DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the 11^th  day of September, 2024

Present      :   Sri. Vinay Menon V., President

                    :   Smt. Vidya A., Member                                                        Date of Filing: 25/10/2022 

                                      CC/203/2022

Jalaja M.,

W/o. Prabhakaran P.V.,

H-10, Gandhinagar,

Pudupariyaram,

Olavakkode, Palakkad – 678 731                                -          Complainant

(By Adv. T.G. Suresh)   

                                                                                                Vs

Manager (Authorised signatory),

Cholamandalam MS GIC Ltd.,

2^nd Floor, Dare House No.2,

NSC Bose Road, Chennai – 600 001                            -          Opposite party

(By Adv. P. Prasad)

O R D E R

By Sri. Vinay Menon V., President

1. Complainant admittedly is a beneficiary under a health insurance policy issued by the OP. At the time of availing policy at the first instance 2019 she was not having any pre-existing diseases.  Thereafter the policy was renewed till 2022.  During the middle of 2020, the complainant came to know that she was suffering from diabetes. Since the agent who had carried the renewal of policy had not enquired about any of the disease which is supposed to be reported at the time of renewal of the policy, she did not inform him also. The complainant underwent a surgery of right shoulder during 2022. The OP repudiated the claim on the ground of non-disclosure of material fact and cancelled her policy. Aggrieved by the repudiation of claim and cancellation of policy, this CC is filed.  
2. OP filed version stating that the claim was rejected and policy cancelled since the complainant was suffering from diabetes for 3 years, a material fact which the complainant willfully suppressed.
3.  The following issues were framed for consideration:

1. Whether the complainant was suffering from any pre-existing disease at the time of inception of the policy?
2. Whether there was suppression of material facts on the part of the complainant ?
3. Whether the insurance company has repudiated the claim as per the terms and conditions of the policy?
4. Whether there is any deficiency in service on the part of OP?
5.  Whether the complainant is entitled to any of the reliefs sought for?
6. Any other reliefs?

4.         (i)           Documentary evidence of complainant comprised of proof affidavit and Exhibits           

A1 to A5.   Marking of Ext.A5 series was objected to on the ground they were photocopies.  Since this Commission is not bound by the strait-jackets of BSA and since the OP has no case that these documents are forged or fabricated, objections are overruled.

(ii)            OP filed proof affidavit and marked Exhibits B1 to B5.    

(iii)        Doctor who treated the complainant was examined as CW1.

   Issue Nos. 1 & 2

5.         From a reading of paragraph No.1 in the memorandum of complaint, it is clear that subsequent to availing the insurance policy on 16/9/2019, the complainant came to know about her condition during the middle of the year 2020. Complainant had renewed the policy on two occasions i.e. 2020-2021 & 2021-2022 period without disclosing the fact that she was suffering from diabetes.  Complainant’s case is that presently, the sugar level is under control and as diabetes is a life-long common disease, the complainant was not aware of reporting the same at the time renewal of the policy. The agent who carried out the renewal also did not enquire any of the disease which, according to OP, was supposed to be reported at the time of renewal of policy.

                        Thus, the complainant herself has admitted that she was suffering from DM from 2020 onwards and that she was under treatment of Dr. Arun of Palakkad and that presently her sugar level is under control and that she had not informed the same to the insurance agent.

6.         Consequently, it can be seen that the complainant was suffering from pre-existing disease which was not reported to the OP. We cannot subscribe to the view or rationale adopted by the complainant that since diabetes was a life-long common disease, the complainant was not aware of reporting the same at the time of renewal of policy. Such a rationale, if permitted to survive would only lead to insurance fraud and misappropriation of public funds, of which the OP is a trustee.

7.         Therefore, we cannot find fault with repudiation of claim and cancellation of policy.

8.         Both the issues of pre-existing disease and suppression of material fact are found against the complainant.

            Issue No.3

9.         Complainant further argued that the treatment underwent by her was not connected to the condition suffered by her. Deposition of the CW1 also corroborate the condition of the complainant. But fact remains that the agreement/contract of insurance itself fructified in its present form based on wrong/willfully adulterated material data, disclosure of which was relevant, vital and material. Had the complainant disclosed that she had been suffering from DM, the policy would not have come to life in its present form.

10.       Pursuant to the discussion in Issue Nos. 1&2, we hold that repudiation of policy by OP is as per the terms and conditions of the policy.     

            Issue No.4,5 & 6

11.       There is no deficiency in service on the part of OP.

12.       Complainant is not entitled to any of the reliefs sought for.

13.       In the facts and circumstances of the case, parties are directed to bear their respective costs.  

                        Pronounced in open court on this the 11^th   day of September, 2024.         

                             Sd/-                                                                                                                       

                                                                                                                Vinay Menon V

                                                                         President

                                                                               Sd/-

                      Vidya.A

                                              Member   

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1   -  Original certificate of insurance    

Ext.A2  –  Copy of  discharge summary    

Ext.A3   -  Copy of repudiation letter

Ext.A4   - Original intimation of cancellation of policy

Ext.A5 (a) to (l)   -  Copy of bills and invoices  

Exhibits marked on the side of the opposite party:

Ext.B1 – True copy  of certificate of insurance

Ext.B2 – Original cashless investigation report  

Ext.B3 –  Original claim form         

Ext.B4 – Copy of discharge summary

Ext.B5 – Copy of repudiation letter.         

 Court Exhibit:  Nil  

Third party documents:  Nil

 Witness examined on the side of the complainant:  Nil

Witness examined on the side of the opposite party:  Nil

Court Witness:

CW1 – Dr. Syam Sunder

NB : Parties are directed to take back all extra set of  documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.