Date of filing:22.4.2013.
Date of disposal:21.1.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
TUESDAY, THE 21st DAY OF JANUARY, 2014
C.C.No.75 of 2013
Between:
Damodar Bhattad, S/o Sivaram Bhattad, Hindu, 53 years, R/o D.No.59-8-1/12, Gatathri Nagar, Near Bhashyam Public School, Patamata, Vijayawada – 520 008.
.… Complainant.
AND
1. The Branch Manager, LIC of India, Jeevan Krishna, Besant Road, Vijayawada – 02.
2. The Manager (Health Insurance), LIC of India, Divisional Office, “Jeevan Prakash”, Bachupet, Kennedy Road, Machilipatnam – 521 001.
3. The Authorized Signatory, Family Health Plan (TPA) Limited, Ground Floor, Srinilaya Cyber Spazio, Road No.2, Banjara Hills, Hyderabad – 34.
. … Opposite Parties.
This complaint coming on before the Forum for final hearing on 9.1.2014 in the presence of Sri Bh.S.Sankar, Counsel for complainant and Sri P.Ramakrishna Paramahamsa, Counsel for opposite parties 1 and 2 and opposite party No.3 remained absent upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Sri S.Sreeram)
This is a complaint filed by the complainant under Section 12 of the Consumer Protection Act for a direction to the opposite parties 1 to 3 to pay Rs.3,01,672-00 towards the medical expenses, award Rs.50,000/- towards compensation for mental agony, for costs and other reliefs.
The brief facts which lead to filing the present complaint are that :
1. The complainant and his wife Anuradha had taken LIC’s Health Plus Plan from the opposite parties after duly following the terms and conditions under policy No.675724200 under proposal Number 13753, dt.19.11.2009, which covers the period from 15.12.2009 to 15.12.2021. They also paid the installment amount of Rs.15,000/- and they were also provided with identity cards bearing No.H067/675724200/01 for himself and H067/675724200/02 for his wife Anuradha. While so, the wife of complainant by name Anuradha fell ill and she was shifted to Heart Care Center on 3.10.2010 where after preliminary examination joined as inpatient and she was diagnozied from CAD – Anetiornio Cordian Infarction (evolved) Moderate LV Dysfunction and was given treatment from 3.10.2010 to 11.10.2010 and the complainant spent an amount of Rs.33,630/-. Later she was taken to Star Hospitals, Hyderabad, where she was subjected to different tests as outpatient from 11.10.2010 to 22.10.2010 and later she was treated as inpatient from 22.10.2010 to 1.11.2010 and an amount of Rs.2,68,042/- was spent for treatment. Later the complainant lodged a claim with opposite parties by submitting the bills, certificates and vouchers in original. But the opposite parties repudiated the claim of complainant on the ground that “pre existing illness irrespective of prior medical treatment or advice as discharge summary of Star Hospitals stated as DM 6 years”. It is further submitted that the wife of complainant was treated for heart ailment and consequent by-pass surgery and the amounts were spent towards the treatment of heart attack and that the opposite parties neglected to follow the principle of insurance. Hence, the complaint.
2. Denying the material allegations made in the complaint, the opposite parties 1 and 2 filed version. The 3rd opposite party remained exparte. The opposite parties 1 and 2 admitted the issuance of policy to the complainant and his wife and also contended that the complainant and his wife committed fraud on LIC and that they have suppressed the material facts and took policy. It is further contended that the complainant and his wife answered all questions as ‘NO’ in Col.NO.E of proposal form and they gave declaration that they have not suppressed any thing. It is further contended that the complainant and his wife suppressed the fact that the wife of complainant is suffering from “Type II Diabetes Mellitus – 6 years, Allergic to cold’ as mentioned in discharge summary. It is further contended that the complainant neither denied nor made any explanation about the pre-existing illness of his wife and because of type 2 diabetes, long term complications from high blood sugar can include heart diseases, strokes and also kidney failure and the Type 2 Diabetes Mellitus is typically a chronic disease associated within a ten year shorter life expectancy and further contended that there is no deficiency in service on the part of opposite parties and prayed to dismiss the complaint.
3. The complainant filed his chief affidavit reiterating the contents of his complaint and got marked Ex.A1 to Ex.A4. The Legal Manager of Divisional Office, LIC, Machilipatnam filed chief affidavit and got marked Ex.B1 to Ex.B4 on its behalf. The opposite parties filed I.A.No.218/2013 for issuance of summons to the doctors at Star Hospitals, Hyderabad where the wife of complainant was treated to give evidence and for production of discharge summary. The said IA was allowed and Dr.Lokeswara Rao Sajja was examined on behalf of opposite parties and Ex.X1 discharge summary was marked through him.
4. Perused the written arguments submitted on behalf of complainant and heard learned counsel for the opposite parties.
5. Now the points that arise for consideration are:
- Whether there is any deficiency in service on the part of the opposite parties 1
to 3 in repudiating the claim of the complainant?
2. If so, whether the complainant is entitled for any relief?
3. To what extent?
POINT No.1 and 2:-
6. On perusal of the material on record i.e., complaint, version and documents, it is an undisputed fact that the complainant and wife of complainant by name Anuradha obtained Health policy from the opposite parties bearing policy No.675724200 on 19.11.2009 by submitting the proposal form (Ex.B1 marked on behalf of opposite parties). The opposite parties 1 and 2 issued a bond under Ex.A1. The date of commencement of said policy is from 15.12.2009 which covers the period from 15.12.2009 to 15.12.2021. The premium amount is Rs.15,000/- per annum. Ex.A4 receipt discloses the said fact and payment of Rs.15,000/- upto 12/2012. Further it is not the case of opposite parties that the said policy was lapsed and it was renewed. The case of complainant is that, the wife of complainant by name Anuradha suddenly fell ill and was shifted to Heart Care Center on 3.10.2010 and from there to Star Hospitals, Hyderabad where she underwent by-pass surgery and an amount of Rs.33,630/- was spent at Heart Care Center and Rs.2,68,402/- has been spent at Star Hospitals. Ex.A2 Inpatient Final Bill details discloses the same. It is the further case of complainant is that when the complainant laid claim, it was repudiated by opposite parties stating that the wife of complainant and complainant suppressed the fact of pre-existing disease of complainant’s wife i.e. Diabetes Mellitus – 6 years. It is further contended that the complainant laid claim for the treatment that was given to his wife in respect of heart ailment and by-pass surgery only and not for any other disease and the ground for repudiation of claim by opposite parties is not tenable. In this regard, the contention of the opposite parties 1 and 2 is that the complainant and his wife suppressed the material facts of pre-existing disease and thereby violated the breach of their duty to disclose the correct facts and that the discharge summary issued by Star Hospitals reveals that the wife of complainant is having ‘Type II Diabetes Mellitus – 6 years” and that the said “Type II Diabetes Mellitus” would result to heart diseases, strokes and kidney failures and as such the complainant is not entitled for any relief. Ex.B1 is proposal form dt.19.11.2009, Ex.B2 is Health Details and Medical Information Form, Ex.B3 is Discharge summary of Star Hospitals (Ex.X1 marked through doctor), and Ex.B4 is repudiation letter dt.10.10.2010.
7. Perusal of record discloses that, the complainant submitted the proposal form on 19.11.2009 i.e. Ex.B1 and as per the Ex.A1 insurance policy, the date of commencement of policy is from 15.12.2009. As per complainant version, his wife suffered ill health and she was joined at Heart Care Center on 3.10.2010 and later joined at Star Hospitals, Hyderabad where she underwent by-pass surgery for her heart ailment. Ex.B3 Discharge Summary discloses that the wife of complainant by name Anuradha has joined in hospital on 22.10.2010, she underwent surgery on 26.10.2010 and discharged on 1.11.2010. Further Ex.B3=Ex.X1 discharge summary discloses that the wife of complainant was a chronic diabetic patient i.e. “Type II Diabetes Mallitus – six years”. It further discloses that coronary artery by pass grafting (four grafts) was performed on beating heart etc. Sec.45 of Insurance Act provides that no policy shall be called in question after expiry of two years from the date of which it was issued. In the instance case, the wife of complainant under went surgery within two years from the date of proposal and as such the opposite party has got every right to enquire in to the matter. Further Ex.B1 reveals that the life assured and complainant are educated persons and they subscribed their signatures in the proposal form after having understood all the contents of proposal form and also given answers to the questions in Col.No.E under the head HEALTH DETAILS AND MEDICAL INFORMATION as follows:
6. | Have you suffered/suffering from any of the following | | |
| a) Hyper Tension or High BP | | No. |
| b) Diabetes | | No. |
As seen from the documentary evidence marked on behalf of opposite parties i.e. Ex.B3=Ex.X1 discharge summary, it is clear that the wife of complainant i.e. Anuradha is a chronic patient of ‘Type II Diabetes Mallitus for six years” and by-pass surgery was conducted to her. But the complainant or his wife, at the time of filling the proposal form, has not informed about the said ailment and as such they have not disclosed the material facts and suppressed the .pre-existing disease of wife of complainant. Further it is not the contention of complainant that the opposite parties people without asking the complainant and his wife and without conducting medical checkup issued the policy. The complainant and his wife being prudent man ought to have informed about the ailments and treatments. Further they informed that their health condition is good in the proposal form. It is settled Law that the contract of insurance is based on good faith on the part of insured and when information on a specific aspect is asked for in the proposal form, the insured is under the obligation to make a true and full disclosure of information on the subject which is within his knowledge. In this case, though the complainant has got knowledge about the ailment, he has not disclosed the same at the time of taking policy. Definitely Sec.45 of Insurance Act is a beneficial legislation and the interest of the insured to be protected. But the fraudulent intention of insured in not disclosing correct facts cannot be entertained.
8. In this regard, it is the contention of complainant is that there is no nexus between the ailment mentioned in discharge summary and the treatment taken by complainant’s wife i.e. heart ailment. To rebut the said contentions, the opposite parties examined the doctor who treated the wife of complainant at Star Hospitals, Hyderabad by summoning him and got marked Ex.X1 discharge summary. He admitted that Type 2 diabetes mellitus is considered as a chronic disease and it is one of the risk factors for coronary heart disease and that the patient had a risk factor of diabetes mellitus. As per Ex.X1 discharge summary, the patient had past history of diabetes i.e. for the last six years. Ex.X1 discloses that she underwent operation in the year 2010 and as such from 2004 onwards she had history of diabetes and the complainant suppressed the said fact and taken policy in the year 2009. As such it is clear violation of terms and conditions of policy. Further as stated by the doctor that the Type 2 diabetes is one of the risk factor for heart disease and the undergoing surgery for heart problem more particularly coronary artery by-pass grafting (four grafts) was performed on beating heart etc strengthen the contention of opposite parties that due to Mallitus Diabetes for six years, the complainant’s wife suffered heart problem.
8. The decisions of Hon’ble National Commission, New Delhi relied on by the opposite parties 1 and 2 in Revision Petitions No.3138/2006 and 2314/2012 are applicable to the case on hand as the facts and circumstances of those cases and the present case on hand are one and the same. In those cases, the Hon’ble National Commission held
“that any inaccurate answer will entitle the insurer to repudiate the liability because there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into contract of insurance”
And further held that
“suppression of pre existing disease was deliberate”
In the present case on hand also, the complainant and his wife suppressed the preexisting disease of wife of complainant, though it is within their knowledge and thereby suppressed the material fact.
9. So far the decision relied on by complainant is concerned, the Hon’ble National Commission held that there is no evidence adduced by the insurance company in regard to the patient having received treatment for diabetes mellitus or he being aware of the suffering from that disease and thereby dismissed the revision. Now coming to the case on hand, it is not the case of complainant that they are not aware of the fact that the complainant’s wife had past history of diabetes and that they are not getting treatment. The complainant has not denied the said facts. As such the said decision is not applicable to the case on hand. Further in the cross examination of the doctor by the complainant, he admitted that basing on the history given by the attendant of patient and reading obtained in the hospital noted in the discharge summary, they noted the patient has type 2 diabetes. If the wife of complainant had no past history of diabetes, the attendant would not have disclosed the same to doctors.
10. In view of foregoing discussion, we hold that there is no deficiency of service on the part of opposite parties in repudiating the claim. The complaint is devoid of merits and is liable to be dismissed.
11. In the result, the complaint is dismissed, but in the circumstances of the case, there is no order as to costs.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 21st day of January, 2014.
PRESIDENT MEMBER MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant:- For the opposite parties:-
P.W.1 Damodar Bhattad D.W.1 Endla Vidyadhar,
Complainant Legal Manager of
(by affidavit) 2nd opposite party.
(by affidavit)
D.W.2 Dr.Lokeswara Rao Sajja
(Examined)
DOCUMENTS MARKED
On behalf of the complainant:
Ex.A.1 23.12.2009 Notarized copy of Health Plus Plan Policy.
Ex.A.2 01.11.2010 In-patient final bill details issued by Star Hospital,
Hyderabad.
Ex.A.3 15.02.2011 Letter from the complainant to the 2nd opposite party along
with postal acknowledgement.
Ex.A.4 02.01.2012 Renewal Premium Receipt issued by the 1st opposite party.
For the opposite parties:
Ex.B.1 19.11.2009 Attested copy of Proposal form for LIC’s Health Plus Policy.
Ex.B.2 19.11.2009 Attested copy of Health details and Medical Information.
Ex.B.3 01.11.2010 Attested copy of Discharge Summary issued by Star
Hospitals.
Ex.B.4 10.12.2010 Attested copy of letter from the 3rd opposite party to the
complainant.
Ex.X.1 01.11.2010 Photocopy of Discharge Summary issued by Star Hospitals.
PRESIDENT
