By Smt. Beena. M,  Member:

This is  a complaint filed under section 12 of the Consumer Protection Act 1986.

2. Brief facts of the case are as follows: -The Complainant had taken a Medi Claim  Insurance Policy  named as “JEEVAN BHARATHI PLAN’’ of  the Opposite Party on 13/08/2003  paying an annual premium of Rs.3,780/-.   As per the terms and conditions of the policy, the policy holder has to remit premium amount every year on 11^th day of August.   She had paid the premium up to the year 2015 and thereafter she could not remit the premium installments for the period from 08/2015 to 08/2018 and she had remitted the unpaid amount with fine for the above period and renewed the policy.   The sum assured for critical illness is Rs 50,000 as per the plan.   While so, the Complainant had consulted a doctor due to the feeling of giddiness and she had been diagnosed with Vertigo and treated for the same.   Subsequently the Complainant  sustained pain on her left breast and she again visited the doctor, and as per the advice of the doctor, the Complainant went to the doctor in Surgery OP No.63 Unit and after several tests, it is confirmed that she has Carcinoma Breast.   During the time of renewal of the policy there were no symptoms of any disease.  Only after getting the test result, she realized that her illness was a critical one.   After treatment, she submitted the claim form to the Opposite Party No. 2 for an amount of Rs.50,000.  But the Opposite Party repudiated the claim without any valid reason.   Hence this Complaint.

            3. On admission of the Complaint, this Commission issued summons to the Opposite Parties.  The Opposite Parties entered appearance and filed version stating the following contentions. 

4. The preliminary contention is that the Complaint is not maintainable and the Complainant has suppressed the material facts while filing the Complaint.   On merit, the fact of taking of policy has been admitted.   The Opposite Party denies the allegations that the Complainant spend more than Rs. 60,000/- for the treatment and she is entitled for Rs. 50,000/- as per the policy and the policy was  renewed without  knowledge of the disease.  The Opposite Party repudiated the claim made by the Complainant as per the terms and conditions of the policy. Due to non-payment of premium, the policy was lapsed from 8/15 onwards.  Thereafter, on 27-06-2018, the policy was renewed   paying the premium arrears  with interest  with declaration of good health and medical examination report.  The Complainant had submitted the claim on 12/2018 with treatment reports.   The verification of the declaration statement and answers shows that all the answers made by the Complainant clearly reveals that pre- existing illness was suppressed and had not disclosed at the time of renewal of the said policy.  Suppression of material facts in connection with pre-existing disease is the violation of policy conditions and claim for female critical illness benefit was repudiated as per the alleged policy conditions mentioned above. So the Opposite Party prayed for the dismissal of the Complaint.

5. Here the points raised by the Commission for consideration are

    1) Whether there is any deficiency in service from the part of Opposite

         Parties?

    2) Whether the Complainant is entitled to get any relieves as prayed

        for?

6. Point No. 1 and 2 :-  For the sake of convenience and brevity both the points are considered together.

            7. The Complainant had adduced oral evidence and she was examined as PW1 and the documents produced were marked as Ext. A1 to A4.   On the side of Opposite Party Ext. B1 to B4 were marked. The Opposite Party had no oral evidence to adduce.

            8.  The case of the Complainant is that her claim was rejected without any valid reason and she is entitled to get the benefit.  In order to substantiate her claim she had produced A1 to A4 documents and gave oral evidence.  Ext. A1 is the policy renewal receipt issued by the Opposite Party dated 27-06-2018, A2 is the letter issued by the Opposite Party dated 20-04-2019, A3 is the Policy Bond and A4 is the Mammogram report.  Opposite Party admitted the contentions that the Complainant is a policy holder and she renewed the policy on payment of arrears due on 27-06-2018.

9. The Commission analyzed and perused the Complaint, version, affidavit, documents marked and the oral evidence adduced by the Complainant.  It is the admitted fact that the policy in question was renewed on 27/06/2018 which is evident from Ext. A1. The reason for the repudiation of the claim of the Complainant as stated by the Opposite Party is the suppression of material facts relating to pre-existing disease and the treatment taken by the Complainant.  Ext. B3 hospital record reveals that the Complainant had given consent for surgery on 29/06/2018 which is after the renewal of the policy. In oral deposition the Complainant has also stated that “29/06/2018 \v amt½m{Kmw  test sNbvXp”.  But Ext. A4 document reveals that Mammogram test was conducted on 18/06/2018.  Here the deposition of the Complainant that Mammogram test was conducted on 29/06/2018 is not true.  From Ext. B3 document it is evident that on 29/06/2018 the Complainant had given consent for surgery which is after the renewal of the policy.   In oral examination, the Complainant has stated that ‘’Surgery OP bn  Surgery  ¡pff k½X]{Xw 20.06.2018 \v Rm³ H¸n-«p-sIm-Sp-¯n-«p-­v ‘’.   From Ext. B3 document we see that it is a mistake as to the date wrongly stated by the Complainant.   As per Ext. B3 it is 29/06/2018 which is also after renewal of the policy.   The biopsy report dated 31/07/2018 reveals that (Ext. B4) the Complainant had Carcinoma left breast status post lumpectomy (Tumor).   The biopsy report is seen dated on 31/07/2018 which is also after renewal of the policy.   In re-examination, the Complainant has deposed that ‘’ 27.06.2018 \v proposal form sImSp-¯-t¸mÄ   LIC  bpsS    Panel Doctor  \ÂInb Medical Certificate   kln-X-amWv \ÂIn-bXv‘’.    The Complainant has also deposed that ‘’proposal form sImSp-¡p¶ ka-b¯v Xe-I-d-¡-¯n\v    vertigo     BsW-¶mWv tUmIvSÀ ]d-ªXv.  F\n¡v  cancer AsW¶v   13/7/2018 \mWv Rm³ Adn-bp-¶Xv.  tUmIvSÀ ]d-ªmWv Rm³ Adn-bp-¶Xvv ‘’.   So as to contradict this statement of the Complainant the Opposite Party has not examined the treated doctor of the Complainant.    The Opposite Party has not examined even the panel doctor of the LIC who issued the Medical Certificate to the Complainant for renewal of the policy of the Complainant.  In further cross examination of the Complainant with permission, the Complainant has deposed that ‘’ vertigo  F¶ tcmK-am-sW¶v tUmIvSÀ BWv ]d-ª-Xv.     Cancer sâ XpS-¡-am-bn-cp¶p, vertigo Aà F¶p ]d-ªm icn-b-Ñ’.   So as to contradict this statement of the Complainant the examination of the treated Doctor was highly essential but the Opposite Party has failed to examine him.   It is quite natural that people may consult doctors and go to hospitals for usual general check ups and treatment for their normal, physical or mental inconveniences which can’t always be viewed with suspicion without valid evidences.    Here, in this case of the Complainant, the facts of the issue are seen as follows:-

1) The Complainant had renewed the health insurance policy with the

    Opposite Party on 27/06/2018 - Ext.A1.

2) The renewal of the Health Insurance Policy was supported by the     

    Medical Certificate issued by the Panel Doctor of the LIC, otherwise the

    Opposite Party would not renew the Policy.

3) The deposition of the Complainant that the certificate was issued by

     the Panel Doctor of the LIC is not disputed by the Opposite Party.

4) So, this Certificate shall support that the Complainant was medically fit

     for renewal of the Health Insurance Policy.

5) The hospital record reveals that the Complainant had given consent for

    surgery on 29/06/2018 which is after renewal of the Health Insurance

    Policy - Ext. B3.  The biopsy report dated 31/07/02018 reveals that the

   Complainant had Tumor, which is also after the renewal of the Health

   Insurance Policy of the Complainant - Ext. B4.

6. In oral deposition, the Complainant has stated that ‘’proposal form

    sImSp-¡p¶ ka-b¯v Xe-I-d-¡-¯n\v    vertigo     BsW-¶mWv

  tUmIvSÀ ]d-ªXv.  the Opposite Party has not examined the treated

   doctor.

7. Another statement in oral examination of the Complainant is that          

’’ F\n¡v  cancer AsW¶v   13/7/2018 \mWv Rm³ Adn-bp-¶Xv. 

   tUmIvSÀ  ]d-ªmWv Rm³ Adn-bp-¶Xv‘’.         Which is also after the

    renewal of the policy.   Here, also to contradict the statement of the

    Complainant, the Opposite Party has not examined the Doctor.

8. Here there is no material to prove the fact that the Complainant was

    aware that she had Cancer/ Tumor   before renewal of the policy.

9. Consulting doctors and going to hospitals in usual course by the

    Complainant for general check ups do not mean that the Complainant

    had awareness regarding Cancer/ Tumor before renewal of the policy.

10. The examination of the treated doctor or an expert opinion was highly

      essential to prove that the Complainant had Cancer/ Tumor which was

      known to the Complainant before renewal of the policy.

11. Here, the Opposite Party has failed to prove that the Complainant had

      Cancer/ Tumor which was known to the Complainant before renewal

      of the policy and the Complainant had deliberately suppressed it while

      renewing the Policy.

10. In the light of the evidences adduced before us, we are of the view that the Opposite Party has repudiated the claim of the Complainant without any  bona fide or valid evidences as to deliberate suppression of pre-existing diseases.  So the Opposite Party has failed to prove the deliberate suppression of pre-existing diseases by the Complainant.  Repudiating the claim of the Complainant without any valid evidence/reason amounts to unfair trade practice/deficiency in service.   So there has been unfair trade practice/deficiency in service from the part of the Opposite Party.  So the Complainant is entitled to get the reliefs as prayed for.

Hence the Complaint is allowed in part and the Opposite Party is accordingly directed to:_

1. To pay the Complainant a sum of Rs. 50,000/- (Rupees Fifty Thousand only) towards the claim of the Complainant.
2. To pay a sum of Rs. 10,000 (Rupees Ten Thousand only) towards compensation and mental agony.
3. To pay an amount of Rs.5,000/-(Rupees Five Thousand only) towards costs of the litigation.

The above amounts shall be payable within 30 days from the date of receipt of the copy of this order, failing which, the said amounts  shall carry interest at the rate of 9% p.a. till the date of payment.    

Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 24^th day of September 2022.

Date of filing :30.08.2019.

                                                                        PRESIDENT (I/C):  Sd/-

                                                                        MEMBER        :  Sd/-

APPENDIX.

Witness for the complainant:

PW1.           Annie Thomas.                Complainant.

Witness for the Opposite Parties:

Nil.

Exhibits for the complainant:

A1.              Renewal Premium Receipt (Revival).   dt:27.06.2018.

A2.              Letter.                                                dt:20.04.2019.

A3.              Policy Schedule.                                 dt:13.08.2003

A4.              Mammogram.                                     dt:18.06.2018.

Exhibits  for the Opposite Parties:

B1.              Copy of Personal Statement Regarding  Health.

B2.              Copy of Discharge Summary.

B3.              Copy of Out Patient Card.                  dt:20.06.2018.

B4.              Copy of Biopsy Full Report.              dt:31.07.2018.