Tamil Nadu

StateCommission

A/252/2015

Apollo Munich Health Insurance company Ltd., The Manager - Complainant(s)

Versus

V.S. Senthil Kumar - Opp.Party(s)

Elveera Ravindran

10 Mar 2023

ORDER

 IN THE TAMILNADU STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHENNAI.

 

Present:   Hon’ble THIRU. JUSTICE R. SUBBIAH  :     PRESIDENT

                 THIRU R   VENKATESAPERUMAL           :      MEMBER

 

F.A. No. 252 of 2015

[Against the order passed in C.C. No.14 of 2013 dated 07.05.2015 on the file of the D.C.D.R.F., Chennai (North)].

 

Friday, the  10^th day of March 2023

 

 

The Manager

Apollo Munich Health Insurance Co.Ltd.,

 now known as

HDFC Ergo Health Insurance Co.Ltd.,

319/4, Valluvarkottam High Road

Nungambakkam, Chennai.                                          ..  Appellant/  

        Opposite party       

 

- Vs –

 

V.S.Senthilkumar

50, EVK Sampath Road

Periyar Thidal

Vepery, Chennai-7                                                     .. Respondent/

             Complainant

 

 Counsel for Appellant / Opposite Party        : M/s. Elveera Ravindran

 Counsel for the Respondent/Complainant    : M/s.S. Maniselvam

                                                       

 

 

This appeal came before us for final hearing on 20.12.2022, and on hearing the arguments of the counsel for the Appellant and on perusing the material records, this Commission made the following :-

 

O R D E R

R.SUBBIAH J., PRESIDENT

 

                This appeal has been filed under Section 15 of the Consumer Protection Act, 1986 as against the order dated 07.05.2015 passed by the District Consumer Disputes Redressal Forum, Chennai (North) in C.C. No.14 of 2013, allowing the complaint filed by the Respondent herein.

 

        2.  The Appellant is the opposite party and the respondent is the complainant.  For the sake of convenience, the parties will be referred as per their ranking before the District Forum. 

 

        3.  The case of the complainant, as given in the complaint filed before the District Forum, is as follows :-

                The complainant was working as a Reporter in the News Media and Fortnightly Magazine, functioning at Periyar Thidal.  He is the only earning person for the survival of his family.  He took a policy with the opposite party namely Health Insurance Policy vide Policy No.140100/11001/1000054936-02, covering the period from 05.12.2011 to 04.12.2012, vide his member ID No.10000712158.   On 26.11.2012 at about 08.30 pm, while he was returning from his office in his motorcycle, near Noor Hotel, Ayanavaram, Chennai, he met with an accident since a dog suddenly crossed the road.  Since he was under the impression that he had sustained only simple injury, he went to home in an auto.  After reaching home, there was a severe pain continuously and so, on the next day, i.e., 27.11.2012, he got admitted himself in Apollo Hospital at Greams Road, Chennai.  After diagnosing, the complainant was informed that he has to undergo surgery since there is a fracture on his right knee.  The surgery was conducted on 27.11.2012.  After surgery, since he was not satisfied with the treatment given to him, the complainant requested to discharge him.  He had incurred a sum of Rs.2,69,037/-.  The Management of Apollo Hospital contacted the Branch Office for the cashless payment since the complainant had availed Apollo Munich Health Insurance Policy.  But, the opposite party refused to pay the bill raised by the Apollo Hospital.  Therefore, he availed loan from his neighbours and settled the bill of Rs.2,69,037/-. Thereafter, he himself got admitted in Soundarapandian Bone & Joint Hospital, Anna Nagar, Chennai and took treatment as in-patient from 03.12.2012 to 11.12.2012, where he incurred an expenditure of Rs.92,383/-.  Apart from that, he had also incurred medical expenses of Rs.5658/-.  Thus, he incurred total expenses of Rs.3,67,078/- for treatment.  Since the opposite party refused to pay the medical expenses, now alleging deficiency of service he has filed the present complaint, for a direction to the opposite party to reimburse the medical expenses of the complainant and to pay a sum of Rs.5,00,000/- as compensation for mental agony. 

   

                3.  The said claim was resisted by the opposite party by filing a version stating that as per their standard practice every proposer applies for a policy in the form of a Standard Proposal Form, wherein the proposer/ complainant is required to fill in the material information.  In the present case, the opposite party had received the duly filled in and signed proposal form from the proposer/complainant on 05.12.2009 for availing health insurance policy seeking to cover himself, his wife and son.  Believing the details and information provided by the complainant in the said declaration, including the medical history, to be true, correct and complete in all respects, giving due credence to the under writing norms of opposite party, Policy No.140100/11001/1000054936 was issued for a sum assured opted as per proposal form, to the proposer/complainant on 07.12.2009 for a period between 05.12.2009 to 04.12.2010.  Thereafter, based on the written request of the complainant to renew the policy, the policy was renewed insuring the complainant along with his wife and son for the period from 05.12.2010 to 04.12.2011.  Again the policy was renewed for the period between 05.12.2011 to 04.12.2012.  Whileso, a pre-authorisation form for cashless facility was received on 28.11.2012 by the opposite party from Apollo Hospital, Chennai for the treatment of the complainant.  Upon reviewing the said pre-authorisation form document, it was observed that the complainant had a past history of heart disease with ventricular septal defect closure during 2005 and so to evaluate the admissibility of the request for cash, in the light of declaration made by the complainant in the proposal form, the complainant was required to submit the following documents:-

a) positive investigative reports supporting the diagnosis in printed form;

b)  documents relating to VSD closure i.e., discharge summary, investigations reports; and

c)  Duly attested treating Doctor’s certificate regarding any intake of Alcohol/drugs by the patient at the time of accident.

From the said documents, it was found that the complainant was suffering from Coronary Atherosclerotic Heart Disease, Double Chambered Right Ventricle, Ventricular Spetal Defect and Normal Sinus Rhythm in 2005, which was a pre-existing health condition and that was not disclosed by the complainant deliberately at the time of availing the policy from the opposite party.  At the time of filing up of the proposal form, these material facts were suppressed by the complainant.  The complainant had misled the opposite party to issue the policy by concealment and suppression of the above material facts.  It is the bounden duty of the complainant to disclose his true and correct medical history in order to enable the opposite party to underwrite the risk cover.  The complainant had mislead the opposite party in issuance of the policy to him, suppressing the relevant and material fact about his past medical condition.   Therefore, he is not entitled for the reimbursement of medical expenses and also for other reliefs and thus sought for dismissal of the complaint.

 

                4.  In order to prove the case, both the parties have filed their proof affidavits and on the side of the complainant, 10 documents have been marked as Exhibits A1 to A10 and 9 documents were filed on the side of the opposite parties and marked as Exhibits B1 to B9.  

                5.   The District Forum, after analyzing the entire evidence on records had observed that though the complainant did not disclose the heart disease, the claim has been made with respect to the treatment given to him for the injuries sustained by him in the accident and not with regard to cardiac ailment.  Accident is an unexpected one and therefore the opposite party is liable to pay the accident coverage and directed the opposite party to pay the compensation amount.  Aggrieved over the same, the present appeal has been filed by the opposite party.

 

                6. There is no representation for the Respondent/ Complainant.  Heard the submission of the learned counsel for the appellant/opposite party and perused the material available on records. 

 

                7.  Assailing the finding of the District Forum, the appellant/ opposite party submitted that as per the standard practice every proposer applies for a policy by means of an application in the form of a standard Proposal Form, wherein the proposer is required to fill in all the material information.  The appellant/opposite party has received the duly filled and signed proposal form from the respondent/ complainant on 05.12.2009 for availing health insurance policy seeking to cover himself, his wife and son.  In the proposal form, Section 9 “General Exclusions” reads as follows:-

“ .... This proposal will be the basis of any insurance policy that we may issue.  Proposer must disclose all facts relevant to all persons proposed to be insured that may affect our decision to issue a policy or its terms.  Non-compliance may result in the avoidance of the policy.  If there is insufficient space for you to provide information whether as requested or otherwise, please attach a separate sheet .....” 

 

Therefore, the proposer is bound to disclose all the material facts in the proposal form.  In the instant case, the respondent/complainant met with an accident on 26.11.2012 and sustained fracture on his right knee.  He took treatment in two hospitals.  First in Apollo Hospital and then in Soundarapandian Bone and Joint Hospital.  In Apollo Hospital he incurred a sum of Rs.2,69,037/- and in Soundarapandian Bone and Joint Hospital he incurred a sum of Rs.92,383/- towards medical expenses.  In respect of the treatment taken in Apollo Hospital, the management of the Hospital contacted the Branch Office of the opposite party.  But the request of the Apollo Hospital was refused stating that there is suppression of material facts on the side of the respondent/complainant.  In fact, the respondent/complainant was suffering from cardiac ailment but the same has been suppressed in the proposal form.  The opposite party/Insurance company while reviewing the pre-authorization form document, found that the respondent/ complainant had a past history of heart disease with Ventricular Septal Defect Closure in 2005 and therefore to evaluate the admissibility of the request for cashless in light of the declaration that complainant had made in the said proposal form, the complainant had to submit certain documents.  Accordingly, the complainant also submitted certain documents.  As per the Discharge Summary, the complainant was diagnosed for Coronary Atherosclerotic Heart Disease, Double Chambered Right Ventricle, Ventricular Spetal Defect and Normal Sinus Rhythm.  Further, the complainant has not denied that he was having cardiac ailment even before taking the policy.  But his contention is that he sustained injuries in the accident, which is an unexpected one and therefore there is no nexus with the injuries suffered in the accident and the cardiac ailment, which he was suffering.  Therefore, there cannot be any impediment in paying the claim amount.  But, we are not inclined to accept this submission of the complainant.  It is settled legal principle that, in matter of insurance policies like the present instance, suppression and misrepresentation of material facts would render the policy invalid in the eye of law.  Such an instance enables the Insurance Company to repudiate the claim arising from the policy for the reason that the principle of uberrima fides/ utmost good faith is flouted due to suppression of material facts.  If the insured has knowledge of facts which others cannot know, he should not resort to suppressio veri/suppression of truth.  In the case on hand, since the insured had suppressed the material facts about his medical history which is the criterion for considering the issuance of the policy itself, by simply referring to the examination by the panel doctor, the complainant cannot expect any positive consideration of the claim.  As such, we find no valid reason to sustain the impugned order passed by the District Forum and hence, the same is liable to be set aside. 

 

                8.  In the result, the Appeal is allowed, by setting aside the impugned order dated 07.05.2015, passed by the District Consumer Dispute Redressal Forum, Chennai (North) in C.C. No.14 of 2013.

 

 

R  VENKATESAPERUMAL                              R.SUBBIAH

         MEMBER                                                            PRESIDENT

 

 

Index :  Yes/ No

 

AVR/SCDRC/Chennai/Orders/March/2023