BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD, THIRUVANANTHAPURAM.
PRESENT
SRI. G. SIVAPRASAD : PRESIDENT
SMT. R. SATHI : MEMBER
SMT. LIJU B. NAIR : MEMBER
C.C. No. 79/2010 Filed on 08.03.2010
Dated: 15.01.2014
Complainant:
S. Muraleedharan Nair, Advocate, Vaisakh, Near Municipality Building, Varkala, Thiruvananthapuram.
(By adv. N.R. Ravikrishnan)
Opposite party:
The Branch Manager, Star Health & Allied Insurance Company Ltd., Zonal Office, S.S. Kovil Road, Thampanoor, Thiruvananthapuram.
(By adv. Mann Janarddanam Nair)
This C.C having been heard on 23.12.2013, the Forum on 15.01.2014 delivered the following:
ORDER
SMT. LIJU B. NAIR : MEMBER
Complainant availed a medi claim policy namely Medi classic Individual Policy from the opposite party companybearing policy No. P/181111/01/2007/000990. The same was renewed after the expiry of the first year and renewed policy No. is P/181111/01/2008/004614 for a sum of one lakh rupees. The policy document dated 01.04.2008 was issued to the complainant after examining the complainant by expert doctor of their own and confirmed that complainant is having no pre-existing disease. Complainant was hospitalized as inpatient from 03.03.2009 to 13.03.2009 in connection with some ailments in the Uthradam Thirunal hospital, Thiruvananthapuram and incurred an expense about Rs. 94,456.49. After the completion of the treatment he put forward the claim with the opposite party vide claim No. Corp/C1/2008-09 PMC 181111/26867 dated 12.08.2009. In Col No. 8 of the claim form the concerned doctor opined that the complainant’s illness was not due to any pre-existing disease. But the opposite party vide letter dated 12.10.2009 failed to entertain the claim stating the complainant had suppressed pre-existing disease as well as suppressed material facts. To the said letter, the complainant issued a reply dated 19.08.2009 disclosing the true facts revealing that the contentions of the opposite party are baseless. The act of the opposite party amounts to deficiency in service for which he is liable to compensate the complainant. In the said circumstances the complainant has no other alternative than to approach this Forum and hence this complaint.
It is admitted by the opposite party that the complainant was having this policy as described. However while compensating this opposite party is bound by the recitals in the policy. Here there is a contract of insurance done in goodwill and the same has been done from the side of the complainant. The complainant was having pre-existing illness and if that be so, under exclusion clause 1 of the recitals of the policy, this opposite party is not bound to compensate. The complainant has suppressed material facts and the existing illness were suppressed from the opposite party and policy was taken. If that be so, this opposite party is not bound to compensate. This aspect has been legally upheld by various courts of law including the Hon’ble Supreme Court of India. The complainant is a habitual alcoholic and he was treated for Alcoholic Hepatitis (Cirrhosis) Intrahepatic Cholestasis Viral Markers negative sufficiently long back and this aspect was totally kept in darkness from this opposite party and policy was taken concealing material facts. The treatments are virtually done for the complications again developed by the complainant after consuming alcohol and which he was medically advised by the doctors not to do so in 2005. This opposite party is again exonerated from indemnifying because policy was taken suppressing material facts and the pre-existing illness. The policy is obtained by suppressing material facts before this opposite party. There is no deficiency at all from the side of this opposite party and they are acting only as per recitals of the policy.
Points raised for consideration are:-
- Whether the repudiation of insurance claim is justifiable or not?
- Is there any deficiency in service on the part of the opposite party?
- Reliefs and costs, if any?
Complainant filed affidavit along with 6 documents which were marked as Exts. P1 to P6 respectively. Opposite party also filed affidavit and documents produced by them were marked as Exts. D1 to D5.
Points (i) to (iii):- Complainant filed this complaint challenging the repudiation of his mediclaim by the opposite party. According to him policy was issued to him after medical checkup and at that time there was no pre-existing disease. When a claim was lodged before the opposite party, they repudiated the claim on the basis of the clause ‘pre-existing disease and suppression of material facts’. He is challenging the same. Heard both sides in detail and perused the documents furnished by rival sides to support their claim. Ext. P1 & P2 are the policy documents in original. Ext. P3 is the copy of medical bill for Rs. 94,456.49. Ext. P4 is the repudiation letter and Ext. P5 is the copy of claim form. Copy of policy schedule with conditions is marked as Ext. D1. Proposal form given by the complainant is produced by the opposite party and is marked as Ext. D2. Original claim form is produced and is marked as Ext. D3. Discharge summary is marked as Ext. D4. Copies of previous discharge summary and case sheets are produced and is marked as Ext. D5. On perusal of Ext. D2, the proposal form the insured has specifically declared that he was not suffering from any disease or ailment at the time of submitting the proposal form or any point of time earlier and that his health condition was good in all respects. In the proposal form the complainant further declared that if after the insurance policy is effected any particulars stated in the proposal form are found incorrect, the insurance company would incur no liability under the policy. The complainant was admitted on 03.03.2009 at SUT Hospital, Thiruvananthapuram for the treat of Cirrhosis liver with portal hypertension and alcoholic liver disease and discharged on 13.03.2009. Later the complainant submitted a completed claim form, medical certificate, bills and lab reports. As per Ext. D3 the medical certificate issued by the treating doctor has clearly revealed that the patient was suffering from HTN since 3 years as on date of admission on 03.03.2009. It means that the illness has commenced from 03.03.2006. The policy commenced on 30.03.2007. Hence HTN is a pre-existing disease. On perusal of Ext. D4 discharge summary also reveals the diagnosis as Hepatocellular failure, DM, HTN, Cirrhosis liver with portal hypertension and alcoholic liver disease. The history column of discharge summary reveals that the patient was having DM & hypertensive with cirrhosis of liver. In the medical certificate the treating doctor has recorded that the present ailment is a complication of pre-existing disease which seems to be corrected as ‘No’. The opposite party collected photocopies of case sheets from SUT hospital where this complainant was previously admitted and treated for the same illnesses and is marked as Ext. D5. The discharge summary dated 28.04.2005 reveals that the patient had chronic complaints of alcoholism and finally diagnosed the illness as ‘alcoholic hepatitis? (cirrhosis)’. Case sheet dated 18.04.2005 also confirms that the complainant had pre-existing ailments/diseases and presently admitted due to the complication of such illness. From the available hospital records, i.e Exts. D3, D4 and D5 it is confirmed that the complainant had taken the policy from the opposite party by suppressing the facts of existing illnesses. As per the policy, pre-existing disease is excluded as per Exclusion clause No. 1 of the policy which states that “Pre-existing disease as defined in the policy, until 48 months of continuance coverage have elapsed, since inception of the first policy with any Indian insurance company”. Moreover it is elaborately explained in the definition head of the policy that pre-existing disease/conditions means any ailments or injury or related conditions(s) for which the insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to insured person’s first policy with the company. On perusal of Ext. D2 proposal form, for questions relating to medical history, complainant answered all the questions as ‘No’. There are a series of questions numbered from ‘a’ to ‘r’ and 8 questions related to medical treatments or investigations. For all these complainant answered in the negative. That proposal form was dated 13.03.2007. As per Ext. D5, it is very clear that the complainant was admitted for treatment for alcoholic hepatitis and Intrahepatic Cholestasis during the year 2005. In the history column it is stated that he had history of gall stones and he is consuming alcohol >6h/day. On discharge he was advised to avoid alcohol and fatty food. Cirrhosis with portal hypertension is doubted. These are all happened during the year 2005 and at the time of filling the proposal form in 2007, for the questions related to medical history and investigations and treatments he replied in negative. So suppression of material facts is clearly established. If there is suppression of material facts, then the insurance contract becomes void from the beginning and the company is not liable to indemnify the insured. Even though the complainant/insured had taken medical examination and was declared fit for insurance, but this medical examination report is based on information supplied by the insured in the proposal form and before the doctor, the contract of insurance is based on the principles of uberrima fidee and the proposer was duty bound to disclose every information sought through the proposal form and personal statement regarding his/her health condition correctly. As per exclusion clause No. 11 of the policy stipulates that the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of ‘convalescence, general debility, run-down condition or restcure, congenital external disease or defects or anomalies, sterility, veneral disease, intentional self injury and use of intoxicating drugs/alcohol’. Hence the treatment expenses of alcoholic related illness are not payable. In the proposal form, Ext. D2, there is a specific question numbered as ‘r’ in medical history, which reads as “Have you ever taken narcotics or other habit forming drugs or been treated or advised in connection with your alcohol consumption or taking of drugs?”. He answered ‘No’. As per Ext. D5, he was advised to avoid alcohol and the diagnosis therein was alcoholic hepatitis. So again the principle of ‘uberrimae fide’ fails. Insurance contracts are ‘contracts of utmost good faith’. The opposite parties issued the aforesaid policy on good faith based on the declaration made by the proposer/insured in the proposal form. Proposal form is the basis of the contract of insurance. As per the contract of insurance the insured has to furnish true and correct facts in the proposal form for issuing the policy. In the proposal form the complainant further declared that if after the insurance policy is effected any particulars stated in the proposal form are found incorrect the insurance company would incur no liability under the policy. So the complainant failed miserably to establish his case. We find nothing wrong with the repudiation done by the opposite party. So the complaint lacks merits and is to be dismissed. Since the first issue is found against the complainant, other points are not considered.
In the result, complaint is dismissed.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 15th day of January 2014.
Sd/-
LIJU B. NAIR : MEMBER
Sd/-
G. SIVAPRASAD : PRESIDENT
Sd/-
R. SATHI : MEMBER
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C.C. No. 79/2010
APPENDIX
I COMPLAINANT’S WITNESS:
NIL
II COMPLAINANT’S DOCUMENTS:
P1 - Copy of medi classic individual policy schedule issued by O.P.
P2 - Copy of claim form for medical insurance
P3 - Copy of medical bill for Rs. 94,456.49
P4 - Copy of claim rejection letter dated 12.10.2009 issued by O.P.
P5 - Copy of claim form for medical insurance.
P6 - Copy of postal receipts.
P6(a) - Copy of letter dated 19.08.2009 issued by complainant to O.P.
III OPPOSITE PARTY’S WITNESS:
NIL
IV OPPOSITE PARTY’S DOCUMENTS:
D1 - Copy of policy schedule with conditions.
D2 - Medi classic proposal form.
D3 - Original claim form for medical insurance.
D4 - Discharge summary issued by SUT Hospital.
D5 - Copies of previous discharge summary and case sheets.
Sd/-
PRESIDENT
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