D.O.F. 02.03.2012

                                            D.O.O. 25.07.2012

IN THE CONSUMER DISPUTES REDRESSAL FORUM KANNUR

Present:      Sri. Roy Paul                     :                President

                   Smt. Sona Jayaraman K.  :               Member

                   Sri. Babu Sebastian         :               Member

Dated this the 25^th day of June,  2015.

C.C.No.62/2012

V.P. Sanilkumar

S/o. V. Narayanan

‘Nandanam’

P.O. Mambaram                                                   :         Complainant

Thalassery Taluk

Kannur – 670 741

(Rep. by Adv. Philip K.K.)

1.The Manager

   Star Health and Allied Insurance Co. Ltd.

   Grand Plaza

   Fort Road

   Kannur-1

2.Star Health and Allied Insurance Co. Ltd          :         Opposite Parties

   Corporate Office

   Near Tank Street

   Valluvarkottam

   High Road, Chennai- 600 034

(Rep. by Adv. V.v. Gopinathan)

O R D E R

Sri. Roy Paul, President.

          This is a complaint filed under section 12 of the Consumer Protection Act by the complainant against the opposite party for Insurance claim amount with compensation and cost.

The gist of the complaint is that :

          The complainant has taken a Medi classic health Insurance policy (individual) from 1^st opposite party commencing from 14.12.2009 to 12.01.2012.  On the basis of the representaion of opposite party, that Rs.1,00,000 would be assured to the insured as the hospitalisation expenses.  Hence he was very prompt in payment of premiums in time.  While so on 18.6. 11 the complainant was admitted at Indira Gandhi Co-operative Hospital, Thalassery due to chest discomfort and later referred to Baby Memorial Hospital, Kozhikode and admitted at there on 20.06.2011 and was designed as CAD etc with advice to take early CABG.  Hence on 22.06.2011 he was admitted at MIMS Hospital, Calicut and underwent for a surgery named OPCAB and got discharged on 02.07.2011 only.  The total expense for the aforesaid treatment was Rs.2,05,178.  The Hospital Authorities were informed about the admission of the complainant at their hospital and treatment given etc to the opposite parties in time.  Thereafter the complainant submitted his claim form with relevant documents to the opposite party.  After three months of submission of claim form the opposite party has repudiated the claim through a letter dated 18.11.2011 stating complainant had preexisting disease and suppressed such material facts etc.  There was no preexisting diseases as alleged by the opposite party.  So the rejection of cliam by the opposite party is highly illegal, hence the complaint.

          The opposite parties appeared on summons before the Forum and filed their separate versions with almost stereo type contentions.  Both of them denied the contentions levelled in the complaint against them as mere false allegations.  They disputed  the period of policy.  According to them the period of policy was from 13.01.2011 to 12.01.2012.  They contented that the insurance policy is a contract based on the principles of utmost good faith entered into between the insurer and insured by way of the proposal Forum.  The Health Insurance Policy purely based on the health status of the insured.  Hence the non-disclosure of material facts is a grave omission on the part of the complainant.  The policy is issued after accepting the facts in the proposal Form on utmost good faith.   Here the complainant deliberately not disclosed the pre-existing diseases suffered by him.  His diabetic mellitus disease was not revealed in the proposal Forum. It was a pre-existing disease.  The medial records produced by the complainant itself reveals the same.  Apart to that he was suffering from Alcoholic liver disease also since 2008.  These can be ascertained from the file CC 109/2009 before this Forum filed by the very same complainant.  Hence there is no deficiency of service or unfair trade practice on the part of the opposite parties as alleged by the complainant.  So the repudiation of claim by the opposite party is justified and the complaint may be dismissed with compensatory cost.

          On the basis of the aforesaid contention levelled by the complainant and opposite parties the following issues were framed for consideration.

1. Whether there is any deficiency of service or unfair trade practice on the part of opposite parties?

2. Whether the complainant is entitled for any relief?
3. Relief and cost?

The complainant himself adduced his oral testimony as PW1 before the Forum and the documents of him were marked as Exhibits A1 to A7.  While the opposite party adduced his evidence as DW2 and one witness on his side was examined as DW1.  The exhibits marked on the side of the opposite party was Exts. B1 to B17.  

          For the sake of convenience the issue No.1 to 3 taken together for consideration.

Issues No.1 to 3 :

          The complainant adduced his oral evidence by way of affidavit in lieu of his chief examination as PW1 and underwent for cross examination by the opposite party also.  The documents produced by the complainant exhibited for the purpose to substantiate his oral testimony as A1 to A7.  The complainant was a policy holder of the opposite party, as per Ext.A3.  The period of the health insurance was from 13.01.2011 to 12.01.2012.  According to PW1 he was hospitalised and underwent for a major surgery during the month of June-July 2011, within the policy coverage period.  The Insurance Company was duly intimated about the hospitalisation in time.  The aforesaid surgery treatments etc are comes under the purview of the insurance coverage.  Hence the repudiation of the lawful claim of the complainant by the company was highly unjustifiable.  The condition stipulated in Exts A1 to A3 are also duly complied by the complainant.  Hence he is entitled for the claim amount from the opposite parties and the relief in the complaint may be allowed. 

          On the other hand the opposite parties vehementally argued and adduced evidence to the effect that the complainant is not entitled for the insurance claim covered under their policy.  The DW2 adduced evidence to the tune that the complainant is a known diabetic patient for so many years who is continuing his treatment at present also.  To substantiate their contention in the written version they relied their document which were marked as Exts B12 and B5 series of documents.  Apart to that they have provided another document ie B13 series in connection with a previous case CC 109/2009 before this Forum filed by the very same complainant for medical claim; as per the records of the said case it is established that the complainant was a patient of Diabetic, alcoholic liver disease and CAD etc since 2009.  Hence at the time of submitting proposal form he deliberately with malefidia intention not disclosed these diseases and obtained the policy.  According to the opposite party it is grave and wilful omission committed by the complainant for unlawful gain.  Hence the complaint is liable to be dismissed with compensatory cost of the opposite parties. 

          On perusal of the evidence, records and arguments of both sides we are of the opinion that a crucial evaluation of available evidence on both sides are warranted.  The main disputes in this matter based on the health history of the complainant at the time of submitting the proposal form for Health Insurance policy.  In the proposal form Ext.B1 nothing mentioned about the diseases or illness suffered from and the column where the complainant was asked to state about whether he is suffered from diabetes, he has stated answer ‘No’.  Apart to that in the column about the details of previous claims made he answered as nill.  According to the opposite parties the aforesaid answeres made in the proposal form are absolutely false and deadly against the facts.  To substantiate their contention they have relied the medical records of the complainant himself.  Exhibit B5 series and B12 categorically stated that he has the past history of diabetes, alcoholic liver disease and CAD etc.  Moreover as per Exhibit B13 series this Forum in another case filed by the very same complainant for medical claim CC 109/09, made valid observations on the basis of the documents produced in it that he was a patient of diabetic and alcoholic liver disease.  Hence the argument of the opposite party about the history of pre-existing diseases of the complainant cannot be discarded at a stretch.  The witness from the side of the opposite party one Dr. Haridas examined as DW1, stated that diabetis as one of the risk factor and it can be affect all the organs of the body.  The argument of the complainant that the diabetics arose due to stress at the time of treatment, cannot be taken into account, because the treatment records produced in CC 109/2009 are also speaks about his earlier history of diseases including alcoholic liver diseases and diabetics.  More over the 1^st opposite party pointed out another thing that the complainant has changed the insurance policy to this opposite party from another company with a fraudulant intention.  As per the records there is breakage in policy continuation also against the pleadings of the complaint.  Under the above circumstance we the Forum hold that there was deliberate suppression of material facts in the proposal form submitted by the complainant.  The opposite parties are bound to supply the goodness of their insurance coverage to the right person in right manner.  Here we could not find any deficiency of service or unfair trade practice on the part of the opposite parties as alleged by the complainant.  Hence the repudiation of the claim of the complainant by the opposite parties are justified.  So the issue No.1 found against the complainant.

          Since the issue No.1 found against the complainant naturally the complainant is not entitled for any relief sought in the complaint.  Moreover the opposite parties argued the case to the tune that the complainant has not approached the Forum with clean hands.  From the foregoing discussions we the Forum also hold that there is suppression of material facts on the part of the complainant at the time of submitting the insurance proposal before the opposite party.  Though he has committed the same nature of practice before this Forum also during the institution of the complaint we the Forum summarise the penal action to be taken against him to a cautious warning.  Hence the prayer of the opposite parties for compensatory cost also discarded in the light of the aforesaid discussions.  The issue No.2 also found against the complainant and answered with issue No.3 accordingly.

          In the result the complaint stands dismissed.  No order as to costs.

Dated this the 25^th day of  July, 2015.

                           Sd/-                      Sd/-              Sd/-

                       President               Member          Member  

APPENDIX

Exhibits for the Complainant

A1. Individual policy schedule.

A2. Premium receipt.

A3. Policy.

A4. Notice to opposite partydated 06.12.2011.

A5. Reply notice.

A6. List of documents produced by complainant before 1^st OP.

A7. Refusal of policy claim.

Exhibits for the opposite party

B1. Proposal form.

B2. Claim form for medical insurance.

B3. Hospital bill dated 19.06.2011.

B4. Doctors’s prescription.

B5. Investigation report.

B6. Discharge summary.

B7 series. ECG reports.

B8. Discharge summary.

B9. Coronary Angiogram Report.

B10. Notice dated 06.12.11.

B11. Reply letter dated 31.12.2011.

B12. Cardiololgy case record.

B13. Proposal form for mediclaim insurance policy.

B14. Claim repudiation letter dated 18.11.2011.

B15. Medi-Classic Insurance Policy (individual)

B.16. Pre-authorisation request form.

B.17. Pre-authorisation request form.

Witness examined for the complainant

PW1.  Complainant

Witness examined for opposite party

DW1. Dr. P.V. Haridas

DW2. Manu Mohan

      /forwarded by order/

                                                                     SENIOR SUPERINTENDENT.