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Metlife 
Submit Complaint..ORDER
1.(a) This Complaint is filed on 10/12/2008 under section 12 of the Consumer Protection Act, 1986, alleging deficiency of service by the Opposite Party-Insurance Company (hereafter OP-Company) in respect of an Insurance Policy Coverage and seeking certain reliefs which according to the Complainant, are appropriate.
The Complaint in brief, is as hereunder;
(b) The Complainant had availed two Medical Insurance Policies bearing Nos.1200600182398 dt.25/11/2005 and 1200500138898 dt/09/04/2006 for Rs.2,50,000/- each. The Complainant was regular in paying the premiums. Those Policies had certain benefits including critical illness coverage of Rs.3,50,000/- and Rs.2,50,000/- respectively. The 1st Policy was for life and the 2nd Policy was for a period of 15 years. The Complainant became critically ill and approached Mallya Hospital, Bangalore. After checkup the hospital Authorities told him that he is suffering from Chronic Renal Failure. Then, the Complainant was admitted to Bangalore Hospital, Bangalore and he had spent huge amount.
(c) The Complainant was advised by the Opposite Party-Insurance Company to submit the Claim Form for that critical illness. The Complainant accordingly submitted the same on 24/11/2006. That treatment had to be for a long time and the Complainant had to take the treatment since there was no other option for survival. However, the Opposite Party-Insurance Company did not honour that Claim. That resulted in a Legal Notice and ultimately, a Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007 on their file. That Complaint came to be allowed and the Opposite Party-Insurance Company was directed to pay a sum of Rs.2,00,000/- and the cost of the litigation at Rs.5,000/-, as per the Order dt.26/11/2007. As per the Medical advise, the Complainant had to expend Rs.15,000/- every month for medication regularly.
As and when the Complainant had to so spend, he is required to lay a Claim on the basis of those Policies since there is Insurance Coverage for medication under those Policies. Accordingly, the Complainant laid a Claim for the subsequent period, but, the Opposite Party-Insurance Company repudiated the same on the ground that there was no such liability to honour the Claim regarding critical illness for the 2nd time. That repudiation of the Claim was unjust and improper since the Opposite Party-Insurance Company could not have repudiated the Claim on that ground. Hence, this Complaint is necessitated to direct the Opposite Party-Insurance Company to pay a sum of Rs.81,720-00/- to the Complainant being the Medical expenses and also to direct to pay cost and compensation.
(d) Along with the Complaint, the Complainant has made available xerox copies of certain documents marking them at Annexures C-1 to C-81.
2.(a) On admission of the Complaint, the Opposite Party-Insurance Company was called upon to produce their Version of the case. Accordingly, the same is made available on 12/02/2009. In brief, it is as hereunder.
(b) This Complaint is neither maintainable at Law, nor on facts of the case. It is true, the Complainant is the Holder of two Medical Insurance Policies issued by the Opposite Party-Insurance Company. They are MET SURAKSHA-TROP with critical illness Rider and MET 100 GOLD with critical illness Rider respectively. The 1st Policy bears No.1200500138898. The date of proposal is 17/10/2005. The sum assured is Rs.5,00,000/-. The critical illness Rider is Rs.3,50,000/-. That Policy was issued on 25/11/2005. The premium is Rs.3,086-00/- payable half yearly. The 2nd Policy bears No.1200600182398. The date of proposal is 19/12/2005. It is for a sum of Rs.2,50,000/-. The critical illness Rider is Rs.2,50,000/-. The date of issue of the Policy is 09/04/2006. The premium payable is Rs.3,746-00/- half yearly. There was also a provision for the benefit of accidental death of the insured.
(c) The Complainant preferred a Claim on 24/11/2006 with regard to the treatment connected with her Chronic Renal Failure. The Opposite Party-Insurance Company sought several clarifications from the Complainant including the details regarding the treatment taken at St.John’s Hospital, KIMS Hospital and Bangalore Hospital. Instead of providing those details, the Complainant filed a Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007, alleging deficiency of service by the Opposite Party-Insurance Company and for issuance of a direction to the Opposite Party-Insurance Company to make the payment claimed therein.
That Complaint came to be allowed by the IVth Additional District Consumer Disputes Redressal Forum, as per the Order dt.26/11/2007 directing the Opposite Party to pay a sum of Rs.2,00,000/- along with the cost of Rs.5,000/-. In that Order, liberty is given to the Complainant to approach the proper Authorities for reimbursement of the amount spent by him for future treatment. Accordingly, the Opposite Party-Insurance Company has paid the sum of Rs.2,00,000/- with cost and treated the same as ex-gratia payment. Now the Complainant has chosen to file this Complaint claiming Rs.81,730-00/-claiming the alleged medical expenses up to 23/10/2008 on the basis of those Policies. Infact, the Complainant has suppressed the truth of the fact that he was suffering from Chronic Renal Failure before the issue of both the Policies. Towards proof of reappearance of the real failure, prior to the issuance of the Policies, the admission record of St.John’s Hospital is produced as Annexure-1 by this Opposite Party-Insurance Company. Further, regarding the 2nd Policy, after the submission of the Application and before the issuance of the Policy, the Complainant had visited Dr.K.S.Ramaprasad with regard to the Renal Failure and this fact has been stated in the critical illness Claim from 24/11/2006 duly signed by the Complainant showing that the “date of appearance of First symptom as 02/03/2006” in the column meant for “history of the case” in the said Claim Form.
The date of the proposal of the 2nd Policy was 19/12/2005 and the Policy was issued on 09/04/2006. There is a declaration in that Application that the non- disclosure of facts or any un-true disclosure in the Application, the very contract becomes null and void and the premium paid till then would stand forfeited to the Opposite Party-Insurance Company. It is evident from the Admission Card and from the admission of the Complainant in the critical illness Claim Form that after filing the said Application and before the issuance of the Policy, there was a change in his general health and that he had to visit the Doctor on 02/03/2006 for Renal Failure. It was never intimated by the Complainant to the Opposite Party-Insurance Company while submitting that 2nd Application Form, nor, thereafter. Since, contract of Insurance is “uberamie fadie” the parties are bound to disclose the true acts while entering into such a contract. But, the Complainant had suppressed the fact of illness in the 2nd Application for Policy.
(d) As per the exclusion Clause No.4 in the above Policies, no amount shall be payable under that benefit of critical illness condition unless it is so caused after the availment of the Policy and if it was existing very much there even previously, that benefit is lost. Further, in the above Policies, Clause-5 provides for termination under the situations stated therein.
(e) It is true, the Complainant had caused a Legal Notice to the Opposite Party-Insurance Company on 31/07/2008. But, the allegations made therein are denied since false. In the circumstances, there is every reason to hold that this Complaint is intended to make profit unlawfully by misrepresenting the Terms and Conditions enshrined in those Policies. Wherefore, this very Complaint has to be dismissed with cost of the Opposite Party-Insurance Company.
(f) Along with the Complaint, the Opposite Party-Insurance Company has made available certain documents marking them at Annexures-1 to 3.
3. In this proceeding by way of evidence the Complainant has made available his affidavit on 03/03/2009. For the Opposite Party-Insurance Company their Associate Director-Legal namely Anil P.M. has sworn to an affidavit which is made available by way of evidence on 17/03/2009 along with the Affidavit. At the end, this Forum heard on merits.
4. In the circumstances, the following points do arise for our consideration and decision in this Proceeding and they are;
(i) Whether there was suppression of the material fact as to any illness of the Complainant at the time of submission of the Applications seeking Insurance Coverage as contended by the Opposite Party-Insurance Company ?
(ii) Whether the Complainant is entitled for the benefit of Insurance Coverage touching critical illness under the Policies?
(iii) Whether the Complainant is entitled for any relief in this case ?
iv) What Order? 5. Our Findings to these points are as hereunder: i) No, ii) Yes, iii) Yes, iv) As per the operative portion of the Order here- below. 6. We shall strengthen our findings on the following:
R E A S O N S
POINT NO.1 (a):- Admittedly, the Complainant was provided with two Policies by the Opposite Party-Insurance Company. The 1st Policy was issued on 25/11/2005 and the next Policy was issued on 09/04/2006. In the 1st Policy, the sum assured was, Rs.5,00,000/-and the sum assured under the critical illness Rider is, Rs.3,50,000/-. In the 2nd Policy, the sum assured was, Rs.2,50,000/- and the sum under the critical illness Rider is, Rs.2,50,000/- It is significant that within a short period of four months, these two policies have come into effect.
(b) First of all, if really there was suppression if any material fact regarding the alleged illness of the Complainant while applying for the Policies at least in respect of the 2nd Policy, the Opposite Party –Insurance Company could have been more alert and would have thought twice whether to issue the Policy or not in the light of the already existing Policy which was obtained just four months prior to the 2nd Policy. The evidence is to the effect that the Opposite Party-Insurance Company had subjected the Complainant to medical check-up and that an increased premium was imposed by the Opposite Party-Insurance Company. That apart, this very same point was raised by the Opposite Party-Insurance Company in the previous proceeding between the parties, which was pending in Consumer Complaint No.943/2007 on the file of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District. That Complaint came to be allowed, as per the Order dt.26/11/2007 a copy of which is, at Annexure C-17 made available by the Complainant along with the Complaint. Significantly, the said Authority had answered the said point against the Opposite Party-Insurance Company in that Order by holding that there was no suppression of material facts touching the alleged illness of the Complainant while submitting the Applications for Insurance Coverage. It is equally significant to note that the said Order of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District has become final. It is submitted by the Learned Counsel representing by the Opposite Party-Insurance Company that there was no Appeal as against the said Order and that what was ordered there-under has been duly complied with by the Opposite Party-Insurance Company.
(c) Wherefore in the above circumstances, we are of the opinion that further discussion may not be necessary as far as this point is answered and accordingly, this point is against the Opposite Party-Insurance Company.
7. POINT NO.2(a):- It is an admitted fact that the above Policies provide certain benefits to the Insured including the benefit touching critical illness. As a matter of fact, in the previous Complaint, that benefit was availed, as revealed in the said Order. It is significant that in the said Order dt.26/11/2007 by the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District, it has been observed that Claim for future reimbursement under critical illness clause can be made by the Insured Complainant before the proper Authorities. Ofcourse, in that Complaint that Claim came to be rejected for the reason that there was no clear evidence in that regard. For better appreciation, we reproduce the relevant part of that Order which is found in page No.6. It reads like this: The Complainant has claimed Rs.15,000/- per month for medication regularly life long. When we peruse the documents at Annexure-D produced by the Complainant, it is an approximate cost estimated by the Doctor. The Complainant has not produced the Bills that how much amount will be required every month for the purpose of regular treatment and for future treatment. This Forum cannot award any cost or compensation, anticipating the cost on the approximate value given by the Doctors and without fixing the period. Hence, the said Claim of the Complainant is hereby rejected. However, the Complainant is at liberty to approach the proper authorities for reimbursement of the amount spent by him for future treatment.”
(b) As already stated, since the above Order has become final, the above observation holds good. That apart, the learned Counsel representing the Opposite Party-Insurance Company has strenuously argued before us placing reliance upon the relevant Clauses of the Terms and Conditions touching the above Policies. The Complainant has made available copies of those Policies including the Terms and Conditions in evidence along with the Complaint itself marking them at Annexure C-1. The relevant part is, Rider – critical illness (CI). As revealed in Clause-2, that Rider will remain effective from the effective date as shown in the Schedule and shall remain valid unless terminated in accordance with the Terms and Conditions shown therein. Admittedly, the Complainant’s illness is, Kidney Failure. Kidney Failure is covered under the Policy as per Clause-3 among other deceases. Clause-5 is very much relevant and as already stated, it is interrelated to Clause-2 period of Coverage. For better appreciation, we reproduce that Clause-5 here. It reads like this: “Termination”: This Rider coverage will terminate on the earliest of any one of the four mentioned below: ‘On diagnosis of Critical Illness Condition within a period of 90-days from issue date or reinstatement of the policy; or, ‘Lapse, surrender of the Policy, conversion of the Policy into a paid-up Insurance; or, ‘The benefit expiry date shown in the Schedule under Rider Details; or, ‘The date of the first occurrence of the event on which, this benefit becomes payable. According to the Learned Counsel representing the Opposite Party-Insurance Company the last a Para that is, the date of the 1st occurrence of the event on which this benefit becomes payable would clearly probabilise that the Complainant as Insured is not entitled for the benefit of that Rider for the 2nd time, since that benefit was availed by him already.
However, we do not think so. Admittedly, the ailment is, Kidney Failure. As revealed in evidence, that ailment is not cured and it is being treated. Further, admittedly the earlier Complaint through which the Complainant sought that benefit and got the same was far a definite period. It is not as if that ailment was cured completely and that the said payment was made, as per the said Order only after the cure of that illness. On the other hand, as already stated, the said illness is still continued and the Insured Complainant is suffering a lot on account of the same. Further, it is not as if that illness is changed and some other ailment has cropped-up.
On the other hand, that critical illness is, Kidney Failure only. In this Complaint, the Complainant has claimed the medical expenses incurred by him touching that critical illness, till 23/10/2008 in a sum of Rs.81,720-00/-. Admittedly, this is the 2nd Claim. Admittedly, the 1st Claim made in the above Complaint before the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District is for the earlier period and that has been paid over by the Opposite Party-Insurance Company. Further, it is not as if the Insured Complainant is not paying the premiums touching the Policies. Admittedly, the premiums are being paid as and when they became payable. That means, the Opposite Party-Insurance Company is collecting the premium regularly from the Complainant. Further, as already stated, the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in the above case has clearly opined that the Insured Complainant is entitled for the future benefit touching critical illness under the said Insurance Coverage.
Wherefore, in the light of the above aspects, we are of the clear opinion that the Insured Complainant is entitled for future reimbursement regarding the Medical expenses incurred by him touching the above critical illness. (c) When that is so, the non-reimbursement of the same by the Opposite Party-Insurance Company would clearly amount to deficiency of service within the purview of the Consumer Protection Act, 1986. Wherefore, this point is answered in favour of the Insured Complainant. 8.POINT NO.3:- It appears, no Claim Petition as such is made by the Insured Complainant before the Opposite Party-Insurance Company regarding the Claim made herein.
On the other hand, according to the Complainant, a Legal Notice was caused on 31/07/2008 to the Opposite Party-Insurance Company requesting them to pay the Medical expenses for the period from 26/02/2008 till 19/07/2008 in a sum of Rs.55,515-00/- and also the Notice charges in a sum of Rs.1,000/-. Ofcourse, that Claim has not been conceded by the Opposite Party-Insurance Company and that made the Complainant to knock the doors of this Forum. However, the facts remains that there was no Claim Form as such by the Complainant for the period subsequent to the period covered under the Order of the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District dt.26/11/2007 which we have referred to above. Wherefore, the Complainant has to lay a Claim in the proper format in that regard and the Opposite Party-Insurance Company has to consider the same on merits and dispose-off the same in the light of the above observations of this Forum.
As stated supra, there shall be interest on the amount payable at 9% p.a. at least from this date, till reimbursement. In the peculiar circumstances, we are not inclined to grant any compensation as such to the Complainant. However, cost of this litigation needy provided to the Complainant at a reasonable rate which according to us, would be Rs.1,000/-. Accordingly, this point is answered. 9. POINT NO.4:- In the result, we proceed to pass the following: O R D E R It is held that the Insured Complainant is entitled for the benefits conferred under the Policies in question in respect of critical illness for the period subsequent to the period referred to by the IVth Additional District Consumer Disputes Redressal Forum, Bangalore, Urban District in Complaint No.CC.943/2007 and the Complainant is at liberty to lay a Claim Petition before the Opposite Party-Insurance Company claiming the amount till the date of that Claim Petition and the Opposite Party-Insurance Company shall decide the same on merits and reimburse the amount which is required to be reimbursed on the merits of that Claim along with an interest at 9% p.a. from this date, till reimbursement.
If desired, the Complainant shall lay the Claim positively within the period of 15 days from this date and on production of the same, the Opposite Party-Insurance Company shall dispose-off the said Claim within the period of 30 days from the date of submission of the Claim Application. In addition to the same, the Opposite Party-insurance Company shall pay a sum of Rs.1,000/- to the Complainant by way of cost of this litigation.
