Chandigarh

StateCommission

A/195/2019

Reliance General Insurance Company Ltd. - Complainant(s)

Versus

Krishan Lal Gupta - Opp.Party(s)

Arun Kumar Adv.

10 Nov 2021

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

 

Appeal No.	:	195 of 2019
Date of Institution	:	04.09.2019
Date of Decision	:	10.11.2021

 

Reliance General Insurance Company Ltd., 2^nd Floor, SCO No.147-148, Madhya Marg, Sector 9-C, Chandigarh (U.T.) – 160009 through its Manager.

…..Appellant/Opposite Party.

Versus

Krishan Lal Gupta resident of House No.568, Sector 20-A, Chandigarh.

…Respondent/Complainant.

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE:   JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Arun Kumar, Advocate for the appellant.

Sh. Manav Bajaj, Advocate for the respondent.  

 

PER  RAJESH  K.  ARYA, MEMBER

                This appeal has been filed by the opposite party (appellant herein) against order dated 24.07.2019 passed by District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (now District Consumer Disputes Redressal Commission-I, U.T., Chandigarh ) (in short ‘the District Commission’), vide which, consumer complaint bearing No.367 of 2018 filed by the complainant (respondent herein) was partly allowed  in the following manner:-

“11.     In the light of above observations, we are of the concerted view that the Opposite Party is found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Party, and the same is partly allowed, qua it. The Opposite Party is directed to:-

[a]    To pay 12800 Australian Dollar and 2967 Australian Dollars (in INR as on 07.04.2018 i.e. date of discharge from the hospital), after deduction of compulsory deductible amount of 50 USD therefrom, to the Complainant on account of the expenses incurred by him;

[b]    To pay Rs.25,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[c]    To pay Rs.10,000/- as cost of litigation;

12.        The above said order shall be complied within 30 days of its receipt by the Opposite Party; thereafter, it shall be liable for an interest @12% per annum on the amount mentioned in per sub-para [a] & [b] above, apart from cost of litigation of Rs.10,000/-, from the date of institution of this complaint, till it is paid.” 

2.             The case of the respondent/complainant before the District Commission was that he along with his wife purchased a Travel Care Policy No.200421828190000140 from the Opposite Party for their travel to Australia, which was issued on 06.03.2018 and was effective from 07.03.2018 to 12.06.2018. Upon reaching Australia, the complainant got ill and visited doctors/hospitals on various occasions and was thereafter hospitalized from 29.03.2018 to 07.04.2018 for fever, myalgia, diarrhea and abdominal pain and upon clinical physical examination, evaluation, investigation at the hospital at Australia, he was diagnosed with Amoebic Liver Abscess and Colitis and was treated for the same. The total expenses/cost for the treatment of the complainant at hospital in Australia amounted to 12800 Australia Dollar i.e. Rs.6,61,059/- approx. and apart from the same 2967 Australia Dollar i.e. Rs.1,48,348/- approx. were paid by him for various doctor/hospital visits and medicines etc. pre and post treatment. He filed claim with the opposite party and also provided all the requisite documents/bills. However, the said claim was repudiated by the Opposite Party vide mail dated 03.05.2018 on frivolous and unreasonable grounds. Hence, a complaint was filed before the District Commission.

3.             On the other hand, while admitting the factual matrix of the case, the appellant pleaded that though the complainant was diagnosed of Amoebic Liver Abscess and was medically treated for the same but the overseas records revealed that he had a medical history of Ischemic Heart Disease – Cardiac Ailment and he underwent Coronary Artery Bypass Surgery in the past and also was presently on regular continuing medications particularly Tab Nebivolol & Tab Clopidogrel for the same. It was further stated that the complainant was having Atorvastatin, Thyroxine & Esomeprazole medications regularly. It was further stated that this history was not disclosed by the complainant during proposal for the insurance from the Opposite Party and had specifically declared as “no” under pre-existing illness/ injury/condition column of the policy terms, which amounted to serious non-disclosure of material facts and violation of terms and conditions of the policy. It was further stated that the claim of the complainant was rightly repudiated vide letter dated 03.05.2018. 

4.             The parties led evidence in support of their case.

5.             The District Commission after hearing the Counsel for the parties and going through the evidence on record partly allowed the complaint as stated above.

6.             The appellant/opposite party has assailed the order of the District Commission on two grounds, firstly, that the District Commission failed to consider the written statement and evidence filed by the opposite party and secondly, he did not disclose the history of Cardic Ailment, dysipidaemia, GORD & Hypothyroidism at the time of filling up the proposal form, which led to repudiation of his reimbursement claim for the treatment obtained overseas. In the written arguments filed on behalf of the appellant, it was stated that the appellant believed the version of the respondent as correct and thereafter, explained the terms and conditions, stipulations, exclusion and coverage of the travel care policy to the respondent. It was further stated that it was specifically mentioned in the terms and conditions of the policy that any pre-existing disease or complication thereof was specifically excluded in General Exclusion No.2 of the Policy. 

7.             On the other hand, in the written arguments filed on behalf of the respondent, it has been stated that the respondent had duly informed the appellant on 06.03.2018, before issuance of the policy that he had to leave for Delhi from Chandigarh on 07.03.2018 morning as he had a flight on 07.03.2018 itself from Delhi to Australia and despite the same, taking advantage of paucity of time available with the respondent, he was mislead and tricked to purchase the policy without disclosure of the hidden clauses and terms of the same. It has been further stated that even if assumed for the sake of argument but not admitted that the clauses being referred to in the policy had to be complied with by the respondent, had he been made aware of the same by the appellant at the time when the proposal was made to him, he would have either disclosed the same or/and purchased the policy from some other reputed company not indulging into such illegal and malicious activities. It has further been stated that at the time of purchase of the policy, respondent was asked to only issue the cheque for payment and no form etc. was got filled from him at all and thereby giving him an opportunity to make any kind of disclosure etc.. It has further been stated that respondent was only asked verbally by the employee of the appellant to disclose his name, age, address. It has been further stated that there had been no communication from the appellant regarding any requirement of information even after receiving the above said cheque and even before issuing the policy to the respondent who was to leave for Australia on 08.03.2018, which was in the knowledge of the appellant. It has further been stated that it is apparent from the conduct of the appellant that it has committed deficiency in providing services to the respondent and adopted unfair trade practice. It has further been stated that due to unfair practices adopted by the appellant, not only the respondent has been going through continuous mental agony and harassment but his hard earned money has also been ushered up by the appellant. It has further been stated that the appellant did not honour the claim, which is illegal and fraudulent on its part. Lastly, it has been prayed that the appeal of the appellant be dismissed.

8.             We have given our thoughtful consideration to the contentions raised by the Counsel for the parties and have also gone through the record of the case and written arguments We are of the considered view that the appeal filed by the appellant is liable to be dismissed for the reasons to be recorded hereinafter. The grounds, which the appellant has taken to lay challenge to the order passed by the District Commission, have already been taken care of vide the said order of the District Commission. No doubt, it is true that ‘Utmost good faith’ is one of the first principles of an insurance contract, which means that both the parties have to be transparent with each other and material facts have to be disclosed both before the policy is issued and after. The appellant did not give any window to the respondent to even understand and know the terms and conditions of the said travel policy, what to talk of the exclusion clauses etc. It is very commonly seen that such practice is being adopted by the Insurance Companies in order to pocket the premium from the consumers, without disclosing them the terms and conditions thereof, which are written in small prints. The respondent was not explained the terms and condition sof the policy of the travel policy by the appellant. 

9.             Not only above, the ailment, for which the respondent was treated abroad, had no nexus with the alleged pre-existing condition of his. While abroad, the respondent/complainant was diagnosed with Amoebic Liver Abscess and Colitis and he was treated for the same, which apparently has no relation with his earlier history of Ischemic Heart Disease – Cardiac Ailment. The Hon'ble National Consumer Disputes Redressal Commission, New Delhi in First Appeal No.477 of 2020 (Bajaj Allianz General Insurance Co. Ltd. v. Avtar Singh Mann), decided vide order dated 17.08.2020, upheld the decision of Punjab State Commission by dismissing the appeal filed by the Insurance Company in limine. In that case, the complainant had taken an Overseas Travel Insurance Policy, namely "TRAVELE LITESILVER", from the Insurance Company. During the validity period of that policy, the complainant visited Canada and suffered ailments and was hospitalized there. The repudiation of the claim on the grounds of pre-existing disease suffered by the complainant was held to be wrong and illegal. Thus, in our considered opinion, we endorse the view held by the District Commission that denial of the claim of the complainant on the ground of pre-existing disease is wrong, which amounted to deficiency in service. The District Commission, in the given facts and circumstances of the case, rightly partly allowed the complaint and directed the appellant/opposite party to pay the claim i.e.  12800 Australian Dollar and 2967 Australian Dollars (in INR as on 07.04.2018 i.e. date of discharge from the hospital), after deduction of compulsory deductible amount of 50 USD therefrom, to the complainant on account of the expenses incurred by him. Further, it also rightly directed the appellant/opposite party to pay compensation and litigation costs to the respondent/complainant. As such,  no case is made out to interfere with the well-reasoned order of the District Commission and the present appeal deserves to be dismissed.

10.           For the reasons recorded above, the appeal filed by the appellant/opposite party is dismissed with no order as to costs. The impugned order dated 24.07.2019 passed by District Commission-I, U.T., Chandigarh in Consumer Complaint bearing No.367 of 2018 is upheld.

11.           Certified copies of this order, be sent to the parties, free of charge.

12.           The file be consigned to Record Room, after completion.

Pronounced.

10.11.2021.

[RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

(PADMA PANDEY)

        MEMBER

 

 

(RAJESH  K. ARYA)

MEMBER

Ad