The Complainant Manna Kumar S/o of late Mahavir Saw, R/o village Murhu, P.S Murhu, Dist-Khunti Jharkhand has filed a complainant case against the opposite parties, alleging for deficiency in service and unfair practice of insurance policy. The complainant had health policy under star health and allied optima insurance company Ltd. The policy No P231112/01/2018/004275 was for the period from 11/01/2018 to 10/01/2019. The first period of the health insurance of the complainant of above policy was dated 11/01/2017 to 10/01/2018 and the second period of health Insurance of the complainant 11/01/2017 to10/01/2019. When the complainant had taken Insurance policy he had no disease. He was a fit and healthy person. He runs studio. The date of taking policy was 11/01/2017. On 23/03/2018 he went to Christian medical collage Vellore for the treatment of Carcinoma tongue disease on that very period the disease lymph vascular and Perimenrel invasion disease was not identified by the Christian medical collage Vellore and these dieses are not mention in the report of medical college. This fact is proved by the report. When the complainant health problem arises,  he went to Tata memorial hospital for treatment. The hospital gave him four certificates of payment for treatment bearing total cost of Rs. 1,30,000/- (certificates of Rs.  10,000/-, 20,000/-, 50,000/-, 50,000/-). The complainant had to pay above amount from 27/03/2018 to 17/04/2018. He paid 10,000/- on 26/12/2018 vide receipt No. RL 502071, Rs- 20,000/- vide receipt No.RL502246,  Rs- 50,000/- vide receipt No.RM 005712 and lastly  Rs- 50,000/- vide receipt No.RM 014398 respectively before the Accounts officer II vide receipt No.  CR/11113 and all the original payment’s Certificate were kept at Tata Memorial Hospital. After treatment the complainant claim for insurance money vide claim No. 0377190 to the insurance company. The health Insurance company denied to give him money saying that the complainant had not mentioned / disclosed the company about the disease and cancelled the policy of complainant. On cancelling the cause of action arises on 23/03/2018. The Complainant financial position becomes measurable and he had to face many difficulties. The complainant approached and filed his consumer Complainant on- 17/12/2019. The Complainant has claimed this amount for relief.

Claims for Star Health and allied Insurance company -         1,30,000/-

Physical and Mental tension and Litigation -                        40,000/-

Total -                                                                         1,70,000/-

The case was admitted on 21/12/2019. Notice issued on – 21/12/2019. After receiving notice opposite party No. 1 Branch manager of star health and, opposite party No-2 Star health and allied Insurance Company Ltd. appeared before the Commission and filed their written statement on 20/02/2020. In written statement the opposite party says that the complainant has taken family optima health insurance plan 2017 from the opposite party namely star health and allied Insurance company Ltd. from its Ranchi branch covering self, spouse Renu Devi and two dependent children being one son and a daughter namely Shivam Kumar and Nidhi Raj Gupta. That the policy no  P/231112/01/2017/004426  is valid from 11/01/2017 to 10/01/2018. The said policy was renewed and the same was numbered as P/231112/01/2018/004275 valid from 11/01/2018 to 10/01/2019. The opposite party stated   that the complainant reported the claim in the 2^nd year of the policy period. The opposite party stated that for reimbursement of the claim of the applicant, certain medical documents /report were asked for from the applicant. While scrutinizing the medical reports submitted by the applicant it was observed from one of the medical reports dated 23/03/2018 of the Christian medical collage Vellore submitted in response to our query that the applicant has undergone tongue biopsy on 10/11/2016 for non healing lesion in right lateral border of tongue which confirms that the applicant has carcinoma tongue prior to the date of commencement of the first year policy. The opposite party stated that become clear that the complainant didn’t  disclose the above mention medical details. Due to misrepresentation and non disclosure of materials facts the claim was repudiation and complainant was communicated vide latter dated 26/04/2019 saying that as per condition No. 6 of Insurance policy if there is misrepresentation and none of disclosure of facts the company is not liable to make payment. The Further as per condition no.6 of the policy, “if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim”. Hence, the claim was repudiation and communicated to the applicant. As per condition no.12 of aforesaid policy the company is able to cancel the policy and to take necessary action. That as per condition no.12 of the policy “the company may moral canceled this policy on grounds of misrepresentation, fraud and moral hazard, non disclosure of material fact as declared in the proposal form/ at the time of claim or non-co-operation of the insured person. In case of health Insurance contracts disclosure of health details are the material facts. That it is relevant to mention that the insured person has a duty to disclose all material facts in proposal while buying an insurance policy. Clause 19(2) of protection of policy holder regulation 2017 reads as under:

                             “the requirements of disclosure of materials information” regarding a proposal or policy apply, under these regulations, both to the insure and insured”. Opposite party stated that the complainant may be punished for non disclosure of the materials facts.

The Complainant has submitted and filed evidence on affidavit and supported the complain case and produced several documents which has been marked as exhibited:-

Complainant has produced himself as Pw-1 with two another witnesses Pw-2 Mukesh Kumar and Pw-3 Amit Kumar Mishra. Witnesses have also supported complainant documents and statement. They have states that during the period of insurance, the Complainant has no disease and has not violated the terms and condition of the company. After taking insurance the complainant become ill. The  Insurance company has not paid insurance money to the complainant. The cancellation done by the company is to harass the complainant.

                             In support of this case opposite party has produced one witness namely Shri Raja Ram Shi and filed his statement in his evidence on affidavit before the forum. He has admitted that he is Assistant Regional Manager of star health and allied insurance company Ltd. Complainant has taken insurance policy in his name and  his wife Renu Devi and a son Shivam Kumar and for a daughter Nidhi Raj our family optima health insurance plane 2017. Complainant was given the documents by the company. During filling the form complainant has not written that he was suffering from any disease. Complainant has claimed before the company during second period of insurance tenure. The Complainant become ill by the disease Carcinoma tongue and admitted in Tata Memorial hospital parell Mumbai on 05/04/2018 and discharge on 10/04/2018. The Complainant has claimed Rs. 106545 (One lakh six thousand five hundred forty five rupees). The Complainant went to Christian medical collage Vellore and was examined on 23/03/2018. According to report of Christian medical collage the complainant has letral border S/P Excision of Erythroleukoplakia of right lateral boarder of tongue dieses on 16/08/2017. According to the medical college it is clear that the complainant had disease  from 1^st year of policy which complainant has not told to insurance company during taking insurance policy. So, the company has cancelled his insurance policy according to the rule an condition No.12 of the company.

                   On the basis of bleeding of forth party evidence produced by the parties the following issues required to be adjudicated in this case-

1. Weather the case is maintainable or not.
2. Weather the case is barred by limitation.
3. Weather there is any deficiency in service by the part of opposite party.
4. Weather the complainant is entitled to the relief as claimed in the complainant petition.
5. Weather the complainant has valid cause of action for filling the case.
6. Weather the case comes under the consumer protection act.

Issue No.3,4 & 6 – This is the main issue to be decided in between the parties  hence this issue is taken up first for consideration and decision their off.

                 From perusal of complainant petition filed by complainant written statement of opposite party affidavit statement of both the parties and written notes of argument of complainant. We found that following facts are admitted facts in this case-

1. That the complainant has taken health and allied insurance company Ltd. Under family health optima insurance policy plan on dated 11/01/2017,  the policy plan no P/23111/01/2017/004426 is valid from 11/01/2017 to 10/01/2018. The said policy was renewed and the same was numbered as P/231112/01/2018/004475 valid from 11/01/2018 to 10/01/2019.
2. Complainant visited Christian medical collage Vellore on November 2016 and August 2017 for the treatment of tongue but at that time it would not be identify malignancy (cancer).
3. The complainant went to Tata memorial hospital Mumbai for treatment on 2018 and court registration no-C.R/11113 DOA on 05/04/2018 DOS 06/04/2018 and DOD 10/04/2018 at Tata memorial hospital Mumbai. Division of Head and Neck Once surgery Department of surgical oncology where it was found for the treatment of Right lateral border of tongue biopsy (dynamos Carcinoma).

          From the perusal of complainant petition of complainant as well as replied by the opposite party it is an admitted position that when complainant got treatment in Tata memorial hospital his life insurance policy was in existence i.e. in continuation. The opposite party (Star health and allied insurance company Ltd.) is not denying the fact of his treatment in Tata memorial hospital and his bill showing the cost of  treatment, the only plea of insurance company for not accepting the claim of complainant is that at the time of taking health policy from 11/01/2018 to 10/01/2019,  the complainant had knowledge that he have been suffering from dynamos Carcinoma. In support of these facts the opposite party has relied upon the document related to treatment of complainant at C.M.C Vellore hospital dated 23/03/2018 which was filed by the complainant himself to the opposite parties.

From perusal of the documents (exhibit 2) I find that complainant had gone on 23/05/2018 for examination /treatment in C.M.C Vellore where some tests including biopsy was done. Further from perusal of finding given in the report it does not appeared that C.M.C Vellore has opined that complainant Manna Kumar was suffering from dynamos carcinoma.

             In view of the above fact the plea of the opposite party (star health and allied insurance company Ltd.) that at the time of renewal of policy that is second time the complainant has knowing that he has suffering from dynamos carcinoma that is tongue cancer is not sustainable. More ever at the time of doing health insurance, medical examination was done by the doctor of company itself. Nothing in this record to show that specific question regarding to any problem in this tongue/ mouth of complainant was specifically asked from him.

          A person takes health insurance policy for protecting himself against the treatment cost which may occure in future. If there is some cut or wound in the tongue of complainant at the time of taking insurance policy it cannot be said that he had knowledge of that he is suffering from dynamos carcinoma.

   In view of the fact discussed above the plea of the insurance company for not    accepting the insurance claim of the complainant is not sustainable.

   Accordingly we come to the conclusion that there is deficiency on the part of opposite party and the case of the complainant comes under the preview of Consumer protection act and further we also come to the conclusion that complainant is entitled to the relief as claimed in the complainant petition.

Accordingly we come to the conclusion that issue no 3,4 and 6 are decided in favour of complainant.

 Issue No.1,2 and 5 – At the time of deciding  issue no 3,4, and 6 we come to the conclusion that this case comes under the preview of consumer protection act and there is deficiency in service on the part of opposite party and we also come to the conclusion that complainant is entitled for relief as claimed in the complained  petition. Thus we come to the conclusion that there is valid cause of action for filing the case and the case is not barred by limitation and maintainable. Thus we come to the conclusion that these issues are also decided in favour of complainant.

          From above fact and circumstance and discussion made here in above, the consumer disputes redressal commission comes to the conclusion that opposite party is liable for his deficiency in service.

Therefore it is ordered

ORDERED

That case is decided in favour of complainant. The opposite party is directed to pay Rs. 130,000/- (One lakh thirty thousand) as medical bill and  Rs. 20,000/- (twenty thousand) for physical and mental tension and litigation. Total Rs. 1,50,000/- (One lakh fifty thousand) to the complainant within 60 days from the date of this order and if the opposite party does not give the amount within the stipulated period the opposite party shall be liable to pay interest of entire amount at the rate of 8% per annum from the date of order till final payment. In case of non compliance the complainant shall be entitled to get the order executed through the process of law.