BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM VAZHUTHACAUD, THIRUVANANTHAPURAM.
PRESENT SRI. G. SIVAPRASAD : PRESIDENT SMT. R. SATHI : MEMBER SMT. LIJU B. NAIR : MEMBER C.C. No. 371/2010 Filed on 22.11.2010 Dated: 31.07.2014 Complainant: Vijayalal, S/o N. Gangadharan, Narayana Gardens, 10 Stone, Nedumangadu, Mancha P.O.th (Party in person) Opposite party: National Insurance Co., II Floor, K.K. Building, Aristo Junction, Thampanoor, Thiruvananthapuram P.B. No. 407 & Branch No. 1, Soumya Building, Puthenchanthai, M.G. Road, Thiruvananthapuram.
(By adv. Prasanna Kumar Nair) This C.C having been heard on 22.07.2014, the Forum on 31.07.2014 delivered the following: ORDER SMT. LIJU B. NAIR: MEMBER Complainant is the policy holder of the opposite party for an amount of Rs. 1,00,000/-. He paid premium amounts for 3 years, whileso on 24.06.2008 he was admitted at Medical College Hospital for chest pain. He was advised to do scan by the consulting doctor and on doing the same it was revealed that his both kidneys were weak and need transplantation. So he started treatment for the same by paying huge amounts. He got admitted at the Cosmopolitan Hospital and from 19.10.2010 onwards dialysis was started. He find it difficult to pay the bills and so he filed the insurance claim before the opposite party. But on 27.10.2010 he got the rejection letter from the opposite party stating that the disease for which he is undergoing treatment was a preexisting one. The claim of the complainant is that he came to know about the disease only on 05.07.2008 and policy was taken on 08.05.2008, two months prior to the diagnosis. So he claims that the rejection is illegal and challenging the same.
Opposite party entered appearance and filed version. They admit the policy issued to the complainant. Initially the policy started for the period from 08.05.2008 to 07.05.2009. On renewal of medical insurance policies, the policies were treated as new policy. The liabilities under the said policies if any are restricted to the terms, conditions and limitation of the respective insurance policies. It is true that the maximum sum insured under medi-claim was for Rs.
1,00,000/- only. However as per exclusion 4.1 of the terms and conditions of the policy, the company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of All diseases/injuries which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after 3 consecutive continuous claims free policy years in respect of all diseases, provided there was no hospitalization for pre-existing ailment during such three years of insurance. The claims submitted by the complainant under policy No.
570203/48/10/8500000776 is admitted and on scrutiny it is revealed that the past history of the complainant was totally inconsistent with the proposal made by him for issuing the medi-claim policy. From the pre-authorization request form issued by the treating doctor it is revealed that he had been hypertensive since two years which establishes the existence of pre-existing disease in the first year of the policy itself. At the time of making the proposal he failed to disclose the same. Insurance policies are issued under the principle of utmost good faith. There is an express question vide item No. 9 in the proposal form to give the details of existing disease/illness/injury to which the complainant has not given any answer. Moreover the outpatient record of Medical College Hospital dated 24.06.2008 narrates the history of the patient as chronic kidney disease and he was advised to review with reports and on such a review made on 05.09.2008 he was advised to undergo certain clinical examination. Though he had the knowledge of the existing conditions he suppressed the same while filling the proposal form. From the records produced by the complainant it is crystal clear that he had hypertension and other acute problems and the same has not been disclosed while taking the policy and the same amounts to fraud and cheating. So as per the terms and conditions of the policy issued to the complainant it was a pre-existing disease and the amount incurred for treatment of the same is not payable for which there is an exclusion clause appended with the policy. Further the pre-existing disease would have been covered if the complainant had renewed the policies without break from inception of the first policy for a continuous period of 3 years provided there was no hospitalization for pre-existing ailment during such 3 years of insurance. So the claim was repudiated as per letter dated 27.10.2010 issued by the opposite party to the complainant. So there is nothing illegal or unfair trade practice on the part of the opposite party in repudiating the claim and the repudiation of the claim is justifiable.
Complainant has been examined as PW1 and Exts. P1 to P5 were the documents produced by the complainant. Opposite party filed affidavit and produced documents which were marked as Exts.
D1 to D7.
Points raised for trial are:- Whether the repudiation is justifiable? Reliefs and costs? Heard both sides and perused the documents. The policies issued in favour ofPoints (i) & (ii):- the complainant is admitted by the opposite party and the copies of which are marked as Ext. D2 and D4. Complainant had initially taken a policy for himself and his family for the period from 08.05.2008 to 07.05.2009. He forgot to renew the same and on 15.05.2009 and 16.07.2010 he got the policy renewed for the period from 15.05.2009 to 14.05.2010 and 16.07.2010 to 15.07.2011 respectively. The policy taken for the risk period from 15.05.2009 to 14.05.2010 was in fact a new policy and not the renewal of the policy which expired on 07.05.2009. Likewise the policy taken for the risk period from 16.07.2010 to 15.07.2011 was also a new policy and not the renewal of policy which expired on 14.05.2010. The liabilities are restricted to the terms, conditions and limitation of the respective insurance policies. On verification of Ext. D2 clause 4.1 states that the company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of All diseases/injuries, which are pre-existing when the cover incepts for the first time. This exclusion will be deleted after three consecutive continuous claims free policy years in respect of all diseases, provided there was no hospitalization for pre-existing ailment during such three years of insurance. As per the discharge summary dated 19.10.2010 issued from the Cosmopolitan Hospital marked as Ext. D5 it is stated that complainant is having advanced renal failure. Further as per pre-authorization request form which has been marked as Ext. D6 issued by the treating doctor Dr. Been Unnikrishnan it is clearly stated that he had been hypertensive for the last two years which establishes that he had pre-existing disease in the first year of the policy itself. So it is clear that complainant had been suffering from the aforesaid ailment for a long period and even at the time of writing the proposal he had not disclosed anything of such a kind the form. It is evident from Ext. D1 that Item No. 9 is the question related to existing disease/illness/injury to which the complainant has not given any answer. On verification of Ext. P3 (a) the outpatient record issued by Medical College Hospital dated 24.06.2008 in the history column it is narrated that complainant is having chronic kidney disease. On going through Ext. P5 prescription sheet of Dr. Jacob George, Associate Professor, Department of Nephrology, Govt. Medical College, Thiruvananthapuram dated 20.06.2008 it is clearly stated that he is detected to have HTN 8 years back on evaluation for headache. Further it is stated that he is having chronic kidney disease. As per the prescription sheet of Dr. George Koshy dated 17.06.2008 marked as Ext. P4 there also stated HTN and his BP is 210/124. These documents are all produced by the complainant. So it is crystal clear that he is having illness at the time of filling the proposal form for taking the medi-claim policy. So the contention of the opposite party in repudiating the claim on the ground of pre-existing disease will sustain and the repudiation of claim is justifiable. So the complainant fails miserably to establish his case.
In the result, complaint is dismissed.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 31 day of July 2014.st Sd/- LIJU B. NAIR : MEMBER Sd/- G. SIVAPRASAD : PRESIDENT Sd/- R. SATHI : MEMBER C.C. No. 371/2010 APPENDIX I COMPLAINANTS WITNESS: PW1 - G. Vijayalal II COMPLAINANTS DOCUMENTS: P1 - Copy of medical records of dialysis unit of the complainant from Cosmopolitan Hospital Book No. I P2 - Copy of medical records of dialysis unit of the complainant from Cosmopolitan Hospital Book No. II P3(series)- Copy of outpatient records of complainant in Medical College Hospital,Tvpm.
P4 - Copy of prescription from Dr. A. George Koshy P5 - Copy of prescription from Dr. Jacob George.
III OPPOSITE PARTYS WITNESS: IV OPPOSITE PARTYS DOCUMENTS: D1 - Copy of proposal form.
D2(series)- Policy No. 570201/48/08/8500000221 of complainant with its terms & conditions.
D3 - Copy of Policy No. 578203/48/09/8500000286 of complainant with its terms & conditions.
D4 - Copy of Policy No. 570203/48/10/8500000776 of complainant.
D5 - Copy of discharge summary from Cosmopolitan Hospitals (P) Ltd.
D6(series)- Copy of pre-authorization request form and medical bills from Cosmopolitan Hospital.
D7 - Copy of rejection letter dated 27.10.2010.
Sd/- PRESIDENT [HON'BLE MR. Sri G. Sivaprasad] PRESIDENT [HON'BLE MRS. R.Sathi] MEMBER [HON'BLE MRS. Liju.B.Nair] MEMBER