hospital records from DM WIMS and Fatima Mata Mission Hospital, Wayanad.  The case of the Opposite Party is that it is a known case of polycystic Kidney Disease (PCKD) and it is also noted that the USG taken on 09.07.2015 shows cyst in Lt Kidney (Small) and Bilateral Mildly enlarged kidneys and hence it is a known case of pre-existing disease.  While taking the policy the Complainant suppressed the existing disease and hence the claim was rejected.

13.  PW1 when cross examined deposed that he took the policy in 2013 as per Ext.B1 including himself, his wife and elder daughter.  Second son was included in the policy in 2015 and the policy which included the 4 persons was renewed during 2018 as per Ext.B4.  He deposed that “27.11.2018 \v am\´hmSn PnÃm Bip]{Xnbn aq{X kw_Ôamb AkpJ¯n\mWv t]mbXv.  Bip]{Xn NnInÕm tcJIÄ tImSXnbn lmPcm¡nbn«nÃ.  Ct¸mÄ Fs¶ ImWn¨Xv aI³ Aron sâ am\´hmSnbn \n¶pw e`n¨ Discharge Summary BWv. Discharge Summary  F\n¡v XÀ¡anÔ.  The said document is marked as Ext.X1 series.  PW1 further deposed that “Fsâ aI\v ta¸mSn DM WIMS  2015  NnInÕ D­mbncp¶p.  AXnsâ tcJ lmPcm¡mXncn¡m³ ImcWw computer  BWpffXv.  hcp¯n In«m³ \S]Sn kzoIcn¨nÃ. DM WIMS  Manoj Narayan BWv NnInÕn¨Xv AXp{]Imcw Fsâ aI\v Kidney kw_Ôamb AkpJaps­¶v tUmIvSÀamÀ kwibw ]dªn«p­v”.  Opposite Party had produced the case records of DM WIMS and the same is marked through the Complainant as Ext.B5 and B6.  PW1 further deposed that “\nc´cw ]\nbpw aq{Xkw_Ôambn AkpJambXpsIm­mWv tUmIvSsd ImWn¨Xv.  aIÄ AtbmW AcpWns\bpw 13.11.2018  am\´hmSn District Hospital  admit sN¿pIbpw Autosomal Recessive Polycystic Kidney disease F¶ AkpJw aIÄ¡pw D­mbncp¶p F¶pw AXnsâ NnInÕ Bbncp¶p”.  The discharge summary of the daughter Ayona Arun is marked through the Complainant as Ext.B8.  In re-examination PW1 deposed that “ARPKD h¶v Ignªm Ip«nIÄ¡v Xq¡¡pdhv hfÀ¨¡pdhv _p²namµyw D­mhpw F¶mWv tUmIvSÀ ]dªXv A¯c¯n Hcp _p²nap«pw Fsâ aI\v CÔ.

14.  In further cross examination PW1 admitted that  “ARPKD bpsS AkpJs¯¡pdn¨v tUmIvSÀ discuss sNbvXn«p­mbncp¶p.  CfbIp«n¡v AkpJ¯nsâ e£W§Ä D­mbncp¶p.  Genetical disorder BsW¶v a\Ênem¡nbn«p­v”.  In further examination PW1 deposed that “ARPKD sb Ipdn¨v  discuss sNbvXXv hn«pamdm¯ aq{X¯n ]gp¸v D­mbt¸mgmWv Ct¸mÄ ASp¯mWv discuss sNbvXXv”.

15.  Deputy Manager Legal was examined as OPW1 from the side of Opposite Party who deposed that “2019 hsc policy renew sN¿pIbpw sNbvXp.  3,00,000/- cq]bpsS t]mfnknbmWv FSp¯Xv. ]n¶oSv Btcm¬ Acp¬ F¶ Ip«nsb aq{X¯n ]gp¸pw ]\nbpambn«v am\´hmSn Pnà Bip]{Xnbn admit sNbvXncp¶p.  tUmISdpsS report {]Imcw InUv\nbn cyst D­v F¶mWv F¶p]dªm F\n¡v ]dbm³ ]änÃ.  ARPKD F¶ tcmKamWv AXv pre-existing disease  BWv F¶v ]dªmWv claim repudiate sNbvXXv.  ARPKD bv¡pff symptoms F´msW¶v AdnbnÃ.  tImSXnbn kaÀ¸n¨ report   symptoms s\ Ipdn¨v ]cmaÀin¨n«nà 2015 apX tcmKapffXmbn«v diagnose sNbvXn«p­v. AXns\ kw_Ôn¨v documents kaÀ¸n¨n«p­v.  Ext.B5, B6 Mims Hospital  \n¶v e`n¨  discharge summary BWv. B report  ARPKD F¶p ]dbp¶ tcmKambncnbv¡mw F¶ kwibw am{XamWv ]dªncnbv¡p¶p”.

16.  In re-examination OPW1 deposed that “tImSXnbn lmPcm¡nb  Mananthavady PnÃm Bip]{Xnbn \n¶p e`n¨ discharge summary bn known case of ARPKD ]dªncn¡p¶Xv”.

17.  In this case the Complainant produced Exts.A1 to A3 documents for proving his case viz  the copy of Policy dated 15.12.2015 copy of repudiation of claim dated 05.03.2019 and copy of endorsement schedule dated 11.04.2019.  Opposite Party had produced the medical history etc to substantiate their case.  In Ext.X1 series the Discharge Summary/ Card dated 27.11.2018 of Aron having 3 ½ years showing history as “k/c/o ARPKD”.  The inpatient Record – Pediatric dated 23.07.2015 which is marked as Ext.B7 shows “presenting complaints as Excessive crying, irritability for two weeks”.  History of present illness shows “mother noticed excessive cry and irritability for about two weeks.  Child had pus coming out of umbilicus since birth and had consulted nearby pediatrician, but not subsided.  Had fever for two days no vomiting/loose stools – k/c/o PCKD”.  In the said document, past history also shows “22^nd day H/O NNH Now admission two days Phototherapy USG on 09/07-showed cyst in Lt Kidney (small size B/L mildly enlarged kidneys”.  Antenatal History shows “Oligohydramnious/Term/AGA (2.5 Kg fwt) Antenatal History showed cyst in Lt Kidney”.  In Ext.B6 short case Record of DM WIMS Hospital history shows “no fever spasmolic cough, known case of polycystic kidney disease/medullary sponge kidney on cephalexin prophylaxis”.

18.  Even though the case of the Complainant is that ARPKD is only a doubt of the doctor, the Complainant was not cared to examine the doctor or to produce documents to prove that the patient had no such disease as far as the case of the second child Aron Arun is concerned.

19.  The case of the Opposite Party is that the Complainant had not produced the documents as requested in the case of Complainant’s elder daughter Ayona Arun.  The specific case of the Complainant is that with respect to the elder daughter, Opposite Party had granted the claim earlier.  Moreover her name was added in the policy in 2013 and the same was renewed upto 2019.  The overall consideration of the case, the Commission feels that an opportunity can be given to the Complainant to produce the documents asked for by the Opposite Party within 15 days and upon getting the documents the Opposite Party shall process the documents and shall settle the claim within a maximum period of 30 days from the date of receipt of documents from the Complainant.  Considering the nature of the case the Commission finds that there is deficiency of service on the part of the Opposite Party as far as the repudiation of claim of the elder daughter is concerned.  Since Opposite Party had earlier given claim for the elder daughter. Hence the following Orders are passed.

1. The Opposite Party is directed to pay an amount of Rs.2,000/- (Rupees Two Thousand Only) to the Complainant towards compensation within 30 days of receipt of copy of this Order otherwise the Opposite Party will be liable for payment of interest @ 6% per annum to the said amount from the date of Order till date of realization.
2. The Opposite Party is also liable to pay Rs.2,000/- (Rupees Two Thousand Only) towards cost of the proceedings.

Hence Consumer Case is partly allowed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 16^th day of May 2024.

Date of Filing:-08.03.2019.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Arun Kumar.                                    Agriculture.

Witness for the Opposite Parties:-

OPW1.          Balu. M.                                Deputy Manager, Legal Star Health.

Exhibits for the Complainant:-

A1.                  Star Family Delite Insurance Policy Schedule for the period of

15.12.2015 to 14.12.2016.

A2.                  Copy of Repudiation of Claim Letter.                           Dt:05.03.2019.

A3.                  Copy of Endorsement Schedule.                                   Dt:11.04.2019.

Exhibits for the Opposite Parties:-

B1.                  Proposal Form.                                                                   Dt:25.11.2013.

B2.                  Proposal Form.                                                                   Dt:15.12.2015.

B3.                  Birth Certificate.                                                                 Dt:30.07.2015.

B4.                  Proposal Form.                                                                   Dt:21.12.2016.

B5.                  Copy of Short Case Record.

B6.                  Copy of Short Case Record.

B7.                  Copy of In-patient Record-Pediatric.

B8.                  Copy of Discharge Summary/Card.

B9.                  Copy of Requirement of additional documents/information letter.

                        Dt:23.01.2019.

B10(Series). Copy of Requirement of additional documents/information letter.

                        (3 Numbers).

X1(Series).    Documents produced by Opposite Parties (36 Pages).

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-