DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD

Dated this the  6^th day of January, 2023

Present      :   Sri. Vinay Menon V.,  President

                  :  Smt. Vidya A., Member                        

                  :  Sri. Krishnankutty N.K., Member                                Date of Filing: 03/04/2019    

     CC/103/2019

Sundaran V.,

S/o. Velayudhan,

299/7, Puthodethara,

Pallassana (PO), Palakkad – 678  505                                               -           Complainant

(By Adv. M/s. C.Sreekumar& M.Hakkim)  

                                                                                    Vs

1. The Manager,

The South Indian Bank Ltd.,

Pallassana Branch, Palakkad.

2. The Managing Director & CEO,

Max Bupa, Health Insursance Co.Ltd.,

Max House 1, Dr.Jha Marg, Okhla,

New Delhi – 110 020.

3. The Manager,

Max Bupa Health Insurance Company,

Servicing Branch, 7B, Puthan Plaza,

40/483 V, MG Road, Kochi – 682 035                              -           Opposite parties          

                   (OP1 by Adv.G.Ananthakrishnan,

                     OPs 2 & 3 by Adv. M/s. Ullas Sudhakaran & Saji Issac)

O R D E R

By Sri. Vinay Menon V., President

1. Complaint pleadings, abridged for convenience, are to the effect that the complainant and his wife were beneficiaries of a Health Insurance Plan floated by OPs 2 & 3.  Premium was paid from the complainant’s account maintained in OP1 bank. Subsequent to availing the policy, wife of the complainant developed some physical inconveniences and therefore approached Thankam Hospital.  Thereafter, she developed further symptoms resulting in diagnosis of cardiac irregularities.  She had to undergo cardiac surgery in BMH hospital, Kozhikkode.  Even though the procedure underwent by the complainant’s wife was covered under the policy availed, the OPs 2 & 3 failed to honor their part of the agreement and did not indemnify the complainant.  Aggrieved thereby, this complaint is filed.
2. OP1 filed version stating that they are not aware of any of the facts pleaded by the complainant except the fact regarding payment of premium amount from the account of the complainant maintained in their branch. 
3. Opposite parties 2 & 3 filed version repudiating the allegation of deficiency in service on their part, justifying the repudiation being based on non disclosure of pre-existing disease suffered by the wife of the complainant. They maintained that  wife of the complainant was a known case of Rheumatic Heart Disease(RHD), Reflex Sympathetic Dystrophy(RSD), Hypothyroidism, and Dyspnea on exertion since more than 10 years and palpitation since many years. The complainant has resorted to suppression of material facts and sought for dismissal of the complaint. 
4. The following issues arise for consideration: 

1. Whether the complainant was suffering from any pre-existing disease as on 01/03/2018 while executing proposal form?
2. Whether the complainant has suppressed any material information regarding pre-existing disease?
3. Whether there is   deficiency in service/unfair trade practice on the part of the opposite parties?

4.         Whether the complainant is entitled to any of the reliefs sought for?

5.         Reliefs, if any?

5.         Evidence comprised of Exhibits A1 to A6 on the part of complainant. OP1 did not have any documentary evidence over and above the proof affidavit filed. Opposite parties 2 & 3 filed proof affidavit and marked Exts.B1 to B5. All documents on both sides were marked without any objection. Eventhough medical records were produced from Thankam Hospital, Palakkad and BMH, Calicut, they were not marked.

            Issue No.1

6.         As per version pleadings of the opposite parties 2 and 3, complainant’s claim for cashless treatment was disallowed as the complainant’s wife was a known case of Rheumatic Heart Disease(RHD), Reflex Sympathetic Dystrophy(RSD), Hypothyroidism, and Dyspnea on exertion since more than 10 years and palpitation since many years. These facts were suppressed by the complainant while availing the policy coverage.

7.         With regard to Pre-existing condition, the complainant has made a brief statement in paragraph 5 of the memorandum of complaint. Para 5 of the memorandum of complaint is reproduced below:

“ 5.       Complainant’s wife,  Selvarani, was undergoing treatment at Thankam Hospital for symptoms of general weakness and hair loss and was under the treatment of Dr.Raja from 7/12/2017 onwards. Abdominal scan was done on 8/12/2017, which showed no abnormality. She was under regular check up and medication for Hypothyroidism under Dr.Raja MD, DM(Gastro) & she was completely well and healthy after the treatment”.

 Thus it is clear that the complainant’s wife was undergoing treatment during the December 2017 for general weakness and hair loss. She was also under treatment for hypothyroidism.

Therefore the complainant was suffering from pre-existing disease as on 01/03/2018 while executing proposal form.

Issue No.2

8.         Ext.B1 is a copy of the health companion proposal form dated 01/03/2018 of OP insurance company filled by the proposer, the complainant.  The relevant portion regarding medical habit and family history (clause 5, on page 3) is reproduced below:

            “5. Medical Habits and Family History

A.         Is the applicant currently suffering from any symptoms or

complaints persisting frommore than 5 consecutive days for

which she has not consulted a doctor                                                –                      No.

B.         Other than routine health checkup, has the applicant

undergone or been advisedto undergo  any diagnostic

test / investigation including but not limited to

Thyroid Profile, Treadmill Test, Angioplasty, Ecocardiography,

Endoscopy, Ultrasound, CT Scan, MRI, Biopsy and FNAC                   –                      No.

C.         Has the applicant been prescribed or taken any

form of treatment or medication (including  oral /

 inhalation / injection) for a period of more than 7 days                  –                      No.

D.         Has the applicant undergone or been advised to

undergo or does she plan to undergo any form of

surgery or procedure                                                                          –                      No.”

Since the wife of the complainant was suffering from hypothyroidism, undergoing Thyroid profile test or any other tests in connection with Thyroidal secretions will be indubitably involved. Hence answers to queries B and C ought to have been “Yes”, but the complainant suppressed material fact by answering in the negative. Thus the complainant has given false answers to queries B and C, supra.

Since the answer to all the above queries were answered in the negative, the complainant has not cared to answer the subsequent questionnaire (Part B to Clause 5) in Ext. B1, thereby leaving out answering the section relating to Endocrine disorders.

9.         Treatment and diagnoses were undergone during December, 2017. Proposal form was filled on 01/03/2018. This difference of approximately two months cannot be held to be long enough to erase any memory of treatment rendered to the complainant’s wife. In the facts and circumstances of the case, we find that the omission is willful.

10.       Resultantly, we hold that the complainant has willfully suppressed material facts and information regarding the treatment underwent by his wife at the time of filling the proposal form.

            Issue Nos. 3 & 4

11.       Opposite party 1 is only a bank wherein the complainant is maintaining an account from where premium was credited. The pleadings or evidence does not show that the 1^st opposite party was in any liable or responsible for repudiation of the claim raised by the complainant.

12.       Having found that the complainant has suppressed material facts relating to the treatment underwent by his wife, the opposite parties are justified in repudiating the claim of the complainant, even-though the opposite parties have failed to prove by cogent evidence their contention of the complainant’s wife being a known case of various malignant conditions spread over many years.

There is no deficiency in service or unfair trade practice on the part of the opposite parties 2 and 3. 

13.       Consequently, the complaint is dismissed.

Issue Nos. 5

14.       Guided by the findings in preceding issues, we find that this is a vexatious complaint aimed at illegal enrichment at the expense of opposite parties 2 and 3 by willful non-disclosure of material facts and acting with the knowledge that their actions and conduct would result in illegal losses to the opposite parties 2 and 3.

Opposite party 1 was also roped in for reasons best known to the complainant. From the pleadings and evidence adduced, we find that they were mere pawns in the malicious activities of the complainant.

The complainant has approached this Commission with unclean hands.  This being a malicious complaint filed with malafide intentions, the opposite parties are entitled to costs.

15.       The complainant is directed to pay an amount of Rs. 15,000/- to opposite party 1 and Rs. 15,000/- to opposite parties 2 and 3 jointly  within 45 days from receipt of a copy of this Order.                    

Pronounced in open court on this the 6^th   day of  January, 2022.

      Sd/-                                                                                                               

                                                                                             Vinay Menon V

                                                      President

                                                           Sd/-

   Vidya.A

                       Member        

          Sd/-                                                                  Krishnankutty N.K.

                                                                                                      Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1   -  Original Policy document for policy bearing No.30748624201800

Ext.A2  –  Original USR (abdomen) bearing HNO 343186 dated 8/12/2017   

Ext.A3  -   Copy of discharge summary dated 12/11/18 from Department of General Medicine.

Ext.A4  -   Certificate dated 1/12/18  issued by consultant physician of Thankam Hospital

Ext.A5 – Discharge summary dated 18/12/18 for UHID No. 1707513

Ext.A6 series – 6 sets of bills pertaining to UHID 0001707513

Exhibits marked on the side of the opposite party:

Ext.B1 – Copy of Health companion proposal form

Ext.B2 – Copy of policy document

Ext.B3 – Copy of pre-authorisation form

Ext.B4 – Copy of denial of authorisation dated 6/12/18

Ext.B5 – Copy of  disallowance of claim

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: Nil

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.