SMT. RAVI SUSHA  : PRESIDENT

         Complainant has filed this complaint  U/S 12 of Consumer Protection Act 1986  ,seeking to  get an order directing  the opposite parties to  reimburse of Rs.21,260/- with 12% interest  from 18/7/2019 till the realization of the amount together with Rs.2,00,000/- towards compensation and cost of the proceedings.

     Complainant’s case is that the complainant purchased a Arogya plus policy bearing No.8551156 on 7/3/2018 from 3^rd OP, the period of policy was one year and before the maturity date the complainant renewed the policy by remitting a final  premium of Rs.10,502/-.  The 2^nd policy came into force on 7/3/2019 and in force up to mid night 6/3/2020. As the complainant has attained an age  more than 55 years  as per the  direction of 3^rd OP , the complainant has undergone medical examination  by the panel of doctors of 2^nd OP.  The policy was issued  only after the OPs satisfied that the complainant do not have any illness or deceases.  The wife of the complainant was also a beneficiary of the policy.  It is submitted that as per the offer in the policy the complainant and his wife are entitled to be reimbursed the medical expenses incure including treatment for cardiac deceases.  On 18/7/2019, the complainant under gone treatment of coronary angiogram at Koyili hospital  Kannur , the panel hospital of 3^rd OP, and paid Rs.21260/- as treatment  expenses.  Thereafter, without any delay the complainant submitted the claim form with required documents  as demanded by 3^rd OP before 1^st OP, OPs 1&2 denies the claim  proposal  by saying  the claim for hospitalization falls beyond  purview of policy coverage as the ailment or illness suffered by the complainant was pre-existing one.  Thereafter on 22/11/2019 complainant issued  a registered lawyer notice but the OPs have not paid any amount  to the complainant or sent any reply to the notice.  The act of OPs  amounts to deficiency in service.  Hence the complaint.

    After receiving notices OPs 1&2 filed  joint version and 3^rd OP filed separate version. Ops 1&2 admitted the  insurance policy and its maturity. OPs 1&2 contended that the claim of the  complainant was rightly repudiated by the OP, on the basis of the  treatment records which categorically  read that the  complainant is a known case of  diabetes mellitus since 18 years, moreover  hypertension  for 2 years.  Whereas, concealing the  above material facts as to health conditions , the policy of insurance was availed.  That the insurance being a contract of indemnity embedded on the principle of utmost good faith there is an obligation on the insured to declare material facts as to the subject matter of insurance.  The complainant suppressed the fact as to long standing pre-existing health condition of DM&HTN, which  amounted to  suppression of material facts and breached the principle of insurance contract. Further  the policy in question excludes complications out of a pre-existing condition for the first 48 months of continuous coverage.  In the  case in hand, the policy is less than 24 months from inception. OPs further stated that the claim was lodged in the  above policy alleging hospitalization of  insured at Koyili hospital for the period  17/7/2019 to 19/7/2019, whereof the patient is said to have undergone  angiogram.  The request for cashless facility was declined  by  the OP since the case  of the complainant prima facie seemed to  be barred by exclusion under the policy.  Hence the complainant was  requested to apply for the claim via reimbursement mode post discharge.  On scrutiny of the documents, it was noted that the complainant is a known case of  diabetes mellitus –II type for  18 years and  hypertension  for 2 years.  The treating doctor  had given clarification  that  hypertension and diabetes mellitus are risk  factors for CAD.  Thus,  undoubtedly pre-existing  DM&HTN are material  fact as to health and it is a risk factor for the current ailment.  Moreover the ailments DM& HTN  any claim for CAD would be exclusion for  first 48 months of continuous coverage.  Hence the claim was repudiated  by the OP vide letter  dtd.23/10/2019.  There is no deficiency in service  or  unfair trade  on  their part.  Hence prayed for the dismissal of the complaint.

   3^rd OP the SBI through  which complainant had taken policy of OPs 1&2, has stated that if during the policy period the complainant makes any claim  the insurer alone is liable to settle the said claim as per terms and conditions contained in the  insurance policy issued by 1^st OP .  Therefore, in case of any claim, the OPs 1&2 are the final authority for settling and paying the claim amount to the complainant on satisfying the terms of the policy and their decision in the matter is final. It is stated that  3^rd OP has no contractual liability to settle the claim and this OP has been wrongly arrayed in the present complaint and there is no deficiency in service.  Hence prayed for the dismissal of the complaint.

     Complainant has filed  his proof affidavit, examined as PW1 and Exts.A1 to A12 were marked.  On the side of OPs, legal manager of OPs 1&2 has filed his chief affidavit and has been examined as DW1 marked Exts.B1 to B8.  Bank manager of 3^rd OP filed his chief affidavit and  was examined as DW2.  After that the learned counsels of parties made oral argument  and  the learned counsel of OPs filed written argument notes also.

   In this case, the only question that arises for consideration is whether the insured complainant suffered diabetes Mellitus since 18 years and  Hypertension since 2 years from 15/7/20190 and suppressed the same when he submitted a proposal on 14/2/2018.

   It is the case of  the OPs 1&2 from Ext.B8 repudiation letter dtd.23/10/2019 that they had proof to show that before the insured proposed  for the policy he had suffered from diabetics Mellitus and hypertension and he failed to disclose the same in the proposal.  In support of their plea, the OPs 1&2 placed reliance  on  Exts.B4 to B7.  Ext.B6 is  the discharge summary issued from Koyili Hospital and it was signed by  Dr.Deepak Raju consultant cardiologist.  In Ext.B6 the treated doctor had not mentioned from which date onwards the insured was suffered from diabetic mellitus and hyper tension.  The diagnosis was  chronic stable Angina II.  In Ext.B4 alone one doctor Gautam Rajan ,Nephrologists stated that DM Type 2(18 years) HTN 2 years.  In the discharge summary it was stated that he was suffering from chronic stable Angina II with history of recent onset effort angina.  Symptoms since February 2019.  Relying on Ext.B4, it is submitted by the learned counsel for the OPs 1&2 that the insured suffered from diabetics Mellitus and hyper tension and treated  prior to the proposal date.  But in Ext.B6 the treatment given was CAD done .  In Ext.B6, though it is mentioned as hypertension ,  diabetics mellitus, the  disease and treatment done was  coronary angiogram.  Only at the first  time of consultation(Ext.B4) the duration of hypertension  and diabetes  mellitus were mentioned.  But the treatment  as per the treatment records shows that was for coronary angiogram.  During cross – examination  PW1 denied the contention of  OPs 1&2 that he had suffered from  diabetes at the  time of giving proposal form.  Here though OPs 1&2 raised contention that the complainant  suffered diabetes during giving proposal, no material showing  that the insured underwent treatment from any medical practitioner  and for what period he was treated for diabetics .  Moreover Exts.B6 the laboratory report from Karunya Diabetic centre dtd.26/2/2018 just after filling  proposal form show that the blood sugar level of complainant was normal.  It is also noted that only in Ext.B4 it was noted that he was suffering from diabetes  since 18 years.  Moreover OPs 1&2 failed to examine the  medical practitioner who filled Exts.B4 to substantiate their  contention.  We are, therefore , not inclined to accept the version of the OPs by solely relying  on Ext.B4, for  arriving at a conclusion , that the complainant (insured) was treated for diabetes mellitus and hypertension on 14/2/2018 and that he intentionally did not  disclose the same at the time of proposal.  So we  are of the opinion that the  complainant did not suppress any  material fact with regard to the state of health  at the time of the proposal and that, therefore, repudiation  of the liability by the OPs amounts to deficiency  of service.  

    Hence the OPs 1&2 are liable to pay to the complainant the treatment expense as stated in Ext.A4 discharge bill dtd.19/7/2019.  Since there is no deficiency in service on the part of 3^rd OP, in repudiating the complainant’s claim, 3^rd OP is exonerated from the liability.

   In the result,  complaint is allowed in part.   Opposite parties 1&2 are directed to reimburse Rs.21260.00/- to the complainant with Rs.10,000/- towards compensation  and Rs.5000/- towards cost of the proceedings.   Opposite parties 1&2 shall comply the order within  one month from the date of receipt of the certified copy of this order.   Failing which, Rs.21260+Rs.10,000/- carries interest@9% per annum from the date of complaint till realization.  Complainant is at liberty to realize the awarded amount by filing execution application as per provision in Consumer Protection Act 2019.

Exts:

A1-Original policy

A2&3- claim form

A4 series-Bills issued by Koyili Hospital

A5-Reference sheet produced  by Koyili hospital(subject to proof)

A6-Karunya Diagnostic centre,Kannur

A7 series- Reference sheet, token, cash bill and re[port issued by  Hegde Hospital,Mangalore(subject to    

      proof)

A8-forwarding letter issued by 3^rd OP to  OPs 1&2 dtd.17/8/2019

A9-repudiation letter

A10-lawyer notice

A11-acknowledgment card

A12- reply notice

B1- Proposal form,

B2-medical record from Koylli hospital Kannur

B3- letter from treating  doctor dtd.14/8/2019

B4-claim form

B5- policy with terms and conditions

B6-  opinion & management notes

B7- Discharge summary

B8- repudiation letter

PW1-Balan.E.K-complainant

DW1-Leo John-Legal manager of OPs1&2

DW2-Sunny Kuriakose- 3^rd OP

Sd/                                                   Sd/                                                     Sd/

PRESIDENT                                             MEMBER                                               MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva           

                                                                       /Forwarded by Order/

                                                                   ASSISTANT REGISTRAR