IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated this the 24th day of August, 2023
Present: Sri. Manulal. V.S, President
Smt. Bindhu.R, Member
Sri. K.M. Anto, Member
CC No. 89/2019 (Filed on 11/06/2019)
Complainant : Mary George,
Anjilivelikattil House,
Manjadi P.O Kuttapuzha village,
Thiruvalla, Pathanamthitta.
(Adv. Aansil Zachariah and
Adv. Adv. P. Rajesh)
Vs.
Opposite party : 1) Star Health and Allied Insurance Co. Ltd.
having its regd. office at New Tank Street
Valluvar Kottam High Road,
Nungumbakkam, Chennai – 600034
Rep. by its Managing Director,
2) Star Health and Allied Insurance Co. Ltd.
having its branch office at II Floor,
Puthenpurackal Complex,
M.C. Road, Kodimatha, Kottayam
Pin – 686013
Rep. by its Manager.
(For Op1 and 2, Adv. Avaneesh V.N.)
3) Chandy Abraham,
S/o. Abraham,
Vadakkeparampil House,
Near Mar Aprem Church,
Vadavathoor P.O.
Kalathipady, Kottayam
O R D E R
Sri. Manulal. V.S, President
Case of the complainant is as follows:
The complainant took medical insurance of the first opposite party from second opposite party based on the advice of the third opposite party. Date of inception of the first policy is 9/9/2014. The policy period is from 29/9 /2016 to 28 /9 /2017. The policy name is senior citizens red carpet and policy number is P/181113/01/2017/ 003603. The complainant underwent treatment for physical ailments at Matha Hospital from 18/6/ 2017 to 24//6//2017. During 2017 only complainant was diagnosed with Rheumatoid Arthritis on right knee. An amount of Rs.2,19,019/- was paid as medical fees. The complainant submitted medical records, bills to the opposite parties for reimbursement of hospital and medical expenses. Claim was repudiated by the opposite parties stating miss representation/ non-disclosure of material fact vide letter dated 16/9/ 2017. Though the complainant clarified the fact vide Letter dated 25/9 /2017 claim review committee of the opposite parties repudiated the claim without understanding the facts. It is alleged in the complaint that the repudiation of the claim was arbitrary, oppressive and malicious. The opposite parties refused to accept the policy of the complainant thereafter. Due to the act of the opposite party the complainant suffered loss, injury and mental agony. So, this complaint is filed by the complainant praying for an order to direct the opposite parties to pay Rs.2,19,019/- along with a compensation of Rs.20,000/- and rupees 10,000/- as cost of this litigation. It is further prayed to direct the opposite parties to continue the Mediclaim insurance of the complainant.
Upon Notice from this Commission, first and second opposite parties appeared before the commission and filed joint version. Despite receipt of notice the third opposite party neither care to appear before the commission nor to file version. Hence the third opposite party set ex -party.
The crux of the version is as follows:
The complainant took a Senior citizen red carpet health Insurance policy from the opposite parties for the period from 29/9/2014 to 28/ 9/ 2015 vide policy number. P/181113/01/2017/00363 for a sum insured of Rs.2 lakhs. At the time of issuing the policy, the complainant was supplied with the terms and conditions of the policy. The opposite party issued the policy to the complainant based on the proposal form submitted by him. In this case, the complainant has disclosed only Diabetes Mellitus and Hyper tension & cholesterol as pre-existing disease in the proposal form.
As per the terms and conditions of the policy benefits will not be available for pre-existing deceases until 48 months of continuous coverage have elapsed, since the inception of the first policy. In claim number CL1/2018/181113/0129505, it is submitted that the complainant was admitted on 18/6/2017 at Matha Hospital for the treatment of Rheumatoid Arthritis and chronic case of arthritis right knee and underwent total knee replacement(Rt) and after the treatment she was discharged on 24//6//2017. After received the claim documents, the opposite parties forwarded query letter dated 14/8/2017 to the complainant and requested to forward the documents regarding the present complaints and duration, or investigation for Rheumatoid Arthritis, all prescriptions and follow up records rheumatoid Arthritis and pre anaesthesia reports, OT Notes and complete in-patient case sheet records. Based on the query letter, the complainant had forwarded the present treatment details and the certificate issued by Dr. Sue Ann Zachariah Who is the assistant professor, government Medical College Kottayam. The medical certificate dated 25/8/2017 issued by Dr. Sue Ann Zachariah clearly stated that the complainant has been diagnosed to have rheumatoid Arthritis in February 2007. It is submitted in the version that medical record from Matha Hospital clearly noted that the complainant had visited the hospital in 2010. That means the complainant was first consulted in the hospital on 2010. On the basis, as a part of the claim processing, the company collected the hospital records from Matha Hospital. The op treatment records dated 23/7/ 2010 clearly reveals that the complainant was treated for pain (Rt) knee of leg and on examination the treating doctor conformed the illness as Osteo Arthritis knee. Moreover, the complainant again consulted the same Hospital on 4/8/2010 and 26/4/ 2011 and the treating doctor clearly noted that the complainant had mild Osteo Arthritis changes and advised to use medication and knee brace. Based on the available medical records it is evident that the complainant had history of Rheumatoid Arthritis and right knee arthritis for which treatment has been taken before the inception of the policy and was not revealed in the proposal form at the time of inception of the policy. As the insured has wilfully suppressed the pre-existing disease in the proposal form, which is the basis of contract at the time of taking the policy.
As per condition number 9 of the policy the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be in correct or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person Acting on his behalf. Hence the opposite party had rejected the claim and the same was communicated to the complainant. The review committee had also confirmed repudiation and the same was informed to the complainant.
As per condition no. 13 of the policy, the company may cancel the policy at any time on the grounds of non-disclosure of any material fact, or non-corporation by the insured person, by sending 30 days’ notice by registered post at the insured person’s last known address. Hence as per the condition, a notice dated 15-9-2017 was issued to the complainant and informed that the coverage in the name of his policy was cancelled. It is submitted in the version that there is no deficiency in service on the part of the opposite parties.
Evidence of this case Consists of deposition of PW1 and PW2 and exhibit A1 to A5 from the side of the complainant and deposition of DW1 to DW3 and exhibit B1 to B3 from the side of the opposite parties. Medical record from Matha hospital is marked as exhibit X1.
On evaluation of complaint, version and evidence on record we would like to consider the following points.
- Whether the complainant had succeeded to prove deficiency in service or unfair trade practice on the part of the opposite parties?
- If so, what are the reliefs
Point No.1 and 2
The specific case of the complainant is that she had availed a Senior citizens red carpet medical insurance policy from the first and second opposite parties for the period from 29-9- 2016 to 28-9-2017 for a sum assured of Rs.2 lakh. According to the complainant, she was diagnosed with Rheumatoid Arthritis on right knee and she underwent treatment for the same at Matha Hospital from 18/6/2017 to 24/6/2017. Though she had lodged a claim for the reimbursement of treatment expenses the opposite parties repudiated the same stating miss representation/ non-disclosure of material fact at the time of availing the policy.
The complaint was resisted by the opposite parties contending that the complainant had history of Rheumatoid Arthritis and Right knee arthritis for which treatment had been taken before the Inception of policy and the same was not revealed in the proposal form. It is proved by exhibit A1 that the complainant took a Senior citizen red carpet health Insurance policy from the opposite parties for the period from 29/9/2014 to 28/9/2015 vide policy number. P/181113/01/2017/00363 for a sum insured of Rs.2 lakhs. Exhibit A2 series are the medical bills issued from Matha Hospital for the treatment of the complainant. On perusal of exhibit A2, we can see that the complainant had treated there from 18/6/2017 to 24/6/2017 and spent Rs.2,19,019/- for her treatment. The claim was repudiated by the first and second opposite parties vide exhibit A3 relying on clause number 9 of terms and conditions of the policy stating that the complainant had not disclosed the history of Rheumatoid Arthritis at the time of the proposal of the policy. PW 1 who is the complainant deposed before the commission that she had treated at Matha Hospital on 23/7/2010, 4/8/2010 and 26/4/2010 for pain on leg. She had admitted during the cross examination that she had treated by doctor Sue Ann Zchariah During the year 2017. She further admitted that exhibit B1 was given by doctor Sue Ann Zchariah to her. Doctor Sue Ann Zchariah examined as PW2 deposed before the Commission that she had diagnosed rheumatoid arthritis for the complainant in around 2016 and she had issued exhibit B1 certificate. PW2 further deposed before the Commission that there is an error in exhibit B1 as the date is shown as February 2007 instead of February 2017. She further deposed that she had not treated the complainant before February 2017 and she is not aware about whether the complainant had treated anywhere else. On perusal of exhibit B1 we can see that the same was issued on 25/8/2017 vide exhibits B1 certificate that the complainant has been diagnosed to have Rheumatoid arthritis in the year 2007 and has been under the treatment of PW2 from 4/2 /2017.
Dw3 deposed before the Commission that exhibit X1 is the treatment records of the patient named Mary George bearing op number 11777/07/10. He deposed before the Commission that he had treated her for Osteo arthritis. She had consulted him in op on 4/8/2010 for review. At that time, she had the symptoms of osteoarthritis and had advice medication and knee brace. He further deposed that knee replacement surgery was performed on 19/6/2017 as the complainant is at the advance stage of osteoarthritis. During the cross examination Dw3 deposed that the complainant had consulted him at the first grade-pre osteoarthritis which is an early stage of disease. It is deposed by the DW3 that as per exhibit X1 on 4/8/2010, 26/4/2011 and 1/3/2014 the complainant had consultation at the outpatient department. On a mere reading of Exhibit B5 proposal form we can see that the complainant has not disclosed her ailment of the knee. The disease of Degenerative joint of knees at advanced stage requiring immediate replacement of both knees. Need for replacement of knees does not arise overnight. It is a long- drawn process. On evolution of above discuss evidence, we are of the opinion that the complainant had availed the insurance policy by suppressing material facts regarding her health condition. During the course of argument, the counsel for the complainant vehemently argued that X1 is not related to the complainant. But on a scrutiny of X1 and A2 bill We can see that the patient ID number in both documents as 11777-07-2010.Therefore we are not inclined to accept the argument put forward by the complainant.
As per condition number 9 of the policy the company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf. In the result, we found that the complainant failed to establish any deficiency in service on the part of the opposite parties and the complaint is liable to be dismissed. Hence the complaint is dismissed.
Pronounced in the Open Commission on this the 24th day of August, 2023
Sri. Manulal. V.S, President Sd/-
Smt. Bindhu.R, Member Sd/-
Sri. K.M. Anto, Member Sd/-
Appendix
Witness from the side of complainant
Pw1 – Mary George
Pw2- Dr. Sue Ann Zachariah
Witness from the side of opposite party
Dw1 – Padma Prabha P.
Dw2 – Prakash Thomas
Dw3- Dr. Rajesh V.
Exhibits marked from the side of complainant
A1 – Policy certificate No.P/181113/01/2017/003603 issued by 1st opposite
party
A2 – Copy of bills issued by Matha Hospital
A3 – Copy of letter dtd.16/09/17 issued by 1st opposite party to complainant
A4 – Copy of letter dtd. 25/09/17 by complainant to 1st opposite party
A5- Copy of letter dtd.12/10/17 by opposite party to complainant
Exhibits marked from the side of opposite party
B1 – Copy of certificate dtd.25/08/17 by Dr. Sue Ann Zachariah
B2 – Copy of OP treatment chart in the name of complainant by Matha Hospital
B3 – Copy of policy No.P/181113/01/2017/003603
B4- Copy of policy terms and conditions issued by opposite party
B5- Copy of proposal form
B6 – Copy of discharge summary by Matha Hospital
B7 – Copy of letter dtd.16-08-17 by opposite party
B8- Copy letter dtd.16/09/17
B9- Copy of letter dtd.12/10/17 by opposite party to complainant
B10- Copy of letter dtd.15-09-17 by opposite party to complainant
Court Ext.
X1 – OP treatment record and medical record in the name of complainant from
Matha Hospital
By Order
Sd/-
Assistant Registrar
