Strict construction of insurance policy terms and conditions, and justifiability of claim rejection based on policy exclusions.

ORDER :

T.S.P. Moosath, Judicial Member—The complainant in CC. No. 184/2015 of the Consumer Disputes Redrssal Forum, Ernakulam, in short, the District Forum has filed the appeal against the order passed by the District Forum by which the complaint was filed by him was dismissed.

2. The averments contained in the complaint are in brief as follows. The complainant had joined in a medi-claim policy with the opposite party insurer on 18.7.2011 and the policy was continuing regularly updated. As per the policy, the complainant was entitled to get back the hospital expenses up to Rs. 2,00,000. He was admitted at Medical Mission Hospital, Kolencherry on 12.9.2014 and was discharged on 14.9.2014, for treatment of sinusitis /HTN type and peripheral vertigo. He was again admitted in the same hospital and was discharged on 1.10.2014 due to disc prolapse C5 and C6. Again he had undergone treatment at Nambiaparambil Ayurveda Panchakarma Hospital, Kaliyar, Idukki and was discharged on 15.10.2014. Thereafter, on 3.11.2014, he was admitted at Amrita Institute of Medical Science, Ernakulam for further treatment and was discharged on 10.11.2014. The total medical expenses in all these hospitals came to Rs 56,885. He submitted the claim forms to the opposite party in time. But the opposite party had rejected all the claims. The complainant was not having any disease at the time of taking the policy. The opposite party could reject the claim only if the disease pre-existing within two years, was not disclosed. The petitioner took the policy on 18.7.2011. The petitioner is entitled to realize the medical bills from the opposite party. The rejection of the claim is deficiency in service.

3. The opposite parties filed version raising the following contentions. Complainant had approached the Forum with unclean hands, by suppressing material facts. The complainant was under a legal obligation to disclose all material facts correctly, honestly and truthfully to the insurer at the time of obtaining the policy. Having failed to do so the contract is rendered void. Insurance being a contract in good faith, the parties to the contract were bound to disclose the true facts. The parties are also governed by the terms and conditions of the policy. The first claim of the complainant was pertaining to the hospital treatment during 12.9.2014 to 14.9.2014 at MOSC hospital, Kolencherry. He was diagnosed of sinusitis, hypertension, Type 2 diabetes and peripheral vertigo. That claim is not admissible since the admission in the hospital was only for diagnosis. As per the terms of the policy, expenses incurred at the hospital primarily for diagnostic purposes and not followed by active treatment is not reimbursable. The second claim pertaining to the period from 29.9.2001 to 1.10.2014 in the very same hospital showed that the complainant was diagnosed of left side C5-C6 disc prolapse. That claim was rejected on the ground that there was suppression of facts in the proposal. The complainant was admitted at Medical Mission Hospital, Kolencherry on 7.12.2010 to 17.10.2010 and was diagnosed of left C5-C6 disc prolapse, and he underwent physiotherapy. The complainant had submitted incorrect information about his health status and concealed material information. Hence that claim was rejected. The third claim and fourth claim are also therefore liable to be dismissed and hence was rejected. The complaint is therefore sought to be dismissed.

4. The complainant filed affidavit and Exts.Al to A9 were marked on his side. Exts.B1 to B6 were marked on the side of the opposite party. Considering the evidence adduced by the parties and hearing both sides the District Forum has passed the impugned order dismissing the complaint. Aggrieved by the order passed by the District Forum the complainant has preferred the present appeal.

5. Heard both sides. Perused the records.

6. There is no dispute to the fact that the complainant had taken a Health Saver policy from the opposite parties and the