DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 3rd day of May, 2024
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member Date of Filing: 24/09/2022
CC/179/2022
Kalimuthu,
S/o.Kannimuthu Nadar,
Palaniyarpalayam Post,
Kozhinjampara, Palakkad – 678 555 - Complainant
(By Adv. K.V.Sujith)
Vs
The Branch Manager,
M/s. Star Health & Allied Insurance Co.Ltd.,
Branch Office, 1st Floor, R.K.Buildings,
Opp.Chitturkavu, Chittur,
Palakkad - 678 501 - Opposite party
(OPs by Adv. M/s.Ratnavally P & Kiran G Raj. A)
O R D E R
By Sri. Vinay Menon V., President
- Complaint pleadings are to the effect that the complainant and his family members were beneficiaries under family health optima insurance plan issued by the opposite party. The 1st inception of the policy was on 23/6/2015 and was renewed from time to time for the last 7 years without any break and finally covering 23/6/2021 to 22/6/2022. Complainant experienced chest pain and was taken to Jubilee Mission Hospital, Thrissur, where-from he had to undergo emergency life-saving procedures. Diagnosis made was rheumatic heart disease, severe MS(Mitral Stenosis) with fair systolic function and was advised to undergo mitral valve replacement surgery. Inspite of filing the entire documents, complainant’s claim was repudiated on the ground it was a pre-existing disease and the complainant was suffering MS from 2011 onwards. The complainant had not taken any medicines of treatment for mitral stenosis / RHD prior to 3/1/2022.
The waiting period is not applicable in complainant’s case. This complaint is filed seeking Rs.3 lakhs for meeting the expenses of treatment and for Rs.2,50,000/- towards compensation and for incidental and ancillary reliefs. - OP filed version submitting that claim was repudiated as the conditions suffered by the complainant was a pre-existing disease and was excluded and was repudiated under exclusion No.3.1 of the policy. Further the complainant also not disclosed the medical history / health details in the proposal form even though there was specific question regarding the complainant’s health. There is no deficiency in service and the complaint is liable to be dismissed.
- Upon a studied consideration of the pleadings and counter-pleadings, the following issues were framed for adjudication:
- Whether the denial of medical insurance to the complainant by the OP is justifiable?
- Whether there is any deficiency in service on the part of opposite party?
- Whether the complainant is entitled to the reliefs claimed?
- Any other reliefs?
4. (i) Evidence of complainant comprised of proof affidavit and Exhibits A1 to A4. Marking of Exts.A3 & A4 were objected to on the ground they were photocopies. Marking of Ext.A4 was further objected on the ground that it can be marked only through the Doctor who issued it. But he has no objection regarding the authenticity of the said documents.
Since this Commission is not bound by Indian Evidence Act and in the absence of any contention that the said documents were forged or concocted, these objections are over-ruled.
(ii) OP filed proof affidavit and marked Exts. B1 to B8. Marking of Ext.B6 was
objected on the ground it was not issued by the complainant.
Ext.B6 is a letter allegedly issued by the complainant to the opposite party. This is a covering letter submitted along with the documents that were sought to be produced by the complainant. The opposite party has not taken any steps to prove the veracity of this communication dated 13/5/2022. The reliability or non-reliability of this document can be considered as and when or if at all the need arises.
Issue No.1
5. Complainant’s case is that he was a beneficiary of the OP for over 7 years starting 2015. There was always an existing policy coverage. During 2022 he suffered a cardiac issue. Claim for expenses incurred was repudiated on the ground that the complainant was suffering from MS since 2011 of pre-existing disease. Complainant asserted that prior to 2022, the complainant had not suffered the condition for which he had underwent treatment. Complainant marked Exts.A1 to A3 to prove his case.
Ext. A1 is the policy certificate covering 23/6/2021 to 22/6/2022. The details of insured persons shows that the complainant, Kalimuthu, has not declared any pre-existing disease.
Ext.A2 is the letter of repudiation. Said repudiation was made on two grounds. One is that the condition suffered by the complainant was a pre-existing disease. Since the present admission and treatment was for the pre-existing disease, ie. Mitral stenosis which the complainant had been suffering from as early as 2011. The claim was repudiated as being a pre-existing disease.
Ext. A3 is part of the treatment records.
Ext.A4 is a certificate issued by the treatment doctor stating that to his knowledge, the complainant was suffering from RHD only for past one year. But we are not inclined to accept this certificate to be a proof that the complainant was suffering from MS for past one year alone. Ext. A4 is not the statement of a fact, by statement of an information that the treating doctor has based on what the complainant has told him. It does not contain any statement regarding MS.
6. Therefore, the question that is to be adjudicated is whether the expenses related to treatment of a pre-existing disease and its direct complications as contemplated under the policy conditions. It is to be noted that even though the complainant had failed to disclose this material fact, repudiation was not made on this ground. Upon finding of this condition, finding was entered in the system and this condition would be treated as a PED for the purpose of future claims from the date of knowledge by the insurer.
7. Ext.B1 is the policy document along with the terms and condition. Clause 2 deals with the policy wordings. In page 7 of Ext.B2, the word pre-existing disease is defined. The definition are reproduced herein below:
“Pre-Existing Disease : Pre-existing disease means any condition, ailment, injury or disease;
i) that is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement
or
ii) For which medical advise or treatment was recommended by or received from a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.”
8. Clause 3 of Ext.B1 (page 7) deals with exclusions. The relevant part is being reproduced as herein below:
“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
- Pre-Existing Disease – Code Excl01
- Expenses related to treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the 1st policy with insurer.
- In case of enhancement of some insured the exclusion shall apply afresh to the extent of some insured increase.
- If the insured person is continuously covered without any break as defined under the portability norms of the extent IRDAI (Health Insurance) Regulations then for the same would be reduced to the extent of prior coverage.
- Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by the insurer.”
9. So as it stands now, complainant would become eligible for coverage for treatment of MS, 48 months from the date was entered in the system of O.P. in 2022.
10. Evidence of O.P. comprised of Ext. B1 to B8.
Ext. B4 is the treatment records of the complainant for the treatment underwent in Jubilee Mission Medical College, Thrissur. History shows that the complainant was suffering from breathless ness since last 10 years.
Ext.B7 is a medical record issued from Thankam Hospital. It is issued by Doctor Jayakumar B., DM(Cardio), DNB (Cardio), Interventional Cardiologist. This document is dated 3/3/2011 and is issued in the name of Kalimuthu. At the time of marking the documents produced by OP, even though marking of Ext. B7 was objected to on the ground it can be marked only through the author of the said document, complainant did not have any case that the said document was forged or fabricated or concocted to defraud the complainant. Hence, we can presume that Ext.B7 is a genuine document and was issued to the complainant. The disease suffered by the complainant as shown in Ext.B7 is MS. The patient was advised PTMC i.e. Percutaneous Transluminal Mitral Commissurotomy, a minimally invasive procedure that is used to treat patients with mitral stenosis.
11. Ext.B2 is the proposal form dated 23/06/2015 filled by the complainant.
(a) In Ext.B2 proposal form, to the query regarding health history, the complainant has answered that he is in good health.
(b) To the 2nd query whether he had consulted or taken treatment or was admitted for any illness or disease or injury, the complainant has answered in the negative.
(c) To question 4 (c) regarding the condition of heart disease, the complainant has answered “No”, i.e. the complainant has not suffered any cardiac issues.
12. Ext.B1 policy is issued based on these undertakings made in Ext. B2. The complainant has failed to adhere to the principle of uberrimae fidei.
13. Therefore, denial of benefits to the complainant is proper and legal.
Issue Nos. 2 & 3
14. Based on the observations and findings in issue No.1, we hold that repudiation of the claim was in line with the terms and conditions of the policy.
15. There is no deficiency in service on the part of the opposite party in repudiating the claim of the complainant.
16. Complainant is not entitled to any of the reliefs sought for.
Issue No. 4
17. Policy was issued and coverage was provided to the complainant and his family based on the false statements made by the complainant in Ext. B2 proposal form. The O.P. has extended the coverage by considering this as a pre-existing disease rather that rejecting the policy. The complainant would become eligible for treatment 48 months from the date of entry of MS in the complainant’s file. Facts reveal that the complainant has willfully tried to defraud the O.P. by withholding/non-disclosure of a condition that was pre-existing and material and also by providing false information. Thereafter he has the temerity to abuse the process of law by approaching this Commission, once the willful suppression has come to light.
18. Conduct of the complainant is malafide and intent upon unlawful enrichment and tantamount to fomenting vexatious litigation. Therefore, we impose a cost of Rs. 5000/- payable to the O.P. by the complainant, within 45 days of receipt of a copy of this Order.
19. With the above Order, we dismiss the complaint.
Pronounced in open court on this the 3rd day of May, 2024.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/-
Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant
Ext.A1 - Copy of policy certificate
Ext.A2 – Copy of letter of repudiation
Ext.A3 - Copy of discharge summary dated 11/1/2022
Ext.A4 - Copy of certificate dated 8/1/22
Exhibits marked on the side of the opposite party:
Ext.B1 - Copy of policy certificate and terms and conditions
Ext.B2 - Copy of proposal form
Ext.B3 - Same as Ext.A3
Ext.B4 – Copy of hospital records of complainant
Ext.B5 – Copy of communication dated 26/4/2022
Ext.B6 – Copy of reply dated 13/5/2022
Ext.B7 – Copy of doctor’s note and lab report dated 3/3/2012
Ext.B8 – Same as Ext.A2
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
