By Sri. Chandran Alachery, Member:
The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite Parties to pay Rs.1,00,000/- towards treatment expenses to the Complainant under the policy with 12% interest and also directing the Opposite parties to pay Rs.50,000/- as compensation and cost of the proceedings.
2. Complaint in brief:- The complainant took a policy from the Opposite Parties named Senior Citizen Red Carpet Policy on 30.04.2013 after paying a premium of Rs.5,000/-. The period of policy is from 30.04.2013 to 29.04.2014. The sum assured is Rs.1,00,000/-. The Complainant after a few months of policy got treatment from EMS Memorial Co-operative Hospital as out patient. Thereafter admitted as an inpatient on 12.07.2013 and got treatment. On 22.07.2013, the Complainant got discharged. The Complainant spend more than Rs.1,00,000/- for treatment. The Complainant thereafter gave claim application through 3rd Opposite party with all documents. Later the Complainant was informed by 3rd Opposite party that the claim is rejected. The Complainant send lawyer notice demanding the policy amount from the Opposite Parties. But the Opposite parties not responded. The act of opposite Parties are deficiency of service from their part. Aggrieved by this, the complaint is filed.
3. On receipt of complaint, notices were issued to Opposite parties and the Opposite Parties appeared before the Forum and filed version. In the version of Opposite parties, the Opposite Parties admitted the insurance taken by the complainant. The case of Opposite parties is that the proposal form is the basis of the policy as per rules and regulations. The Complainant is bound to give proper information regarding the present and past health status at the time of filling the proposal form. The Complainant got admitted in EMS Memorial Co-operative Hospital on 12.07.2013 and was diagnosed with peripheral artery Disease Type II Diabetic Mellitus, Hyper Tension and surgically Managed with percutaneous Transluminal Angioplasty and was discharged on 22.07.2013. As per the statement of treating doctor in discharge summary, the Complainant was suffering from the above disease before the inception of the policy. The complainant had the history of amputation of left index toe 4 years back which was not even mentioned in the proposal form. So there in suppression of material facts. The suppression of material facts makes the contract void ab inito. So the repudiation of claim is right and there is no deficiency of service from the part of Opposite Parties.
4. On perusal of complaint, version and documents the forum raised the following points for consideration.
1. Whether there is deficiency of service from the part of Opposite parties?
2. Relief and cost.
5. Point No.1:- The Complainant filed proof affidavit and is examined as PW1 and documents are marked as Exts.A1 to A7. The confronted document is marked as Ext.B1. The Opposite Party also filed proof affidavit and the Opposite Party is examined as OPW1 and Exts. B2 to B9 are marked. Ext.A1 is the policy, Ext.A2 is the letter send to the Complainant by the Opposite Party demanding him to produce certain documents. Ext.A3 series are the bills, Ext.A4 is the discharge summary, Ext.A5 is the lawyer notice send by the Complainant to the Opposite Parties, Ext.A6 series are the postal receipts, Ext.A7 series are the Acknowledgments. Ext.B1 is the original proposal form, Ext.B2 is the Policy Schedule, Ext.B3 is the Claim form, Ext.B4 Copy of Doctors initial assessment, Ext.B5 is the copy of discharge summary, Ext.B6 is the copy of Repudiation letter, Ext.B7 is the reply letter send to the Complainant by the opposite parties, Ext.B8 is the Authorisation letter, Ext.B9 is the copy of Surgery Report dated 19.05.2011. Admittedly, the policy is a Senior Citizens Red Carpet Policy wherein no medical check up is required before joining the policy. The Complainant is an aged person having 64 years old at the time of joining the policy. Normally there will be life style diseases in an aged person which are not major diseases. So it is the duty of the Opposite Party to have a detailed check up before joining the policy and issuance of policy. If the insured person not disclosing major existing diseases in the proposal form, it is a suppress of material fact. The Opposite Parties should expect some life style disease in an aged person which may not be known to the insured person and may not be shown in proposal form. According to the Forum in Senior Citizens Policy, the Opposite Parties can take a lenient view in allowing the claim. More over, the humanitarian consideration also, the Opposite Parties can settle the claim. The Opposite Parties need not go to the strict provision of policy in these type of policy. Non-settling of claim in a Senior Citizens Policy is a clear deficiency of service from the part of Opposite Parties. Point No. 1 is found accordingly.
6. Point No.2:- Since point No.2 is found in favour of Complainant, the Complainant is entitled to get cost and compensation.
In the result, the complaint is partly allowed and the Opposite parties are directed to pay Rs. 1,00,000/- (Rupees One Lakh) towards, treatment expenses for which bills are produced and the Opposite Parties are also directed to pay Rs.2,000/- (Rupees Two thousand) only towards cost and compensation. The Opposite Parties shall comply the order within 30 days from the date of receipt of this order failing which the Complainant is entitled to get 12% interest from the whole sum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Forum on this the 4th day of April 2017.
Date of Filing:15.02.2016.
PRESIDENT : Sd/-
MEMBER : Sd/-
MEMBER : Sd/-
/True Copy/
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witnesses for the complainant:
PW1. Aboobacker Complainant.
Witness for the Opposite Parties :
OPW1. Manu Mohan Senior Executive, Star Health.
OPW2. Dr. K.V. Gopinath Senior Surgeon, EMS Hospital Perinthalmanna.
Exhibits for the complainant:
A1. Senior Citizens Red Carpet Insurance Policy – Schedule.
A2. Letter. dt:10.03.2014.
A3 series ( 29 Nos) Bills.
A4. Discharge Summary
A5. Copy of Letter. dt:17.07.2015.
A6 series (3 Nos) Postal Receipts.
A7 series (3 Nos) Acknowledgment
X1 series Medical Records of Mr. Aboobacker.
Exhibits for the Opposite Parties:
B1 Star Senior Citizen Red Carpet Insurance – Proposal Form.
B2. Copy of Senior Citizens Red Carpet Insurance Policy- Schedule.
B3(3Nos) Claim Form for Medical Insurance. dt:17.08.2013.
B4. Copy of Doctors initial Assessment. dt:12.07.2013.
B5. Copy of Discharge Summary.
B6. Copy of Repudiation of Claim. dt:17.02.2014.
B7. Copy of Letter. dt:16.11.2015.
B8. Authorisation Letter. dt:28.05.2016.
B9. Copy of Surgery Report.
