D.O.F:15/01/2020
D.O.O:09/12/2022
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KASARAGOD
CC.No.10/2020
Dated this, the 09th day of December 2022
PRESENT:
SRI.KRISHNAN.K :PRESIDENT
SRI.RADHAKRISHNAN NAIR.M : MEMBER
SMT.BEENA.K.G : MEMBER
K.M. Jose, aged 61 years,
S/o. K.M.Mathew,
Kudiyiruppil House, Avali,
Sankarampady.P.O, : Complainant
Kasaragod 671541
(Adv. M.Narayanan)
And
- The Regional Manager
Star Health & Allied Insurance Company Ltd.,
No.15, Sri Balaji Complex,
-
Chennai 600034: Opposite Parties
- The Branch Manager
Star Health & Allied Insurance Company Ltd.,
-
Kasaragod 671121
(Adv. C. Damodaran)
ORDER
SRI.RADHAKRISHNAN NAIR.M : MEMBER
The complaint is filed for compensation on the ground of service deficiency
on the part of the Opposite Parties.
The fact of the case in brief is that the complainant took a Senior Citizen Red Carpet Health Insurance policy of the Opposite Parties by remitting the premium amount of Rs.9,978/- on 23.03.2019 in the name of his wife Smt. Mary Jose, vide. the policy No. P181325/01/2019/001144. The insurance policy was taken as induced by an agent of the opposite parties, namely, Mr. Mamman, who convinced the complainant that the insured would get Rs.2,00,000/-for treatment, in case she is hospitalised. The entire health history of Smt. Mary Jose was explained to the agent before taking the policy. The period of in insurance coverage is from 23.03.2019 to 22.03.2020. Subsequently, Smt. Mary Jose was admitted in KMC Hospital at Manglore, due to chest pain on 06.09.2019 and treated there till 14.09.2019 and spent total of Rs.2,02,227/- towards hospital charges. The opposite parties were informed about the case on the date of admission itself over their toll free number. Thereafter a claim No.CL1/2020/181325/0432363 has been filed along with all the documents as required by the opposite parties, but the same is repudiated by the opposite parties without valid grounds. The opposite party states that the complainant suppressed some facts of treatment under gone by the insured 10 years back, and obtained the policy. The complainant had explained everything to the agent and not suppressed anything regarding the earlier treatment.
The denial of insurance benefit to the complainant amounts to service deficiency on the part of the Opposite Parties due to which the complainant suffered mental agony. Hence the complaint is filed for a direction to the opposite parties to pay the complainant Rs. 2,00,000/-, being the assured insurance benefit along with Rs. 1,00,000/- as compensation and costs.
The opposite parties entered appearance and filed written Version. As per the version it is admitted that the Opposite Parties have issued a Senior Citizen Red Carpet Health Insurance policy in the name of his wife Smt. Mary Jose vide. the policy No.P181325/01/2019/001144 on 23.03.2019. The sum assured was Rs 2,00,000/-. At the time of issuing the policy, the complainant was supplied with the terms and conditions of the policy. Moreover it is clearly stated in the policy schedule “The insurance Policy is subject to conditions clauses warranties exclusions etc. attached”
As per the terms and conditions of the Senior Citizen Red Carpet Health Insurance policy, only those pre-existing diseases, which are specifically covered by the proposal form are covered under the policy. So it is compulsory that the information regarding the health must be provided in the proposal form, for the company to provide coverage with suitable co-payment, ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. In the proposal form the complainant had specifically declared that his wife was not suffering from any disease or ailment at the time of submitting the proposal form or at any point of time earlier and that his health condition was good in all respect.
The complainant had submitted two claims before the opposite parties. In CLI/2020/181325/0560040 the complainant’s wife was admitted at Kasaragod Institute of Medical Sciences on 05.09.2109 for diabetes mellitus, coronary artery disease and Idiopathic Thrombocytopenic Purpura. After the treatment she was discharged on 06.09.2019. In the discharge summary, the treating doctor had noted that the patient is a known case of Astma, Varicose, ITP (Immune Thrombocytopenic Purpura) and done Splenectomy. In CLI/2020/181325/0432363 the complainant’s wife was admitted at KMC Hospital Manglore on 06.09.2019 for the treatment of IHD (Ischemic Heart disease). After the Treatment, she was discharged on 14.09.2019.
As per the records of KMC Hospital Manippal, the complainant’s wife had under gone treatment at the hospital from 10.04.2010 to 18.05.2010 for Idiopathic Thrombo cytopenic Purpura and underwent laproscopic splectomy, Type 2 diabtes mellitus, and hyper tension.
As per the condition 6 of the policy, the company shall not be liable to make any payment under the policy in respect any claim, if information furnished at the time of proposal found to be incorrect or false and the same was communicated vide letter dated 20.11.2019. As per the condition No.12 of the policy, the company may cancel the policy on ground of misrepresentation, fraud, moral hazard, nondisclosure of material facts as declared in the proposal form and /or claim form at the time of the claim and non-co-operation of the insured by sending 30 days notice by registered letter at the insured persons last known address. Hence a notice was issued by the company to the complainant on 18.11.2019. Thus the policy No. P181325/01/2019/001144 was cancelled due to the non-disclosure of material facts and had refunded the premium amounting to Rs.9,978/- vide. DD No.856104 dated 20.12.2019. Therefore the opposite party has rightly decided to repudiate the claim and there is no service deficiency or unfair trade practice on the part of the Opposite Parties. The Opposite Parties are not liable to pay any amount to the complainant and the complaint is liable to be dismissed.
The complainant filed proof affidavit in lieu of chief examination and documents Ext.X1 is marked. He witness was cross examined as PW1. The document Ext.X1 is the entire file related to the claim of the complainant produced by the opposite party.
The opposite party's did not adduce any oral evidence nor marked any documents.
Based on the pleadings and evidence of the rival parties in this case the following
issues are framed for consideration.
1. Whether the complainant is entitled for any amount towards the insurance benefit?
2. Whether there is any service deficiency on the part of the opposite parties?
3. If so, what is the relief?
For convenience, all these issues are considered together.
Here the specific case of the complainant is that his insurance claim related to the treatment of his wife, which was filed along with all the documents as required has been repudiated by the opposite parties without valid grounds.
The opposite parties submit that the insurance Policy is subject to conditions clauses warranties exclusions etc. attached. The complainant’s claim was repudiated on the basis of the terms and conditions. In the proposal form the complainant had suppressed certain material facts regarding the pre-existing diseases of the insured. As per the records of KMC Hospital Manippal, the complainant’s wife had under gone treatment at the hospital from 10.04.2010 to 18.05.2010 for Idiopathic Thrombo cytopenic Purpura and underwent laproscopic splectomy, Type 2 diabtes mellitus, and hyper tension and this aspect is not revealed by the complainant at the time of taking the insurance policy. In the proposal form the complainant had specifically declared that his wife was not suffering from any disease or ailment at the time of submitting the proposal form or at any point of time earlier and that his health condition was good in all respect . Thus the complainant suppressed the material facts regarding the earlier treatment and obtained the insurance policy.
The opposite parties argue that as per the condition 6 of the policy, the company shall not be liable to make any payment under the policy in respect any claim if information furnished at the time of proposal found to be incorrect or false .Therefore the opposite parties rightly repudiated the claim of the complainant.
The complainant submit that the insurance policy was taken as induced by an agent of the opposite parties, namely, Mr.Mamman, who convinced the complainant that the insured would get Rs.2,00,000/-for treatment, in case she is hospitalised. The entire health history of Smt. Mary Jose was explained to the agent before taking the policy.
Here it is pertinent to not that the policy obtained by the complainant is Senior Citizen Red Carpet Health Insurance policy. As admitted by the opposite parties in their version, as per the terms and conditions of the Senior Citizen Red Carpet Health Insurance policy, only those pre-existing diseases, which are specifically covered by the proposal form are covered under the policy. It is also submitted that, So it is compulsory that the information regarding the health must be provided in the proposal form, for the company to provide coverage with suitable co-payment , ie, 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured.
The complainant submits that the policy was taken through an agent of the opposite parties, namely, one Mr. Mamman. The policy document produced by the opposite party (Ext.X1) would also show that aspect. The policy chosen by the complainant is the Senior Citizen Red Carpet Health Insurance policy, and as per
the version of the opposite parties , the pre-existing diseases which are specifically mentioned in the proposal form are covered by the policy. But strangely, no pre-exisiting disease of the insured is mentioned in the proposal form.
It is clear from the records that the complainant obtained the insurance policy not by directly approaching the opposite parties at their head office and furnishing some false information. The complainant was canvassed by an insurance agent and accordingly a policy was taken. So the agent was expected to supply and convince the complainant with correct information regarding the each and every insurance plan.
Here it appears that the insurance agent either had not informed the complainant about the insurance policy plan or he had not taken much strain to get recorded the pre-existing diseases of the insured in the proposal form. Instead he simply opted to fill the relevant columns of the proposal form with a big No and took the signature in order to obtain premium amount from the complainant. There is gross negligence and omission on the part of the agent of the opposite party in gathering correct material facts from the insured and getting the same recorded.
Since the insurance plan that the complainant opted to take was the Senior Citizen Red Carpet Health Insurance policy and as far as the terms and condition is concerned the material facts related to the pre-existing diseases are very much relevant. There is no chance of getting any benefit by suppressing those facts for the complainant, other than loss. So it cannot be held that the complainant was suppressing the material facts of pre-existing diseases of the insured, while submitting the proposal form.
Also, the opposite parties did not adduce any evidence to show that the complainant had deliberately suppressed the material facts related to the treatment undergone by his wife long back and filed the proposal form.
Therefore considering the facts and circumstances of the case and in the absence of rebuttal evidence this commission is of the view that the denial of the insurance benefit to the complainant on the basis of technical ground is not justified and there is service deficiency on the part of the Opposite Parties, due to which the complainant suffered mental agony.
Therefore the Opposite Party is liable to pay Rs.2,00,000/- the sum assured and also compensation for Mental agony and hardships. This commission hold that Rs.20,000/- will be a reasonable amount of compensation in this case.
ln the result, the complaint is allowed and the Opposite Parties are directed to pay a total amount of Rs. 2,00,000/- (Rupees Two Lakh only) with 8% interest per annum from 15.01.2020, the date of complaint till payment, to the complainant. The Opposite Parties are also directed to pay Rs.20,000/- (Rupees Twenty thousand only) as compensation and Rs.5,000/- (Rupees Five Thousand only) towards the costs to the complainant.
Time for compliance is 30 days from receipt of the copy of the Judgement.
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Exhibits
X1. The entire file related to the claim of the complaint
Witness Examined
PW1. Jose. K.M
Sd/- Sd/- Sd/-
MEMBER MEMBER PRESIDENT
Forwarded by Order
Assistant Registrar
Ps/
