COMPLAINT FILED: 29.05.2008<br /> <br /> BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT BANGALORE (URBAN)<br /> <br /> 22nd AUGUST 2008<br /> <br /> PRESENT :- SRI. A.M. BENNUR PRESIDENT<br /> SRI. SYED USMAN RAZVI MEMBER <br /> SMT. M. YASHODHAMMA MEMBER <br /> <br /> <br /> COMPLAINT NO. 1214/2008<br /> <br /> <br /> COMPLAINANT Shri. Raghunand,<br /> S/o. Shamanna,<br /> Aged 62 years,<br /> Resident of No. 320,<br /> 1st Main Road,<br /> Cambridge Layout,<br /> Ulsoor,<br /> Bangalore – 560 008.<br /> <br /> <br /> Advocate (Sumangala A. Swamy)<br /> <br /> <br /> V/s.<br /> <br /> <br /> OPPOSITE PARTIES 1. The Cholamandala M S<br /> M C General Insurance Co. Ltd.,<br /> Dave House, 2nd Floor, No.2,<br /> N S C Bose Road,<br /> Chennai – 600 001.<br /> <br /> <br /> 2. Cholamandam M S<br /> Cennal IMS Co. Ltd.,<br /> #9/1, Ulsoor Road,<br /> Bangalore – 560 092.<br /> <br /> <br /> Advocate (Ravi S. Samprathi)<br /> <br /> <br /> 3. Paramount Health Management,<br /> Elite House, 1st Floor,<br /> 54/A, Vasanji Road,<br /> Off Anderi Kurla Road,<br /> Chakala, Anderi East,<br /> Mumbai – 400 093.<br /> <br /> <br /> O R D E R<br /> <br /> This is a complaint filed U/s. 12 of the Consumer Protection Act of 1986 by the complainant to direct the Opposite Party (herein after called as O.P) to reimburse the medical bill to the tune of 28,000 US dollars and pay a compensation of Rs.50,000/- and for such other reliefs on an allegations of deficiency in service. <br /> <br /> The brief averments, as could be seen from the contents of the complaint, are as under:<br /> Complainant wanted to go to U.S.A to meet his daughter from Bangalore. Before going to U.S.A he has obtained the health insurance policy from OP on 12.10.2007 and made payment of a premium of Rs.11,723/-. OP issued the policy schedule with respect to the short term travel which includes medical expenses of 50,000 US dollars. Complainant traveled as per the schedule on 16.10.2007 to U.S.A. During his stay at U.S.A he was hale and healthy, daily going for jogging and cycling, but unfortunately he fell down due to some giddiness and become semi-conscious. On 03.11.2007 as per the advise of his daughter he went to Adventist Health Care Hospital for treatment. He was subjected to CT scanning, it was noticed that there is a blood clot and he needs surgery. He got admitted into hospital as an inpatient and a surgery was conducted on 04.11.2007, blood clot was removed he was discharged on 06.11.2007. Complainant intimated the OP to settle the medical bills, but somehow it failed to do so. Complainant incurred medical expenses of nearly 28,000 US dollars. The repeated requests and demands made by the complainant to OP, went in futile. With all that OP unfortunately repudiated the claim on the ground that the treatment taken is for pre-existing condition. The said repudiation is unjust and improper. Complainant caused the legal notice to OP, there was no response. Thus he felt the deficiency in service on the part of the OP. Under the circumstances he is advised to file this complaint and sought for the relief accordingly.<br /> <br /> 2. On admission and registration of the complaint, notices were sent to the OP’s. OP.3 was though served with a notice, remained absent, hence placed ex-parte. OP.1 and 2 on their appearance filed the version denying all the allegations made by the complainant in toto. According to OP the policy issued by them covered the risk of health during overseas travel other than pre-existing disease or ailments, which were not there prior to taking up of the policy. The insurance contract between the parties is with utmost good faith. But in this case complainant has suppressed certain material facts which are well within his knowledge. The CT scan report of the hospital revealed at large right convexity subdual hematoma-apparently had a trauma prior. Even the history noted by the concerned hospital speaks to earlier fall in a motor vehicle accident in the month of September 2007 that is prior to issuance of the insurance policy. That means to say complainant had sustained such kind of clot prior to taking up of the policy, but still he suppressed the same and went to Amercia took the treatment. Hence the repudiation made by OP is just, proper and after due application of mind. Complainant violated the terms and conditions of the policy. Hence he is not entitled for the relief claimed. The complaint is devoid of merits. Among these grounds, OP prayed for the dismissal of the complaint.<br /> <br /> 3. In order to substantiate the complaint averments, the complainant filed the affidavit evidence and produced the documents. OP has also filed the affidavit evidence and produced the documents. Then the arguments were heard.<br /> <br /> 4. In view of the above said facts, the points now that arise for our consideration in this complaint are as under:<br /> <br /> Point No. 1 :- Whether the complainant has proved <br /> the deficiency in service on the part of the OP?<br /> <br /> Point No. 2 :- If so, whether the complainant is <br /> entitled for the reliefs now claimed?<br /> <br /> Point No. 3 :- To what Order?<br /> <br /> <br /> 5. We have gone through the pleadings of the parties, both oral and documentary evidence and the arguments advanced. In view of the reasons given by us in the following paragraphs our findings on:<br /> <br /> Point No.1:- In Affirmative<br /> Point No.2:- Affirmative in part<br /> Point No.3:- As per final Order.<br /> <br /> <br /> R E A S O N S<br /> <br /> 6. At the outset it is not at dispute that the complainant has taken overseas health insurance policy from OP by paying a necessary premium on 12.10.2007. The copy of the policy schedule is produced. With regard to the medical expenses sum assured is 50,000 US dollars. It is further contended by the complainant that as per the schedule he reached U.S.A on 16.10.2007. During his stay at U.S.A he was hale and healthy, going for jogging and cycling everyday. But unfortunately one day he fall down from cycle due to some giddiness and as per the advise of his daughter he went to Adventist Health Care Hospital on 03.11.2007, wherein he was subjected to CT scanning. The said scan report revealed the presence of clot which needs the surgery. He underwent surgery on 04.11.2007, blood clot was removed he was fit for discharge and he was discharged on 06.11.2007. The documents to that effect are produced and these facts are not at dispute.<br /> <br /> 7. Now it is the grievance of the complainant though they made several requests and demands to OP to settle the said medical bills of the Adventist Health Care Hospital as contemplated and promised under the policy, they failed to do so. That is the reason why complainant got issued the legal notice. The copy of the legal notice is also produced. On insistence OP repudiated the said claim contending that there is a violation of the terms and conditions of the policy and treatment taken is to a pre-existing condition. Complainant felt that the said repudiation is unjust, improper and without due application of the mind. According to the complainant he has incurred in all 28,000 US dollar towards the said treatment. Of course his own legal notice issued to OP speaks to the hospital expenses of 18,536 US dollars and the claim made is for 18,536 US dollars only.<br /> <br /> 8. The evidence of the complainant appears to be very much natural, cogent and consistent. There is nothing to discard his sworn testimony. As against this unimpeachable evidence of the complainant, the defence set out by the OP is that they issued the policy with utmost good faith believing the oral submission made by the complainant with regard to his health condition. Admittedly this health insurance policy is covering the medical expenses in overseas short-term travel to an extent of 50,000 US dollars. OP would have been more diligent while accepting the proposal and issuing policy. It would have definitely subjected the complainant for the medical examination, who is aged more than 60 years. Why he was not subjected to medical examination is not known. So this kind of attitude of the OP amounts to deficiency in service. <br /> <br /> 9. In addition to that OP has come up with a defence that the so called blood clot must have been occurred due to the earlier fall, which has taken place in the month of September 2007. If there was the earlier fall in the month of September 2007 and if the complainant has sustained such kind of clot, we do not think that he would have kept mum without taking a treatment in a recognized hospital, that too when he gets the headache due to such kind of clots. Now the burden is on the OP to show that the complainant did take such kind of treatment from certain hospital prior to submission of a proposal.<br /> <br /> 10. Unfortunately no such documents are produced by the OP to show that complainant has taken treatment for such a blood clot in India in the month of September 2007. OP issued the policy on 12.10.2007 complainant traveled on 16.10.2007, that too to U.S.A. To get a visa to U.S.A is not a joke. Complainant must have applied for the visa well in advance or presuming for a while he had an earlier visa to travel U.S.A. OP would have produced the document to that effect, after conducting the thorough investigation because the amount involved in the claim runs into lakhs. Again no such steps are taken. The contention of the OP that the Adventist Health Care Hospital record show with regard to the earlier fall rather does not find force. A stray entry made in the hospital record will not come to their assistance. In addition to that whether the blood clot noticed by the Adventist Health Care Hospital is a recent one or an old one, if it is old how old it is is not known. Though OP says that it repudiated claim on the basis of the opinion of expert Doctors. No document produced nor the affidavit of the said Doctors is filed. <br /> <br /> 11. A man aged 60 years may slip and fall due to many more reasons. If the version of the OP is believed that complainant sustained the injury in motor vehicle accident on September 28th definitely there would have been visible injuries, there would have been a Police case. No such complaint is produced. No proof of existence of earlier external injury when complainant appeared before OP seeking for issuance policy on 12.10.2007. The allegations of OP that complainant suddenly went to U.S.A to take treatment for pre-existing ailment has no basis. It can’t be believed. So all these circumstances clearly goes to show that the defence set out by the OP appears to be defence for defence sake. Whether complainant had prior trauma prior to this so called report of CT scan dated 03.11.2007 is not known. If that were to be the fact what is the reason for such kind of trauma is not proved and established by OP. <br /> <br /> 12. Under such circumstances we find the repudiation made by the OP is unjust and improper. For no fault of the complainant, he is made to suffer both mental agony and financial loss. There is no proof that the treatment taken by the complainant is for pre-existing ailment or disease. But there is a proof of deficiency in service on the part of the OP. Under such circumstances the complainant is entitled for the relief claimed. Accordingly we answer point nos.1 and 2 and proceed to pass the following: <br /> <br /> O R D E R<br /> <br /> The complaint is allowed in part. OP.1 to 3 are jointly and severally directed to pay the medical bills to the tune of 18,536 US dollars to the Shady Grove Adventist Health Care Hospital towards the medical expenses incurred by the complainant and settle the claim accordingly and pay a compensation of Rs.10,000/- to the complainant along with a litigation cost of Rs.1,000/-. This order is to be complied within 4 weeks from the date of its communication. <br /> <br /> (Dictated to the Stenographer and typed in the computer and transcribed by him, verified and corrected, and then pronounced in the Open Court by us on this the 22nd day of August 2008.) <br /> <br /> <br /> <br /> <br /> MEMBER MEMBER PRESIDENT<br /> <br /> <br /> <br />