SMT. MOLYKUTTY MATHEW : MEMBER

 This is a complaint filed by the complainant U/S 35 of Consumer Protection Act 2019 for an order directing the opposite parties jointly and severally to pay the forfeited policy premium of Rs.84,261/- to the complainant, to pay medi-claim of Rs.11,273/- to 1^st complainant and to pay  compensation of Rs.1,00,000/- to the complainants for the deficiency of service on their part.

The case of the complainant in brief

            The 1^st complainant is the policy holder No.141600/11301/AA01152298 along with his wife Rasheeda the 2^nd complainant under the Health Wallet Insurance Scheme of the 1^st OP.  The policy period of complainant is 04/09/2019 to 03/09/2020.  The 1^st complainant has undergone for medical check up on 05/12/2019 at Meitra Hospital, Calicut which is within the policy period and he  has forwarded the details of medical check up and demanded medical claim amounting Rs.11,273/- from 3^rd OP through whom the complainant’s took the policy and paid premium amount of Rs.84,261/- by cheque drawn on Union Bank Payyannur branch and collected by 1^st OP.  But OP No.3 has rejected the claim though all the relevant documents have been submitted on 09/12/2019.  In spite of granting the medical claim amount 1^st OP has received a notice of termination of complainant’s policy No.141600/11301/ AA01152298 stated that “with reference to non disclosure letter dated 14/01/2020 the OP cancelled the complainants’ policy.  The reason stated that the suppression of material fact known case of diabetes mallrtier.  Since 2009 and hypertension since 2013.  If so the complainant could have been subjected for medical examination before the policy was issued.  But as per the terms  no test is required till 60 years of age.  The 1^st OP terminate the policy and not allowed the medical claim of Rs.11,273/- to the 1^st complainant as legally covered by the policy.  The act of OPs the complainant caused much mental agony and financial loss.  So there is deficiency of service and unfair trade practice on the part of OPs.  Hence the complaint.

            After receiving notice OP1, 2,3 and 4 appeared before the commission and filed their written version.  OP No.5 called absent and no version field.  OP No.1,2,3 and 4contended that upon receipt of the duly filled up proposal form, pre-policy medical examination and believing the information to be true and correct along with the initial premium, the OPs evaluated and processed the proposal form and issued policy and sum assured of Rs.25,00,000/-.  The OP further submits that the policy kit contain all relevant documents, ie free look period, ie., 15 days from the receipt of the policy document.  During the pendency of the policy period the complainant filed re-imbursement claim vide claim ID:1250219 for an amount of Rs.11,273/- for the hospitalization of the complainant on 05/1/2019 at Meitra Hospital.  On discharge summary it was noted that the complainant had past history of diabetes mellitus since 2009 and hypertension since 2013  ie, prior to the policy inception.  The OP is only liable as per the terms and condition of the policy.  The relevant section VII J of the policy the terms and conditions-  Non disclosure or misrepresentation- Cancelled the policy ab initio from the inception date or the renewal date or the policy may be modified by US, at our sole discretion, upon 30 day notice by sending an endorsement and the claim under such policy, if any shall be rejected repudiated forth with”.  So the complainants are not entitled to an amount of Rs.84,261/- towards forfeited  premium, Rs.11,273/- for the claim amount and an amount of Rs.1,00,000/- towards compensation.  The OP’s side there is no deficiency in service or unfair trade practice and the complaint may be dismissed.

            On the basis of the rival contentions by the pleadings the following issues were framed for consideration.

1. Whether there is any deficiency of service on the part of OPs?
2. Whether the complainant is entitled for any relief?
3. Relief and cost?      

The evidence consists of the oral testimony of Pw1 and Ext. A1 to A13 were marked.  On OP side Ext.B1 and X1 also marked.

Issue No.1

The complainant adduced evidence before the commission by submitting his chief affidavit in lieu of his chief examination to the tune of the pleadings in the complaint and denying the contentions in the version. He was cross examined as Pw1 by the OP.  The documents Ext.A1 to A13 marked on his part to substantiate his evidence. According to the complainant he is the policy holder of OP and the agent of OP promised that the OP is providing medical claim also.  But the OP rejected the medical claim and forfeited the policy also.  At the time of evidence Pw1 stated that “കന്പനിയുടെ terms and conditions മനസ്സിലാക്കിയിട്ടാണ് പോളിസി എടുത്തതെന്ന് പറഞ്ഞാല്?  വായിച്ചു നോക്കിയില്ല.സുഭാഷ് പറഞ്ഞതു പ്രകാരമാണ് പോളിസി എടുത്തത്.  In re-examination Pw1 states that Enrolment form ല് Agent പറഞ്ഞ പ്രകാരമാണ്ഒപ്പിട്ടത്.  So the complainant produced Ext.A6(series) the medical bills for Rs.11,273/- incurred for the hospital expenses.  In Ext.A1 is the insurance policy, Ext.A2 is the original health wallet policy kit contain the cashless card also. In Ext.A5 is the publication to Apollo Munich Health Insurance contains the details “ഡയബെറ്റിക് ഉള്ളവര്ക്കായി പ്രത്യക പ്ലാനുകള് 50 വയസ്സിന് ശേഷം പോളിസി എടുക്കുന്നവര്ക്കുള്ള മെഡിക്കല് പരിശോധന ചെലവ് Apollo health വഹിക്കുന്നു”. Since the OP is denied the medical expense. So there is deficiency of service on their part.

            The OP is vehemently stated that there is no deficiency of service on their part.  They relied upon Ext.B1 and Ext.X1 to substantiate their defense.  On perusal of the pleadings, documents and evidence we the commission hold that the complainant is the policy holder of Health wallet Insurance scheme.  The insurance coverage from 04/09/219 to 03/09/2020.  The complainant undergone medical check up on 05/12/2019  at Meitra hospital, Calicut which is within the policy period.  The OPs produced some Hon’ble Supreme court decisions is General Assurance society Ltd. Vs Chandmull Jain (1966 3 SCR 500) Oriental Insurance company Ltd. Vs. Cherian II (1999) CPJ 13(SC), National Insurance Co. Ltd Vs. Rameshwar Lal -Revision petition No.1751 of 2017 dated 18/09/2019 has held that “contract of Insurance is to be construed as it is written in the policy documents – once there is a specific exclusion of the policy, the same cannot be permitted under any circumstances.

So we are of the considered view that the OPs are jointly and severally liable to pay the medical bills for Rs.11,273/- to complainant.  But they failed to do so.  So we hold that there is deficiency of service and unfair trade practice on the part of all OPs.   Hence the issue No.1 found in favor of the complainant and answered accordingly.

Issue No.2 &3

            As discussed above the complainant   is the policy holder of OP’s Heath Wallet Insurance Scheme of OP No.1.  The 1^st complainant undergone for medical check up on 05/12/2019 at Meitra hospital Calicut and he incurred for Rs.11,273/- within the policy coverage period.  So we hold that the OPs are directly bound to redressal the grievance caused to 1^st complainant so the  complainant is entitled to get the medical expenses as described   is Ext.A6(series) from the OPs.  Therefore we hold that the OPs are liable to pay the medical bills for Rs.11,273/-  to the complainant along with Rs.6,000/- as compensation and Rs.2,000/- as litigation cost.  Thus the issue No.2 and 3 are also accordingly answered.

            In the result the complaint is allowed in part directing the opposite parties jointly and severally liable to pay the medical bill for Rs.11,273/- to the complainant along with            Rs. 6,000/- as compensation for mental agony of the 1^st complainant and Rs.2,000/- as litigation cost within 30 days of receipt of this order.  In default the amount of Rs.11,273/- carries 9% interest per annum from the date of order till realization.  Failing which the complainant is at liberty to execute the order as per the provisions of Consumer Protection Act 2019.

Exts.

A1- Insurance policy

A2- Original  Certificate issued to Income tax department letter dated  17/07/2019

A3-Health Wallet.

A4-Cheque –Photo copy(Rs.84,261)

A5-Publication notice

A6(series)-Medical bills(4 in numbers)

A7-Repudiation letter

A8-Policy termination notice

A9-Orginal Cancellation letter

A10-Lawyer notice

A11-Acknowledgment

A12-Postal receipt (4 in numbers)

A13-Return letter with cover.

  Sd/                                                                            Sd/                                                       Sd/

PRESIDENT                                                                   MEMBER                                                   MEMBER

Ravi Susha                                                               Molykutty Mathew                                     Sajeesh K.P

(mnp)

/Forward by order/

Assistant Registrar