DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 19th day of September, 2022
Present : Sri.Vinay Menon V., President
: Smt.Vidya A., Member
: Sri.Krishnankutty N.K., Member Date of Filing: 20/12/2018
CC/180/2018
Krishnakumar K.,
S/o. M.Chandrasekharan,
Kousthubham, Polpully P.O., Palakkad – 678 612
(By Adv. C. Madhavan Kutty) - Complainant
Vs
1. The Manager,
M/s Star Health and Allied Insurance Co. Ltd.,
Palakkad Fine Centre, 4th Floor, T.B. Road, Palakkad.
2. M/s Star Health and Allied Insurance Co. Ltd.,
No. 1, New Tank Centre, Valluvakottam High Road
Nungambakkom, Chennai – 600034 - Opposite parties
(By Adv. M/s Ratnavally & Kiran G. Raj)
O R D E R
By Sri. Vinay Menon V., President
- Complainant claims to be a ‘Ported insured’ of the opposite parties since 2016. Complainant had been an insured under the health coverage policies provided by Oriental Insurance Company from 2010 onwards. Resultantly, the complainant is to be considered as being under the continuous coverage of the opposite party and not as a fresh entrant to the policy coverage. Yet, when the complainant underwent treatment for Kidney disease during 2018, the opposite party repudiated the claim of the complainant on baseless and flimsy grounds. There is deficiency in service on the part of the opposite parties.
- Opposite parties admitted that the complainant was a ‘Ported insured’ under them. But they contended that while filing proposal form, the complainant has not disclosed the material fact that the complainant was suffering from kidney diseases he was suffering from. In view of the willful non-disclosure, his claim was repudiated. There is no deficiency in service on the party of the opposite parties.
- Issues that arise for consideration are as follows:
- Whether, the status of a Ported insured provides immunity from disclosing material facts at the time of preparing proposal form?
- Whether the compliant has suppressed material information?
- Whether the complainant was aware of the material facts at the time of submission of proposal form?
- Whether there is any deficiency in service on the part of opposite parties?
- Whether the complainant is entitled to any of the reliefs sought for?
- Reliefs, if any?
4. Evidence comprised of Exts. A1 to A15 and Exts. B1 to B17 and proof affidavits. Exts. A1 to A10 were objected to on the ground that they were photostat copies. Since this Commission is not bound by the principles of Evidence Act, and in the absence of any allegation that the aforesaid documents are forged or fabricated, we allow the documents to be relied upon in evidence.
Issue No. 1.
5. It is an undisputed fact that the complainant is a ‘ported insured’. The complainant had been under the continuous and unobstructed cover provided by the Oriental Insurance Ltd from 2010 onwards. Thereafter he got himself ported to the insurance coverage provided by the opposite parties considering the opposite parties’ “wide coverage and tie up with many hospitals than the Oriental Insurance Co.”
6. A vital factor that is to be considered herein is that the porting herein is not an intra-company transfer wherein the policy holder got ported from a scheme of one company to another scheme of the same company. This is an inter-company transfer whereby the complainant got transferred from a scheme of one company to the scheme of another entirely different company. Entrance to the benefits of the new insurer presupposes satisfaction of the underwriter of the new company, for which the complainant is bound to provide information in accordance with the requirements of the company. To that end, the complainant is bound by the principles of ubbrime fidae. Once the proposal is accepted based on the information, as existing on the date of filling it, provided in the proposal form, the subsequent insurer steps into the shoes of the first company and would have to provide cover.
7. Hence we are of the opinion that porting of the complainant from scheme of one company to scheme of another, as is in this case, the complainant would have to disclose every material facts, as sought for by the subsequent insurer, in accordance with the principles of ubbrime fidae.
Issue Nos. 2 & 3.
8. For the sake of convenience, these two issues can be considered together. Ext. B1 is the proposal form bearing number 82727425. Coverage is for a period covering 16.09.2016 to 15.09.2017. Page 3 and 4 contains the “Health History” of the complainant.
To the general question in “Health History”, “(1) Are you in good health and free from physical and mental disease or infirmity. If not give details”, the complainant has answered in the affirmative that he is in good health.
To question (2), “Have you consulted/taken treatment/been admitted for any illness/diseases/injury/surgery. If yes, details”, the complainant has answered “No”.
To a rather pointed question (4), “Have you ever suffered or suffering from any of the following: (i) Diseases of the stomach, intestine, liver, gall bladder/pancreas, Kidney, urinary bladder, Urinary Tract Diseases – If yes, since when?”, the complainant has answered “No”. The complainant has stated that he was not suffering from any diseases as stated, including any ailments of the Kidney.
The entire questionnaire is answered in the negative; meaning that the complainant has unequivocally stated that the complainant is healthy and is not suffering from any of the medical conditions that would, in the normal course, if disclosed, make the opposite party either reject the proposal or would prevent issuance of a policy at the normal rates of premium.
9. The opposite parties vouch by Exts. B9, B10, B11, B12, B13 (series) to prove that the complainant was suffering from Pre-existing Disease and that the complainant had failed to willfully disclose the same at the time of answering the questionnaire while preparing the proposal form.
Exts. B9 to B12 are laboratory reports of the complainant availed during 2014. All the reports show higher than normal creatinine level, which means that the kidneys were not functioning properly.
Exts. B13(a) to (d) are medications issued by Dr. V.M. Ganesan, Consultant Nephrologist, Thankom Hospital for consumption by complainant during the year 2014 and 2015.
10. During 2018, the complainant was admitted with complaints of CKD, stage V. Going by the aforesaid documents, one can easily come to the conclusion that the complainant was aware of his condition and was undergoing treatment under Department of Nephrology, Thankom Hospital. Complainant has no case that the documents relied on by the opposite parties does not pertain to the complaint.
11. Hence we hold that the complainant has willfully concealed material facts regarding his illness from the opposite parties.
Issues 4
12. Apropos the issues stated above, we hold that there is no deficiency in service on the part of the opposite parties.
Resultantly, this complaint is dismissed.
Issues 5 & 6
13. In view of the findings in Issues 1 and 2, we hold that the complainant is not entitled to the reliefs as sought for.
Eventhough cost should follow in the normal course, considering the fact that the complainant is a person who is suffering from a debilitating disease like CKD, we are not imposing costs on him. Parties are directed to suffer their respective costs.
Pronounced in open court on this the 19th day of September, 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 – Copy of policy schedule bearing No.442000/48/2011/1964
Ext.A2 - Copy of policy schedule bearing No.442000/48/2012/1606
Ext.A3 – Copy of policy schedule bearing No.442000/48/2013/1387
Ext.A4 – Copy of policy schedule bearing No.442000/48/2014/1369
Ext.A5 – Copy of policy schedule bearing No.442000/48/2015/1437
Ext.A6 – Copy of policy schedule bearing No.442000/48/2016/1469
Ext.A7 – Copy of policy schedule bearing No.P/181214/01/2017/002998
Ext.A8 – Copy of policy schedule bearing No.P/181214/01/2018/003959
Ext.A9 – Copy of advance premium receipt dated 15/9/2018
Ext.A10 – Copy of communication 24/08/2018 regarding repudiation of claim.
Ext.A11 – Original discharge summary from Dept.of Nephrology dt.24/3/18
Ext.A12 – Original discharge summary from Dept.of Nephrology dt.29/10/18
Ext.A13 – Original discharge summary from Dept.of Nephrology dt.12/10/2018
Ext.A14 – Original discharge summary from Dept.of Nephrology dt.15/8/18
Ext.A15 – Series of 226 bills pertaining to the treatment availed by the complainant.
Exhibits marked on the side of the opposite party
Ext.B1 – Copy of proposal form
Ext.B2 – Copy of portability form
Ext. B3 – Copy of policy schedule bearing No.P/181214/01/2017/002998
Ext.B4 – Copy of policy schedule bearing No.P/181214/01/2018/003959
Ext.B5 – Customer information sheet of family health optima insurance policy.
Ext.B6 – Copy of request for cashless hospitalisation.
Ext.B7 – Copy of query on pre-authorisation.
Ext.B8 – Copy of medical records of Thankam Hospital, Palakkad
Ext.B9 – Copy of Laboratory report of bio-chemistry dated 15/4/2014
Ext.B10 – Copy of Laboratory report of bio-chemistry dated 16/4/2014
Ext.B11 – Copy of Laboratory report of bio-chemistry dated 04/9/2014
Ext.B12 - Copy of report from Dept. Of laboratory medicine.
Ext.B13 (a) to (d) – Copies of medicines prescribed by Dr.V.M.Ganesan, Consultant
Nephrologist.
Ext.B14 – Copy of rejection for pre-authorisation for cashless treatment.
Ext.B15 - Copy of discharge summary dated 30/6/2018
Ext.B16 – Copy of repudiation of claim.
Ext.B17 – Communication dated 31/8/2018 regarding non disclosure of pre-existing disease.
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
Cost : No cost allowed.
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.
