CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.109/2011
MRS. SHASHI BAJAJ
W/O SH. K.C. BAJAJ
29 PUSA ROAD, DELHI
…………. COMPLAINANT
Vs.
- M/S BAJAJ ALLIANZ GENERAL INSURANCE CO. LTD.
GE PLAZA, AIRPORT ROAD, YERWADA, PUNE-411006
ALSO AT:
C-31/32, CONNAUGHT PLACE, NEW DELHI
- M/S AIRWORTH TRAVEL & TOURS PVT. LTD.
506, MANISHA BUILDING,
75-76, NEHRU PLACE, NEW DELHI
…………..RESPONDENTS
Date of Order:17.08.2018
O R D E R
A.S. Yadav - President
The case of the complainant is that for her visits from New Delhi to Vancouver, Canada and Los Angeles, USA, she approached OP-2 for making arrangements for her travel which included ticketing as also overseas insurance. OP-1 is an insurance company. The complaint paid a sum of Rs.1,28,668/- to OP-2 for tickets and a sum of Rs.13,135/- towards insurance cover. During her stay in Vancouver, Canada the complainant had to be hospitalized and remained in Richmond hospital Vancouver in Canada on 24.05.2010. For her treatment in the said hospital at Vancouver, she paid a total sum of $1700. The complainant lodged a claim with OP-1, however, her claim was repudiated vide letter dated 14.10.2010 on the ground of alleged “non-disclosure of material information” and alleged ‘pre-existing condition’.
It is further stated that as desired, OP-2 was given the complete details for the purpose of medical insurance of the complainant during her stay in a foreign country. Nothing whatsoever was concealed by the complainant and the details of the information sought by OP-1 for the purpose of insurance were completely disclosed to them. It is stated that at no point of time before the departure of complainant from New Delhi either of OPs ever informed that there was any special disclosure to be made by the complainant. In fact OP-2 delayed the handing over of the policy at the very last moment on the date of departure from New Delhi. As per the policy, OPs have to supply a travel kit which contains the terms and conditions of the policy. It is stated that no travel kit was ever supplied to the complainant at any point of time.
Terming the action of OP as deficiency in service, the present complaint has been filed whereby the complainant has sought a sum of Rs.81,600/- towards the amount spent by the complainant on her treatment at the hospital and further claimed Rs.3 lakhs towards compensation and Rs.11,000/- towards litigation expenses.
OP in reply took the plea that there is no deficiency in service on the part of OP. It is stated that as per the declaration received from treating doctor, the complainant has history of hypertension, coronary artery diseases and PTCA done Hence the expenses are attributable to, arising out, traceable to and a complication of the pre-existing disease and the same are not payable under policy exclusion clause 2.4 and 2.4.12, which, inter alia, stipulates that the company shall not be liable to make payment in respect of any claim arising out of or attributable to any medical condition or complication arising from any pre-existing problem or for which care, treatment or advice was sought, recommended by or received from a physician. Bedsides the said history has not been disclosed by the complainant in the proposal form; thus preventing OP from making a clear assessment of the risk to be insured and taking decision on whether an insurance cover was to be given and if so, with relevant exclusion. Accordingly the claim was rightly repudiated on account on non-disclosure of material information and also for pre-existing condition vide letter dated 14.10.2010. It is prayed that the complaint be dismissed.
We have gone through the case file carefully.
The insurance policy is placed on record wherein it is specifically stated that the policy coverage is as per policy terms and conditions mentioned in the travel kit provided with this policy schedule. It is also stated that the policy holder may refer the same on the website as well.
It is a fact that as per the declaration received from the treating doctor, the complainant has history of hypertension, coronary artery diseases and PTCA done Hence the expenses are attributable to, arising out, traceable to and a complication of the pre-existing disease.
The repudiation letter dated 14.10.2010 is reproduced as under:-
We had received documents for the above referenced claim and have observed the following after assessment:-
- As per medical documents received, you presented to the overseas hospital with complaint of severe breathlessness, hypertension and had taken medical care accordingly. As per the declaration received from treating doctor, you have history of hypertension, coronary artery diseases and PTCA done. Hence, the expenses are attributable to arising out, traceable to and a complication of your pre existing ailment which is not payable under policy exclusion clause 2.4 and 2.4.12(copied below).
- The Company shall be under no liability to make payment hereunder in respect of any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following:
2.4.12 Any medical condition or complication arising from it which existed before the commencement of the Policy Period, or for which care, treatment or advice was sought, recommended by or received from a Physician.
- As per medical documents received, you were presented with complaint of sever breathlessness, hypertension, and had taken medical care accordingly. As per the declaration received from treating doctor, you have history of hypertension, coronary artery diseases and PTCA done. The said history has not been disclosed in proposal form preventing us from making a clear assessment of the risk to be insured and taking a decision on whether an Insurance Cover was to be given and if so, with relevant exclusions. Thus there is “Non-Disclosure of Material Information”.
In view of the above, we regret to inform you that the claim stands denied as the claim falls under “Non-Disclosure of Material Information” and also “pre-existing condition”.
It was a case of pre existing disease. There is no deficiency in service on the part of OP. OP was justified in repudiating the claim. Hence the complaint is dismissed.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(RITU GARODIA) (H.C. SURI) (A.S. YADAV)
MEMBER MEMBER PRESIDENT
