PBEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, ERNAKULAM.
Dated this the 27th day of August 2012
Filed on : 14/06/2011
Present :
Shri. A Rajesh, President.
Shri. Paul Gomez, Member.
Smt. C.K. Lekhamma, Member
C.C. No. 309/2011
Between
G. Vinayan, : Complainant
S/o. Govindhan Nair, (By Adv. Tom Joseph,
Pularli, Kadathy house, Court road, Muvattupuzha)
Market P.O., Muvattupuzha-686 073.
And
1. The Managing Director, : Opposite parties
M/s. ICICI Lombard General (By Adv. R. Ajit Kumar
Insurance Co. Ltd., Zenith House, Varma, 39/1747, Chittoor
KK Marg, Opp. Race Course, road, Ernakulam South,
Mahalaxmi, Mumbai-400 034. Cochin-682 016)
2. M/s. ICICI Lombard General
Insurance Co. Ltd.,
Amritha Towers, 1st Floor,
Velloorkunnam,
Muvattupuzha-686 673.
O R D E R
A Rajesh, President.
Shortly stated the facts of the complainant’s case are as follows:
The complainant has been a holder of health insurance policy of the opposite party continuously from 2007. While so during the currency of the policy the complainant was admitted at Muvattupuzha Medical Centre from 21-03-2011 to 23-03-2011 with complaints of fever, myalgia excessive tiredness and anorexia. The disease was diagnosed as viral Hepatitis. He incurred a sum of Rs. 7,533/- towards treatment expenses. Thereafter he was referred to Lakeshore Hospital, Ernakulam and underwent treatment from 23-03-2011 to 06-04-2011 for HBV related acute Hepatatis. He had to spend Rs. 51,985/- towards treatment expenses. The insurance claim application submitted by the complainant was rejected by the first opposite party vide letter dated 06-06-2011 stating that the complainant had not disclosed that he had been diagnosed as diabetes mellitus since 2000. The rejection of the insurance claim by the opposite party amounts to deficiency in service. The complainant is entitled to get the insurance claim of Rs. 59,518/- with interest together with costs of the proceedings. This complaint hence.
2. The version of the opposite party is as follows:
The complainant availed health insurance policy of the opposite parties for the period from 08-04-2010 to 07-04-2011. But the complainant was not holding the policy of the opposite party since 2007. As per the hospital records the complainant had been suffering from diabetes mellitus since 2000 which is prior to the inception of the policy. He has a past history of Hepatitis and acute chronic liver disease as well. The complainant had not disclosed these material facts to the opposite party at the time of execution of the proposal form. The liability of the opposite parties is strictly limited to the terms and conditions of the policy. There is no deficiency in service on the part of the opposite parties. The complaint is devoid of any merit and liable to be dismissed.
3. No oral evidence was adduced by the parties. Exts.A1 to A4 and B1 were marked on the side of the complainant and the opposite parties respectively. Ext. X1 also was marked. Heard the learned counsel for the parties.
4. The points that came up for consideration are as follows:
i. Whether the complainant is entitled to get insurance claim
from the opposite party?
ii. Whether the opposite parties are liable to pay costs of the
proceedings to the complainant. ?
5. Point No. i. According to the complainant he has been holding insurance policy of the opposite parties from 2007. The opposite parties disputed the same stating that there is nothing on record to prove the same. The complainant has not taken any steps to substantiate the contention to prove the same otherwise.
6. Ext. A2 insurance policy goes to show that the opposite parties issued health care policy for the period from 08-04-2010 to 07-04-2011. Ext. A3 discharge summary would show that the complainant had undergone treatment for Viral Hepatitis for the period from 21-03-2011 to 23-03-2011 at Muvattupuzha Medical Centre, Muvattupuzha. He was referred to Lakeshore Hospital Ernakulam and he had undergone treatment at the Hospital from 23-03-2011 to 06-04-2011 evidenced by Ext. A4 discharge summary. In the latter hospital the disease was diagnosed as HBV RELATED ACUTE HEPATITIS? ACUTE ON CHRONIC LIVER DISEASE.
7. The insurance claim of the complainant was repudiated by the opposite parties stating that the complainant had been suffering from various ailments prior to the inception of the policy and the complainant had suppressed the same in Ext. B1 proposal form. The leaned counsel for the opposite parties vehemently relied on Ext. X1, case sheet maintained at Lakeshore Hospital, Ernakulam and contented that the complainant had been suffering from various ailments like Bonchitis, diabetis and Hypertention. Ext. X1 goes to show that the complainant has been undergoing treatment from 16-09-2003 for various ailments at Lakeshore Hospital, Ernakulam.
8. It is pertinent to note that why the complainant had not disclosed any of the above ailments in Ext. B1 proposal form for reasons unexplained. Had the complainant disclosed his ailment in Ext. B1 the opposite parties might not have accepted the policy or would have appreciated the premium from the complainant. The learned counsel for the opposite party rightly contented that the policy is issued believing the representatives of the insured to be true, upon utmost good faith on the principle of Ubremie Fide. Moreover the Hon’ble Supreme Court in Satwanth Kaur Sandhu Vs. New India Insurance Co. Ltd. (2009 CTJ 965 (SC) has held that, “There was suppression of material facts in regard to the health of the insured and therefore the respondent insurer was fully justified in repudiating the insurance contract”.
6. In the present context we are only to bow to the better wisdom of the Higher Judiciary and disallow the complaint for reasons expressly above mentioned.
Pronounced in the open Forum on this the 27th day of August 2012
Sd/- A Rajesh, President.
Sd/- Paul Gomez, Member
Sd/- C.K. Lekhamma, Member.
Forwarded/By Order,
Senior Superintendent.
Appendix
Complainant’s exhibits :
Ext. A1 : Copy of termination notice
dt. 06-06-2011
A2 : Copy of schedule
A3 : Copy of discharge summary
A4 : Copy of discharge summary
dt. 06-04-2011
X1 : Case sheet.
Opposite party’s Exhibits : :
Ext. B1 : Proposal form
