SRI.K.T.SIDHIQ, PRESIDENT

            Shorn of unnecessaries the case of the complainant is as follows:-

            Complainant is the holder of a Health Insurance Policy No. 004039205 under BSLI Saral Health Plan issued on 28-03-2010 for whole life.  The premium amount is Rs.18,501/- per annum and the sum assured is Rs.10,000,00/-(Ten lakhs). During the subsistence of policy complainant underwent medical treatment and other medical process at Fortis Hospitals Limited, Bangalore for Triple Vessel Coronary Artery Disease.  He underwent a surgery also on 25-11-2010 and discharged on 01-12-2010. Though he submitted a claim for re-imbursement,  it was not honoured  for a long time. Hence he caused a lawyer notice on 05-05-2011.  To which opposite party  sent a reply dated 10-06-2011 stating that as per the medical records the complainant was suffering from hypertension, diabetes mellitus and chest discomfort on exertion prior to the issuance  of policy and the claim was rejected by treating the policy as null and void.   Complainant had spent Rs.10,000/- for his treatment and medicines. The non-settlement of the claim by the opposite party amounts to deficiency in service.  Therefore the complaint.

2.         According to opposite parties 1 & 2 the complainant had purchased the policy suppressing the material facts that he had been suffering from Diabetes Mellitus, Hypertension (HTN) with chest  discomfort on exertion since 4 years, which was prior to the submission of application form.  The benefits offered as per the Health policy are subject to exception provided under the terms and conditions of subject policy.  Amongst others, the policy holder is not entitled for any claim directly or indirectly caused by/ based on/ arising out of /or however attributable to any pre-existing disease and its complications.  In the case on hand the claim of the complainant has been arisen caused by and based on pre-existing disease and therefore, the claim was rejected by opposite parties 1 & 2.  It was in accordance with the terms and conditions of the subject policy.  

            Further while  filling the application Form, the complainant had to make an insurability declaration, the answers for which the complainant had given  in a negative.   Basing as this information and declaration made in the above proposal form, the opposite party issued the policy.  Further the complainant had an option to surrender the policy during free look period if he was not satisfied with the terms and conditions of the policy. But the complainant did not opt to surrender the policy during free look period.

3.         On 21-01-2011, opposite party received a claim form through opposite party No.3  where in a claim for Rs.2,25,930/- as an expenditure alleged to have arisen out of the complainant’s treatment in the hospital was raised.  The complainant in support of his claim submitted various medical records.  On perusal of medical records it is revealed that the complainant was suffering from HTN (Hypertension) and DM (Diabetes Mellitus) since one year and also suffering from I.H.D (Ischemic  Heart Disease) along with chest discomfort on exertion since 4 years which is much prior to the date of proposal i.e. 31-03-2010.  The complainant suppressed these material facts while  submitting the proposal for the policy.  Thus the life assured intentionally and deliberately did not disclose  the pre-medical history to opposite parties 1 & 2 and induced them to issue the policy in his name.  The repudiation of the claim on the ground of pre-existing disease is therefore just and proper and it doesnot constitute any deficiency in service and the complainant is not entitled for the relief claimed and hence the complaint is liable to be dismissed.

4.         Complainant field proof affidavit and Exts A1 to A8 marked on his side.  He is cross-examined by the learned counsel for opposite party.  On the side of opposite parties Exts B1 & B2 marked.  Both sides heard and documents perused.

5.         The only point for consideration is whether the rejection of the medical claim  submitted by the complainant to the opposite parties is justifiable or not?

6.         The specific plea of the complainant is that opposite parties repudiated his claim illegally and it amounts to deficiency in service and they are liable to honour his claim amounting to Rs.2,10,000/- on the strength of the Health Insurance Policy (BSLI Saral Health Plan).

7.         In order to substantiate the contention that complainant was suffering from pre-existing disease at the time of proposing for the policy itself the opposite party called for the case sheet pertaining to the treatment of complainant from FORTIS Hospitals, Bangalore & Lakeshore Hospital, Ernakulam. The case sheet produced from Lakeshore Hospital Ernakulam is marked as Ext.B1  and the case sheet of FORTIS Hospital is marked as Ext.B2.  As per Ext.B1 it is seen that complainant has treated from 01-11-2010 to 20-11-2010.  In the Discharge Summary in the column History and Examinations it is recorded that Patient is a known case of Coronary Artery  Disease.  Triple Vessel Disease with Diabetic presented to them with complaints of occasional chest pain and breathlessness on exertion which increased recently.

8.         In Ext.B1, page 26, the admission history Physical Examination and Treatment Plan is recorded.  There the present complaints are noted as below.

            C/o. Occasional chest pain, breathlessness on exertion increased recently.

           History. Known Diabetic, Hypertension, 1 ½  years CAD-DVD ( 4 Years)

            This would indicate that complaint was suffering from the diseases noted in Ext.B1 prior to the proposal of the policy itself.

            This is further corroborated as per Ext.B2 case sheet produced from FORTIS HOSPITALS, Bangalore.  In Ext.B2 also in the discharge summary it is noted that the patient had the complaints of DM, HTN with history of chest discomfort on exertion since 4 years. This would indicate that the complainant had the aforesaid pre-existing disease that he suppressed while proposing for the policy. 

9.         The contract of insurance is a contract uberrimae  Fidei.  A person who desires to take policy must disclose the insurer all the materials facts/circumstances because the insurer knows nothing and assured knows everything.  The special facts are commonly in the knowledge of the insured and the insurer trusts the assured’s representations. The insurer proceeds on the belief that the insured has not suppressed any facts and circumstances in his knowledge and induce the insurer to believe that risk doesnot exist.  Suppression of such material facts is make the contract void  and therefore insurer is not liable to honour the claim.

            In view of the above we dismiss the complaint with no order as to costs.

 Sd/-                                                                                                                  Sd/-

MEMBER                                                                                                   PRESIDENT

Exts.

A1.Birla Sun Life Insurance policy details.

A2.Bill

A3.Dishcarge Summary of  Kapil Nassar  Fortis Hospital

A4.Inpatient Bill of  complainant

A5. 05-05-2011 copy of lawyer notice.

A6. 10-06-2011  reply notice.

A7. Returned registered letter

A8. Renewal Premium Receipt.

B1. Patient record of KapilAbdul Nassar, issued by Lakeshore Hospital & Research

      Centre Ltd, Kochi.

B2.Recoreds of the complainant Fortis Hospital, Bangalore.

PW1.Kappil Abdul Nassar.

  Sd/-                                                                                                                    Sd/-

MEMBER                                                                                                      PRESIDENT

                                                                        Forwarded by order

                                                             SENIOR SUPERINTENDENT

Pj/