THE CONSUMER DISPUTES REDRESSAL FORUM, KOZHIKODE.
C.C.133/2012
Dated this the 4th day of April 2017
(Smt. Rose Jose, B.Sc, LLB. : President)
Smt.Beena Joseph, M.A : Member
Sri. Joseph Mathew, MA, LLB : Member
ORDER
Present: Beena Joseph, Member:
This petition was filed on 20.03.2012 against illegal repudiation of medical insurance by the opposite parties.
The case of the complainant is that, she had taken a medical Insurance policy from Star Health and allied insurance Company Ltd for the period from 15.12.2010 to 14.12.2011. There after the complainant admitted Fathima Hospital on 16.06.2011 due to cellulitis on her leg and she was discharged on 22.06.2011. Earlier she was treated there for kidney complaint. After the discharge from the hospital, she made insurance claim before the opposite party with all relevant records. But the opposite parties rejected the claim of the complainant stating that complainant was treated earlier for kidney disease and 16.06.2011 also she was admitted for the same. The case of the complainant is that she admitted at Fathima hospital for some other disease ie. cellulitis on her leg and this disease has no connection with the previous disease. Hence the claim of the complainant is legally justifiable. The doctor who treated the complainant issued a certificate, wherein, he stated that she had undergone treatment on 16.06.2011, 22.06.2011 for cellulites on her leg and this disease has no connection with the previous disease. The complainant forwarded the certificate and other records to the opposite party, complainant suffered financial loss and mental agony for which the opposite party liable to pay to the complainant sufficient compensation. The act of the opposite party amounts to unfair trade business practice, deficiency in service and negligence on opposite party’s part. Many times complainant contacts with the opposite party for health insurance claim and send many letters but they had repudiated this claim without any sufficient reason. Complainant submitted all documents to the opposite parties. Therefore complainant prays to refund of an amount of Rs.11,152/- and compensation of Rs.10,000/- for mental agony suffered by the complainant and cost.
Notice issued to both parties, both of them appeared and opposite party filed version stating the following facts.
Opposite party filed version and all the allegations and averments are denied by them. The petition is not maintainable either law or on facts. It is admitted that complainant had taken a fresh Medi classic individual insurance policy from the opposite party for the period from 15.12.2010 to 14.12.2011. The proposal form is the basis and integral part of the contract, on that basis the policy is issued. The policy is issued strictly according to the terms and conditions. In this case complainant has admitted the terms and conditions and exclusions set in the policy. The policy issued to the complainant is essentially a health insurance policy. So the information regarding the health status of the complainant at the time of filing the proposal and earlier thereto, are material for proper underwriting of the proposal. The policy is issued after accepting the facts on the proposal. The insured has not mentioned any disease in the proposal form in the medical history column.
The insured was admitted at Fathima hospital Calicut on 16.06.2011 for the treatment of chronic complaint of glomerulo Nephritis, cellulitis(L) Lichen Amylodosis. Moreover the present complaints column it was recorded that the patient is a known case of chronic complaints of glomerulo Nephritis and now admitted with cellulitis of left leg with regional Iymphadenitis, fever, pain and pyoderma. In the medical certificate, the treating doctor had recorded the past history of patient as chronic complaints of glomerulo nephritis. From the above it is evident that the insured was suffering from glomerulo nephritis and was under medication. To understand the exact duration of past illness the opposite party obtained the past treatment records of the complainant from Fathima Hospital, Calicut. The discharge summary for the inpatient treatment from 06.06.2006 to 08.06.2006 clearly shows that the complainant was suffering from chronic glomerulo nephritis even to the then treatment. She has been suffering from pyoderma over both legs also during the period. The chronic conditions of the complainant have been in existence through 2006. To avoid any error in our judgment, the opposite party sought an expert medical opinion from a Nephrologists, he opined that the patient was suffering from CGN with pyoderma and was also taken treatment. CGN is caused due to pyoderma, CGN is an irreversible condition. Hence in his opinion, he confirmed that though the patient was suffering from CGN with pyoderma since 2006, both are pre-existing and ara continuous since then. The patient was aware of the existing illnesses. Based on the available documents including professional opinion, the opposite party rejected the claim on the grounds of pre existing disease and suppression of material facts.
It is submitted that the pre existing disease is specifically excluded as per the Exclusion Clause Number 1 of the Medi classic policy condition. Exclusion clause number 1 of the policy stated that “ the company shall not be liable to make any payment under this policy in respect of any expense whatsoever incurred by the insured person in connection with or in respect of pre existing disease as defined in the policy until 48 months continuous coverage have elapsed, since inception of the first policy with the company.
In the proposal form complainant has stated that, she was not suffering from any disease or ailment at the time of submitting the proposal form. Further she declared that, if after the insurance policy is affected, any particulars stated in the proposal form are found incorrect, and the insurance company would incur non liability under the policy. So the claim is rejected on the basis of suppression of pre existing disease. The claim repudiation letter was intimated to the insured on 17.11.11. The insured willfully suppress the pre existing disease at the time of applying for policy. The intentional withholding of material facts would amount to fraud and would vitiate the contract. Hence the contract is void from the very beginning due to suppression of material facts.
The above complaint has filed vexatiously and frivolously to harass the opposite party in order to attain unlawful enrichment from the opposite party who are dealing with public money under the control of IRDA and Govt.of India. So opposite party must exercise abundant caution in dealing with claims by applying all conditions correctly. The opposite parties have not caused any mental agony or sufferings to the complainant. Hence complainant is not entitled to get any relief from the opposite party. The opposite party have not committed any deficiency in service or unfair trade practice as alleged. Therefore opposite parties are entitled to get compensatory cost from the complainant for the reason that (1) Her disease was diagnosed in 2006 (2) The complainant fraudulently suppressed her existing illness(3) complainant dragged the opposite parties into an unnecessary litigation knowing fully well that she had taken treatment for a pre existing illness. Therefore petition is liable to be dismissed with compensatory cost.
Points to be considered.
- Whether the petition is maintainable or not?
- Is there any service deficiency or illegal trade practice adopted by opposite parties?
- Whether the disease is pre existing or not?
- Whether the repudiation of claim is proper or not?
- If yes, what are the awards to be passed?
In this matter complainant filed affidavit and examined as PW1 Ext.A1 to A3 marked on his side. Ext.A1 is the discharge bill of Fathima Hospital dtd 22.06.11, Ext.A2 is the medical certificate issued by doctor Thomas Mathew dtd.22.06.11. Ext.A3 is the discharge summary of Fathima Hospital. Opposite party filed affidavit and examined as RW1 and Ext.B1 to B6 marked. Ext.B1 is the proposal form, B2 is the policy certificate, Ext.B3 is claim form, Ext.B4 is the discharge summary, B5 is the claim repudiation letter, Ext.B6 is discharge summary dtd.08.06.2006.
On analyzing the evidence and documents produced by both parties it is seen that points to be considered as interlinked which required common discussion. So all these points can be considered together. The complainant herein claims that she had obtained a medical insurance policy from the opposite party for the period from 15.12.2010 to 14.12.2011. There was no dispute with respect to the policy taken by the complainant. Hence the petition is maintainable before this forum.
After obtaining the medical insurance the complainant herein was admitted in Fathima Hospital, Kozhikode on 16.06.2011, within the insurance coverage period and discharged on 22.06.2011 with a complaint of cellulitis of left leg with regional lymphedenitis, fever pain and pyoderma since one week. Later the doctor diagnosing the disease of the petitioner is as 1) chronic case of glomerulo nephritis 2) Cellulitis left leg 3) lichen amylodosis, she was discharged with an advice to continue medicine and to review after three weeks. And she incurred an amount of Rs.11,520/- towards the medical expenses. All these are clear from Ext.A1 to A3. Regarding these aspects there was no dispute. After the discharge from the hospital complainant claimed hospital expense from the opposite party. This claim of the complainant was repudiated by the opposite party stating that the above disease was pre existing and cannot be entertained, which clear from Ext.B5. The case of the complainant is that the repudiation was illegal and improper and she is entitled to get the claim.
The respondents herein alleges that the disease of complainant was pre existing one and the policy was a fresh one, the petitioner purposefully did not inform the existence of the disease in the proposal form and the above claims of insurance is hit by the conditions of the contract. As per condition 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 as defined in the policy until 48 months of continuous coverage have elapsed, since inception of the 1st policy with any Indian insurance company. On analyzing the documents and evidence it is proved that the above policy was a fresh one and the petitioner was not stated anything regarding the pre existing diseases in the proposal form submitted by her. The petitioner admits that she was treated for kidney disease in the year 2006. Now she was admitted and treated for cellulitis on her left leg which has no connection with the Kidney complaint.
The opposite party herein had produced the document regarding the treatment taken by the petitioner on 06.06.2016 from Fathima Hospital, Calicut which marked as Ext.B6. Ext.B6 is the diagnosis of complainant’s disease by doctor Thomas Mathew, Head of the dept. of Nephrology. At that time they diagnosed that the complainant was suffering from chronic glomerulo nephritis in exacerbation acute pyoderma legs with pain, sever aches and pain and respiratory infection and anxiety state. The above document shows that the petitioner was suffering from CGN since last many years which developed acute pyoderma over both legs with fever and pedel odema. And she was advised to take medicines and to review after three weeks. At the time of cross examination of the complainant by the opposite party she deposed that she was under the treatment of Dr.Thomas Mathew, (Nephrologist) for the last 20 years.
All these clearly establish that petitioner was suffering CGN pyoderma and cellulitis for several year, these are interlinked diseases in connection with Nephritis which was suppressed by the petitioner while obtaining policy. More over the policy is a new one which comes under the exclusion clause number III(1) of the contract. Hence there is no merit in the case.
So the petition is dismissed without cost.
Dated this 4th day of April 2017.
Date of filing: 20.03.2012.
SD/-MEMBER SD/- PRESIDENT SD/-MEMBER
APPENDIX
Documents exhibited for the complainant:
A1. Discharge bill of Fathima Hospital dtd.22.06.2011.
A2. The medical certificate issued by Doctor Thomas Mathew dtd.22.06.2011.
A3. Discharge summary of Fathima Hospital.
Documents exhibited for the opposite party:
B1. Proposal Form dtd. 15.12.2010.
B2. Copy of Medi-Classic Health Insurance Policy certificate along with terms and conditions.
B3. Claim Form submitted by Amina.M.P. along with the medical certificate.
B4. Discharge summary of Fathima Hospital
B5. Claim repudiation letter dtd.17.11.2011.
B6. Discharge summary dtd.08.06.2006.
Witness examined for the complainant:
PW1.Amina.M.P.(Complainant)
Witness examined for the opposite party:
RW1. Mridulla, Madathil Meethal, Manass House, PO. Vengeri, Calicut.
Sd/-President
//True copy//
(Forwarded/By Order)
SENIOR SUPERINTENDENT
