DISTRICT CONSUMER DISPUTES REDRESSAL FORUM PALAKKAD
Dated this the 14th day of November 2017
Present : Smt.Shiny.P.R. President
: Smt.Suma.K.P. Member Date of filing: 30/09/2016
: Sri.V.P.Anantha Narayanan, Member
(C.C.No.149/2016)
Tom George
S/o George,
Kizhakke Parambil House,
Chittady (PO),
Mangalam Dam,
Vandazhi, Alathur,
Palakkad. - Complainant
(Adv.M.Raveendran & M.J.Vince)
V/s
1. The Managing Director,
M/s Star Health and Allied Insurance Co.Ltd,
No.1 Corporate Office,
New tank street,
Valluvarkottam,
High Road, Nungampakkam,
Chennai – 600 034.
2. The Branch Manager,
M/s Star Health and Allied Insurance Co.Ltd,
Sharco tower, T.B.Road,
Ottappalam – 679 101, Palakkad. - Opposite parties
(Adv.A.Rajivijaya Sankar)
O R D E R
By Smt.Suma.K.P. Member,
The above complaint is filed for directing the opposite party to pay the claim amount of Rs.2 lakhs which is the maximum insured amount to the complainant along with other reliefs.
The complainant has availed a Medi Claim Policy from the opposite party on 19-11-2011 by which the opposite party has agreed to indemnify the medical expenses of the complainant’s son George Tom, aged 28 years in case of any treatment and hospitalization. The complainant has paid the required premium as instructed by the opposite party and the complainant has renewed the policy from time to time and the present policy is of the Forth renewal. The insured who is the son of the complainant met with an accident in the year 2009 and sustained Head injuries and is suffering from the related disease. While taking the policy, the complainant had informed the opposite party about the factum of accident and as required by them, the copy of the entire medical records relating to the treatment after accident were also submitted to the opposite party. Only after going through the documents, the opposite party has issued the policy with insured sum of Rs.2 lakhs and the fact of the accident was very well incorporated in the column pre-existing disease. The complainant paid the premium regularly every year and lastly on 16-11-2015, he has paid a sum of Rs.3,297/- whereby the renewed policy bearing No. P/181218/01/2015/001222 was issued by the opposite party. The insured was treated at PARAS Hospital, Haryana from 17-02-2016 to 28-02-2016 as in patient and had incurred a sum of Rs.3,69,218/- towards the treatment expenses. For the said amount, the complainant had preferred a claim for cashless treatment with opposite party which was repudiated as per the letter dated.20-02-2016 stating that the ‘present hospitalization is for the management of an ailment, which is related to a pre-existing condition clause and non disclosure of Neurological disease’. Subsequently they have issued a notice dated.24-02-2016 whereby they informed their intention to cancel the policy for violation of condition No.13 of the policy w.e.f 04-04-2016. Later as per letter dated.01-04-2016 the opposite party has cancelled the policy and refunded the premium by way of Demand Draft dated.30-03-2016. The acts of the opposite party is against the terms and conditions of the policy and is clear violation of the existing laws for cancellation of the policy. The opposite party cannot arbitrarily close the policy according to their whims and fancies. Only to repudiate the claim, the opposite party has come forward with a case of non disclosure of disease which cannot sustain in view of the endorsement in the policy. The acts of the opposite party amounts to clear deficiency of service. They should not have repudiated the claim nor cancelled the policy. In fact the complainant has not concealed anything while taking the policy. Fact of pre-existing disease is clearly mentioned while taking the policy. So the opposite party committed a mistake in repudiating the policy. The complainant is entitled to get the claim amount of Rs.2 lakhs from the opposite party and they are also liable to pay the same. Due to the acts of the opposite party, the complainant has suffered a lot of mental agony, financial stress and strain and physical disabilities for which he is submitted to get a sum of Rs.1,00,000/- as compensation from the opposite party and the opposite party is liable to pay the same. Hence the complainant had approached before the Forum seeking an order directing the opposite parties to pay the claim amount of Rs.2 lakhs which is the maximum insured amount to the complainant and also to pay an amount of Rs.1 lakhs towards mental agony, stress and strain and financial loss suffered by the complainant along with cost of this proceedings.
Complaint was admitted and notice was issued to the opposite parties for appearance. The opposite parties entered appearance through counsel and file version stating the following.
Complaint has been filed by suppressing material facts and alleging false statements. The opposite party admits that the complainant had taken policy of Family Health Optima Insurance Policy for the period from 19.11.11 to 18.11.12 and the sum insured was Rs.3 lakhs covering the complainant, his wife and two children. At the time of entering in to the contract, the insured had revealed that the son of the complainant George Tom had an accident in 2009. Thus the fact of the accident happened in 2009 was endorsed in the schedule. Thereafter the complainant converted the policy from Family Health Optima to Medi Classic Individual Policy on 19-11-2013 and the policy as renewed up to 18-11-2016. Proposal form is the basis and integral part of the insurance contract, on which the policy is issued. The policy is issued strictly according to the terms and conditions and the complainant here in had admitted the same, and had sign the proposal form of the policy. Being a health policy the complainant is bound to give proper information regarding the present and past health status at the time of filing the proposal which is material for proper under writing of the proposal. The policy is issued after accepting the facts in the proposal form on utmost good faith. After going through the proposal form, it is noted that the proposal has only revealed about the accident happened in 2009 to his son. Based on the declaration of the complainant, believing the same the policy was issued in the proposal form the complainant further declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the insurance company would incur “no liability” under the policy. It is submitted that the company has received a pre authorization request from Paras Hospital Gurgoan, Haryana stating the complainant’s son was admitted on 17-02-16 and was provisionally diagnosed with “known case of head injury with operated case of arachnoid cyst with Hydrocephalus”. The hospital had also sent the consultation sheet along with the pre-authorization request. Specifically stated in the past history column: - “H/o B/L Clavicle#, H/o DVT (R) lower limb in June 2010. H/o Endoscopic Cysto Cisternostomy via, left temporal burr hole on 06-09-2011, H/o Excision of post tracheostomy cutanneuous fistula & hypertrophic scar on 07.05.2012”. On receiving the pre-authorization request, the opposite party had issued a query letter dated.19.02.2016 to the hospital forwarding the following documents:- (a) Previous RTA discharge summary, (b) As per case sheet patient had H/a DVT 2010 send its discharge summary, (c) As per case sheet patient had decreased responsiveness since 1 year and hence its treatment details, (d) CT/MRI reports and images. In reply to the said query, the hospital had forwarded the discharge summary of Christian Medical College, Vellore dated.03-06-2010. Discharge summary of Jubilee Mission Medical College Hospital, Thrissur dated. 07.11.2009 and the MRI/CT scan dated.17.02.2016. As per the submitted records it is clear that the patient had undergone endoscopic Cysto Cisternostomy in September 2011. This fact about the surgery done in September 2011 and neurological disease was not revealed which were found to the existing at the time of taking the policy i.e on 19/11/2011. Moreover as per the discharge summary of Christian Medical College, Vellore dated.03-06-2010, it was clearly recorded that the patient “at the age of 14 years of age was operated on left frontoparietal region for evacuation of arachnoid cyst”. The insured has not revealed the past history of surgery done in 2011 in the proposal form except the accident happened in 2009. This amounts to non disclosure of material fact. Hence the company had repudiated the cashless facility and informed the same to the hospital. As per condition no.13 of the policy, “the company may cancel the policy on grounds of non disclosure of material facts or non co-operation by the insured person, by sending the insured 30 days notice by registered letter at the insured persons last known address”. Accordingly the opposite party had issued a notice to the insured on 24-02-2015 to the last known address informing him about the cancellation of the policy in respect of Tom George w.e.f 04.04.2016. Thus the renewed policy No. P/181218/01/2016/001412 in respect of George Tom was cancelled w.e.f 04-04-2016 due to the known disclosure of PED-ENDOSCOPIC CYSTO-CISTEROSTOMY and had refunded the premium amounting to Rs.3,297/- vide DD no.594342 dated.30-03-2016 which was informed to the complainant vide letter dated.01-04-2016. There is no deficiency in service or unfair trade practice on the part of the opposite parties in the above matter. The policy is governed by the terms and conditions and if the complainant had revealed about the surgery done in 2011, the same policy would not have been issued. But the complainant had not revealed the same. The opposite party repudiated the claim and cancelled the policy only because of the willful lapses on the part of the complainant and violation of the terms and conditions of the policy. The complainant could have submitted his justification for continuation of the policy as reply to the cancellation notice. By not replying to the cancellation notice he has been stopped from raising this contention. The opposite parties are not liable to pay the claim amount of Rs.2 lakhs to the complainant. There is no negligence, deficiency of service, or unfair trade practice on the part of the opposite parties and the complainant is not eligible to get any compensation. Hence the complaint has to be dismissed.
Complainant filed chief affidavit. Opposite parties also filed chief affidavit. Opposite party also filed application seeking permission to cross examine the complainant. Exts.A1 to A7 was marked from the side of the complainant. Ext.B1 to B11 was marked on the side of the opposite party. Complainant filed affidavit stating that original bills are submitted before the opposite party. Evidence was closed and the matter was heard.
The following issues that arises for consideration are.
1.Whether there is any deficiency of service from the part of opposite parties?
2.If so what are the relief and cost?
Issues 1 & 2
We have perused the affidavits and documents produced before the Forum. It is evident from Ext.A1 that the complainant has availed a medi claim policy from the 1st opposite party on 19.11.2011. The opposite party submitted that the proposal form is the basis and integral part of the insurance contract on which the policy is issued. The policy is issued strictly according to the terms and conditions. The policy issued to the complainant being a health policy, the complainant is bound to give proper information regarding the present and past health status at the time of filing the proposal which is material for proper under writing of the proposal. The policy is issued after accepting the facts in the proposal form on utmost good faith. The complainant alleges that while taking the policy the complainant had informed the opposite party about the accident occurred to the complainant’s son and as required by them, copy of the entire medical records relating to the treatment after accident were also submitted. Only after going through the documents the opposite party has issued the policy with insured sum of Rs.2 lakhs and the fact of the accident was very well incorporated in the column pre-existing disease. The complainant had paid the premium regularly every year up to 16.11.2015, and the policy was renewed by paying a sum of Rs.3,297/- on 16.11.2015. The complainant son was treated at Paras Hospital Haryana from 17.02.2016 to 28.02.2016 as in-patient for in the complainant had preferred a claim for cashless treatment with the opposite party which was repudiated as per the letter dated.20.02.2016 stating that the present hospitalization is for the management of an ailment, which is related to a pre-existing condition clause and non disclosure of neurological disease. As evident form Ext.A5, after going through the proposal form which was marked as Ext.B1 and B2, it is noted that the proposer has only revealed about the accident happened in 2009 to his son. In the proposal form the complainant further declared that if after the insurance policy is affected, any particulars stated in the proposal form are found incorrect, the insurance company would incur “no liability” under the policy. While perusing Exts.A2 & A3 it was clear that the complainant’s son had under gone Endoscopic Cysto-Cisterostomy in September 2011. The fact about the surgery done in September 2011 and the neurological disease was not revealed at the time of taking the policy i.e on 19.11.2011 as per Ext.A3 dated.02.06.2010, it was clearly recorded that the patient “at the age of 14 years of age was operated on left front of parietal region for evacuation of arachnoid cyst”. The insured has not revealed the past history of surgery done in 2011 in the proposal form except the accident happened in 2009. The opposite party had contended that as per condition No.13 of the Exts.B1 and B3 document “the company may cancel the policy on grounds of non disclosure of material facts or non-corporation by insured person, by sending the insured 30 days notice by registered letter at the insured persons last known address”. It is evident that as per Ext.B9 the opposite party had issued the same. Thus the renewed policy in respect of complainant’s son was cancelled w.e.f 04.04.2016 due to the non disclosure of material facts and the opposite party had refunded the premium amounting to Rs.3,297/- which was informed to the complainant as per Ext.B11. The opposite party contends that the insurance policy is governed by the terms and conditions of the policy and the complainant is eligible to receive the benefits only as per the terms and condition. Any deviation from the terms and condition of the policy will result in this entitlement of the benefits as per the insurance policy. The cancellation of the policy was strictly as per the terms and conditions. Hence there is no deficiency of service or unfair trade practice on their part. The complainant could have submitted his justification for continuation of the policy as reply to the cancellation notice. By not replying to Ext.B11 notice, he has no right to claim the benefits under the policy. In the light of the above discussions, we cannot attribute deficiency of service or unfair trade practice on the part of the opposite parties. Hence the complaint is dismissed without cost.
Pronounced in the open court on this the 14th day of November 2017.
Sd/-
Shiny.P.R.
President
Sd/-
Suma.K.P.
Member
Sd/-
V.P.Anantha Narayanan
Member
Appendix
Exhibits marked on the side of complainant
Ext,A1 - Medi classic Insurance Policy (individual) issued by Star Health Allied
Insurance Company Ltd
Ext.A2 - Photo copy of Discharge Summary dated.16.03.2010 of Jubilee Mission
Medical College, Thrissur
Ext.A3 - Photo copy of Discharge Summary dated.03.08.2010 of Christian Medical
College, Vellore
Ext.A4 - Photo copy of Discharge Summary dated.02.08.2011 of Christian Medical
College, Vellore
Ext.A5 - Photo copy of Rejection of Pre-Authorisation for Cashless Treatment
dated.20.02.2016 ) issued by Star Health Allied Insurance Company Ltd
Ext.A6 - Photo copy of letter dated.24.02.2016 sent by Star Health Allied
Insurance Company Ltd for Non declaration of Pre-existing disease
Ext.A7 - Photo copy of letter dated.01.04.2016 sent by Star Health Allied
Insurance Company Ltd for Non disclosure of PED-policy cancellation
Exhibits marked on the side of Opposite parties
Ext.B1 - Attested true copy of Proposal Form of Star Health and Allied Insurance
Company Limited to the complainant
Ext.B2 - Attested true copy of Proposal Form of Star Health and Allied Insurance
Company Limited issued to the complainant
Ext.B3 - Customer Information sheet of Star Health and Allied Insurance Company
Limited to the complainant
Ext.B4 - True copy of Pre-Authorisation Request Form of Star Health and Allied ‘ Insurance Company Limited
Ext.B5 - True copy of Query on Pre-Authorisation letter dated.17.02.2016
Ext.B6 - Photo copy of Query on Pre-Authorisation letter dated.19.02.2016
Ext.B7 - Photo copy of Discharge Summary dated.18.08.2010 of Christian Medical
College, Vellore
Ext.B8 - Attested True copy of Rejection of Pre-Authorisation for Cashless Treatment
Ext.B9 - True copy of letter dated.24.02.2016 of Non declaration of Pre-existing
disease
Ext.B10- True copy of letter dated.01.04.2016 of Non-disclosure of PED-policy
cancellation
Ext.B1 - True copy of Endorsement schedule of the policy
Witness examined on the side of complainant
Nil
Witness examined on the side of opposite party
Nil
Cost
Nil
