IMPORTANT POINTS
(1) Health Insurance Policy [Mediclaim Policy] – Repudiation based on exclusion clause which was not communicated to insured can never be pressed into service to deprive insured from claiming relief.
(2) Contract of insurance is based on principle of utmost good faith which is applicable to insured as well as Insurance Company.

JUDGMENT

Ajith Kumar D., Judicial Member—This is an appeal filed by the opposite party in C.C.No.59/2019 on the files of the District Consumer Disputes Redressal Commission, Alappuzha (the District Commission for short).

2. On 25.10.2021 the District Commission had partly allowed the complaint and directed the 1st opposite party to pay Rs.74,026/- (Rupees Seventy Four Thousand and Twenty Six only) along with 9% interest, to refund Rs.1,846/- (Rupees One Thousand Eight Hundred and Forty Six only) along with interest @9% by the 3rd opposite party, to pay Rs.15,000/- (Rupees Fifteen Thousand only) each by the 1st and 3rd opposite parties and costs Rs.3,000/- (Rupees Three Thousand only). There was also a stipulation in the order against the 3rd opposite party to pay the amount to the complainant and realise the same from the persons responsible.

3. Being aggrieved by the aforesaid order, this appeal has been filed.

4. The complaint was filed by one Sudhakara Shenoi by resorting to Section 12 of the Consumer Protection Act, 1986. The complainant had renewed his health insurance policy coverage in 2018 with the 1st opposite party through the 3rd opposite party, Canara Bank, Mullackal Branch who was the agent of the 1st opposite party. The Canara Bank had introduced a special scheme for their account holders with attractive offers of reimbursement of entire hospitalisation expenses. Accordingly, the complainant had renewed his Mediclaim policy through the 3rd opposite party. He remitted Rs.12,097/- (Rupees Twelve Thousand and Ninety Seven only) on 07.04.2018 to the Canara Bank, Alappuzha. He had also incorporated the copy of his existing policy which had a coverage up to 08.04.2018 with a view to avail the policy in continuation with the earlier coverage.

5. The complainant had received the policy schedule and collection receipt cum adjustment voucher from the 1st opposite party on 21.04.2018 by ordinary post. As per the policy, the insurance coverage commenced from 11.04.2018 to 10.04.2019 and the amount of premium charged was only Rs.10,251/- (Rupees Ten Thousand Two Hundred and Fifty One only). Since there was difference in the period of coverage and premium amount, the complainant had filed a complaint. The opposite parties had wilfully shown a wrong date of commencement of the policy by ignoring the previous policies. The 1st opposite party had unilaterally altered the period of insurance and thereby changed the status of the insurance policy without the consent of the complainant. Hence, there was deficiency in service.

6. On 20.05.2018 the complainant was admitted in the Lakshmi Hospital, Ernakulam for chest discomfort, abdominal pain and vomiting and was discharged on 30.05.2018. The illness of the complainant was diagnosed as acute cholecystitis with CBD dilation. The complainant was further referred to Medical Trust Hospital, Ernakulam on 30.05.2018 with a reference letter from where the complainant was subjected to detailed radiological examination. Though the complainant had first consulted the Medical Trust Hospital on 30.05.2018, the date was wrongly shown in the report EUS as 05.04.2018 instead of 30.05.2018.

7. On 30.05.2018 the complainant had remitted Rs.5,000/- (Rupees Five Thousand as endosonography charges. On 03.06.2018 the complainant was admitted at Medical Trust Hospital, Ernakulam for Endoscopic Retrograde Cholangio Pancreatography (ERCP) and was discharged on 05.06.2018. He had spent an amount of Rs.74,026/- (Rupees Seventy Four Thousand and Twenty Six only) for the treatment. The complainant intimated the hospitalisation to the 2nd opposite party on 31.05.2018 through a registered letter. But no reply was sent by the opposite party. Subsequently on 13.07.2018 the complainant had submitted the entire documents by registered post to the 2nd opposite party by claiming the amount. The 2nd opposite party had sought for certain other clarifications in respect of the claim of the complainant and accordingly, the