By. Smt. Beena. M, Member:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
2. Brief facts of the case are given below:
The Complainant had taken Family Health Optima Insurance Policy on 17.01.2012 from the Opposite Party. It has been alleged that the said policy was initially issued for the period from 17.01.2012 to 16.01.2013 and the Complainant had renewed the said policy from time to time every year after its expiry. The last renewed policy number was P/181324/01/2018/003020 and its duration was 17.02.2018 to 16.02.2019. Up to that date altogether the Complainant had paid more than Rs.80,000/-.
3. While so, the Complainant was suffering from breathing difficulty and urinary problems, was admitted in Dr.Thankavelu Hospital at Erode in Tamilnadu on 11.04.2018 and he was discharged from the said hospital on 14.04.2018 and thereafter again admitted on 03.05.2018 and discharged on 05.05.2018. In this regard the Complainant had incurred an expenses of Rs.73,057/-. Subsequently, the Complainant applied for the claim of Rs.73,057/-along with all the required medical documents and bills. But the Opposite Party repudiated the claim. The reason stated for repudiating the claim is that at the time of taking the policy the Complainant suppressed material facts and details of pre-existing disease. The Complainant had ‘PSORIASIS’ from 2003 onwards and in the year 2011 the Complainant underwent for ‘Coronary Angiogram’. After that the Opposite Party removed the name of the Complainant from the policy. Thereafter, several times the Complainant approached the Opposite Party and attempted to get the claim amount. However, the Opposite Party was not ready to reconsider the claim of the Complainant. This act of Opposite Party is deficiency in service and Unfair Trade Practice. Due to repudiation of the claim so many difficulties had to be faced by the Complainant. Hence the present Complaint is filed against the Opposite Parties seeking the reliefs to direct to pay the treatment charges to the tune of Rs.73,057/- along with interest at the rate of 12% from the date of 13.06.2018, and to pay Rs.1,00,000/- as compensation for mental agony and for litigation expenses, and direct to include the name of the Complainant into the policy.
4. Upon notice of this complaint, the Opposite Party appeared, and filed written version and contested the case. The Opposite Party denied the allegations regarding the deficiency in service and their liability as claimed by the Complainant. The Opposite Party averred that the Complainant firstly took a medical health policy from them on 17-01-2012 to 16-01-2013 and which had been renewed up to 16-01-2015 for a sum insured of Rs.1,50,000/-. Thereafter the Complainant converted the policy from Medi classic Health Insurance policy to Family Health Optima Insurance Policy on 11.02.2015 to 10.02.2016 and the same has been renewed up to 16.02.2019. The terms and conditions of the Policy were explained to the Complainant at the time of proposing the policy and the same was served to the Complainant along with the policy schedule. The proposal form is the basis of insurance contract, on that basis the policy is issued. In the proposal form, the Complainant has specifically declared that he was not suffering from any diseases or ailment at the time of submitting the proposal form. In the proposal form, the Complainant further declared that if after the insurance policy is effected, any particulars stated in the proposal form are found incorrect, the insurance company would incur ‘no liability’ under the policy. In claim number CLI/2019/181324/0018621, the Opposite Party received a preauthorization request form for the cashless treatment from the Abirami Kidney Care, Dr.Thangavelu Hospital, Erode which stated that the Complainant was admitted in the hospital on 11.04.2018 for CAD, Psoriasis, CKD & LRTI. The treating doctor clearly mentioned in the preauthorization request form that the Complainant had history of CAG done in 2011 and Psoriasis since 2003. Based on the above mentioned medical documents, the Opposite Party denied cashless facility. After discharge from the hospital, the Complainant submitted claim form along with discharge summary, bills and reports to the Opposite Parties. Based on the available medical records, it is evident that the Complainant has history of Psoriasis since 2003 and CAD since 2011 and was not revealed in the proposal form at the time of inception of policy. The Insured has willfully suppressed the pre-existing diseases in the proposal form, which is the basis of contract. The allegations made in the complaint are false. So, the Opposite Party prayed for dismissal of the complaint with compensatory costs.
5. On perusal of complaint, version, and documents, the Commission raised the following points for consideration:-
(1).Whether there has been any deficiency in service from the part of
the Opposite Parties?
(2).Whether the Complainant is entitled to get reimbursement of
medical claim from the Opposite Parties?
(3).Whether the Complainant is entitled to get any other relieves as
prayed for?
6.Point No. 1 to 3 :- For the sake of convenience and brevity all points are considered together.
7. The Complainant has filed evidence by way of affidavit supporting his claim and was examined as PW1 and the documents produced were marked as Ext. A1 to A5. The Opposite Party has also filed evidence in affidavit supporting its version and Mr.Balu, the Asst.Manager, Legal, M/s Star health and allied insurance company Ltd was examined as OPW1 and Ext.B1 to B9 were marked.
8. Perused the complaint and the version of the parties. It is the admitted facts that the Complainant had purchased the policy and presently renewed upto 16.02.2019, the admission of Abirami Kidney Care, Dr. Thankavelu Hospital, Erode Tamilnadu for treatment, the repudiation of the claim on the ground of non-disclosure of pre-existing disease as per policy condition. It is denied that there is deficiency in service on the part of the Opposite Parties. The Complainant alleges that he had taken a Family Health Optima Insurance policy from the Opposite Parties and he was hospitalized and underwent treatment. On submission of the bills for expenses incurred, the Opposite Party repudiated the claim on the ground of non-disclosure of pre-existing disease. The Complainant alleges that this is deficiency in service. The Opposite Party contended that, the Complainant had suppressed the material facts with regard to his health condition. The Counsel for the Opposite Party has also relied on the decisions in the case of Satwant Kaur Sandu v. New India Assurance Co. Ltd (2009) 8 SCC 316, Reliance Life Insurance Co. Ltd & Anr v. Rekhaben Nareshbhai Rathod reported in civil appeal No. 4261 of 2019, and has contended that the terms and conditions of the insurance policy have to be construed strictly as it is a contract between the parties. There cannot be any dispute on this well settled principle. The main issue to be discussed in this case is whether the Complainant had suppressed details of his illness at the time of joining the policy which has reasons to repudiate the claim. We have perused the Ext.A1, the copy of the insurance policy issued by the Opposite parties. It shows the policy purchased by the Complainant and it is not disputed. Ext.A2 is the discharge summary of the Complainant, issued by the Department of Cardiology. Ext.A3 is the Certificate issued by Dr. T. Saravanan which shows that the Complainant was having Psoriasis. Ext.A4 is the discharge summary which proves that he had been treated as an inpatient at Abirami Kidney Care in Dr. Thangavelu Hospital, erode from 11.04.2018 to 14.04.2018. Ext.A5 is also discharge summary which shows that she had been treated again on 03.05.2018. It is true that the Complainant had psoriasis and heart disease. The Opposite Party repudiated the claim stating that, this was pre-existing disease to the policy and has not been disclosed in the proposal form. As per the proposal form given by the Complainant, no pre-existing disease was declared by him. The proposal form produced by the Opposite Party before the Commission and the same is marked as Ext.B1. Ext.B2 is the terms and conditions of the Family Health Optima Insurance plan. Ext. B3 Pre- Authorization Request Form, in which the remarks made with regard to psoriasis from 2003 stands completely belied in the light of the clear recital of facts stated by Dr. Saravanan in the certificate. The case of the Opposite Parties that the Complainant did an angiogram in the year 2011 prior to the proposal and he also produced Ext.B6 to prove this statement, on perusal of this document it is seen that, Doctors History Taking Chart issued by the Abirami Kidney Care, Dr. Thangavelu Hospital Erode dated 11.04.2018, there is no seal of the hospital in the document which is only a photo copy without any authentication. Hence this document cannot be considered by us in evidence.. Ext. B7 is the Repudiation of claim. As per records the Complainant was admitted in Abirami Kidney care, Dr.Thagavelu Hospital on 11-04-2018 due to breathing difficulty & decreased urine output. This is a sudden illness. The insurer cannot reject a claim by citing an existing medical condition that was not disclosed by the insured in the proposal form at the time of issuance of the policy. Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter. The object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent. If the insured suffers a sudden sickness or aliment which is not expressly excluded under the policy, a duty is cast on the insurer to indemnify the Complainant for the expenses incurred thereunder.
9. Hence in the instant case, the repudiation of the policy by the Opposite Party is illegal and not in accordance with law. This act of the Opposite Party is deficiency in service/unfair trade practice from the part of them. Consequently the Complainant is entitled to be indemnified under the policy. In the view of the above discussion, we hold that the Complainant is entitled to get reimbursement of claim and compensation.
10. The third prayer of the Complainant has no relevance as the term of the policy is elapsed. Hence we do not consider it as a matter to be decided.
In the result, the complaint is partly allowed.
- The Opposite Parties are directed to pay the claim of Rs.73,057/- (Rupees Seventy Three Thousand and Fifty Seven Only) towards the expenses incurred to the Complainant for the treatment with interest at the rate of 6% per annum from the date of filing this complaint till realization.
- The opposite parties are directed to pay to the Complainant Rs.35,000/-(Rupees Thirty Five Thousand only) as compensation, which include the cost of litigation.
The Opposite Party shall make the compliance of the order within 30 days from the date of this order otherwise the amount will carry interest at the rate of 8% per annum.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 21st day of June 2022.
Date of Filing: 01.03.2019.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the complainant:-
PW1. T. K. Sivan. Complainant.
Witness for the Opposite Parties:-
OPW1. Balu. M. Assistant Manager.
Exhibits for the Complainant:-
A1. Family Health Optima Insurance Plan for the period of 17.02.2018
to 16.02.2019.
A2. Treatment Details issued by Department of Cardiology.
A3. Medical Certificate issued from Dr. Thangavelu Hospital. Dt:05.05.2018.
A4. Discharge Summary issued by Dr. Thangavelu Hospital.
A5. Discharge Summary issued by Dr. Thangavelu Hospital.
Dt:25.05.2018.
Exhibits for the Opposite Parties:-
B1. Proposal Form. Dt:17.01.2012.
B2. Family Health Optima Insurance Plan.
B3. Copy of Pre-authorisation Request Form. Dt:11.04.2018.
B4. Copy of Denial of Pre-Authorization for cashless Treatment.
Dt:11.04.2018.
B5. Copy of Discharge Summary from Dr. Thangavelu Hospital.
B6. Copy of Doctors History taking Chart (Nephrology).
Dt:11.04.2018.
B7. Repudiation of claim Letter. Dt:04.06.2018.
B8. Repudiation of claim Letter. Dt:13.06.2018.
B9. Letter. Dt:08.05.2018.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
ASSISTANT REGISTRAR
CDRC, WAYANAD.
