Chandigarh

DF-I

CC/367/2018

Krishan Lal Gupta - Complainant(s)

Versus

Reliance General Insurance - Opp.Party(s)

Manav Bajaj

24 Jul 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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Consumer Complaint No.	:	CC/367/2018
Date of Institution	:	02/08/2018
Date of Decision	:	24/07/2019

                 

Krishan Lal Gupta, R/o H.No.568, Sector 20-A, Chandigarh.

 

…..Complainant

 

V E R S U S

 

Reliance General Insurance, 2^nd Floor, SCO 147-148, Madhya Marg, Sector 9-C, Chandigarh, U.T. India – 160009, through its Manager.

 

…… Opposite Party

QUORUM:	RATTAN SINGH THAKUR	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	DR. S.K. SARDANA	MEMBER

                               

ARGUED BY	:	Sh. Manav Bajaj, Counsel for Complainant.
	:	Sh. Yugansh Siwach, Counsel for Opposite Party.

 

PER SURJEET KAUR, MEMBER

1.         The facts, in brief, are, the Complainant along with his wife purchased a Travel Care Policy No.200421828190000140 from the Opposite Party for their travel to Australia. The policy was issued on 06.03.2018 and was effective for the period from 07.03.2018 to 12.06.2018. Upon reaching Australia, 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, Complainant was diagnosed with Amoebic Liver Abscess and Colitis and was treated for the same. The total expenses/cost for the treatment of Complainant at hospital in Australia amounted to 12800 Australia Dollar i.e. Rs.6,61,059/- approx. (Indian Currency) and apart from the same 2967 Australia Dollar i.e. Rs.1,48,348/- approx. (Indian Currency) were paid by him for various doctor/hospital visits and medicines etc. pre and post treatment. As per his entitlement, the Complainant approached the office of Op for claiming the reimbursement for the above said expenses/costs incurred by him. He had also provided all the documents/bills of his treatment, hospitalization, doctor/hospital visits, medication etc. However, vide-mail dated 03.05.2018, the claim of Complainant was repudiated by the Opposite Party on frivolous and unreasonable grounds. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Party, the complainant has filed the instant complaint.
2.         Notice of the complaint was sent to Opposite Party seeking its version of the case.
3.         Opposite Party contested the complaint and filed its written statement, inter alia, admitting the basic facts of the case. It has been pleaded that the Complainant moved to hospital on 2903.2018 for medical attention to “fever, myalgia, diarrhea, abdominal pain”. The critical physical examination, evaluation, investigation at the hospital provided him diagnosis of Amoebic Liver Abscess and thereafter he was medically treated for the same. The overseas records also reveal that Complainant had a medical history of Ischemic Heart Disease – Cardiac Ailment and Complainant underwent Coronary Artery Bypass Surgery in the past and also was presently on regular continuing medications particularly Tab Nebivolol & Tab Clopidogrel for the same. Apart from this, he was having Atorvastatin, Thyroxine & Esomeprazole medications regularly. This history of Cardic Ailment, dysipidaemia, GORD & Hypothyroidism 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. This amounts to serious non-disclosure of material facts, which is violation of terms and conditions of the policy. Hence, the claim of the Complainant was rightly repudiated vide letter dated 03.05.2018. Thus, pleading that there is no deficiency in service or unfair trade practice on its part, Opposite Party has prayed for dismissal of the complaint.
4.          The parties led evidence in support of their contentions.
5.         We have gone through the entire record and have also heard the arguments addressed by the Learned Counsel for the parties.
6.         The sole grouse of the Complainant through the present Complaint is, despite charging the premium, the Opposite Party arbitrarily and illegally repudiated his genuine claim per repudiation letter dated 03.05.2018 (Annexure C-3).
7.         Per contra, the reasons for repudiating the claim was due to non-disclosure of the pre-existing disease.
8.         As per Annexure C-3 the repudiation letter and the medical record produced on the Complaint by the Complainant himself, it is quite clear that he was having background history of Cardiac Ailment-IHD and was continuously taking medical treatment for the same which as per Opposite Party was not disclosed while taking the policy in question. However, we are not impressed with the same, as the Complainant had taken the treatment of fever, myalgia, diarrhea and abdominal pain at Australia and not any treatment with regard to the heart ailment. In other words, the disease, for which the Complainant was treated, did not have any nexus with his being heart patient, therefore, the reasoning given by the Opposite Party for repudiating the claim is altogether baseless. 
9.         It is important to note that the Complainant had to travel on 8.3.2018 and the policy in question was sold on 07.03.2018. Thus, the Opposite Party failed to get the Complainant medically examined before issuing the policy. This leads to the irresistible conclusion that the Opposite Party taking advantage of paucity of time available with the Complainant, mislead and tricked to purchase the policy in question without disclosure of the hidden clauses and terms of the same. To our mind, the Complainant is a bonafide subscriber of the health policy from Opposite Party. It is a settled principle of law that while raising objections with regard to the pre-existing disease, the Insurance Company must satisfy itself about the health status of the subscriber of such policy by getting him/her medically examined. Such views are expressed by the Hon’ble State Consumer Disputes Redressal Commission, New Delhi, in the case titled as Oriental Insurance Co. Ltd. V/s Hemant Bhandari, III (2005) CPJ 418, wherein while expressing its opinion, the Hon’ble State Commission has held that if insured is not medically examined, the insurance company cannot take advantage of its wrongs – person once insured under medi-claim, company obliged to pay actual expenses incurred by the insured. Hence, in the given situation, denial of the claim of the Complainant on the ground of pre-existing disease is wrong and the same amounts to deficiency in service.  
10.         The Complainant in the prayer clause of the Complaint has claimed 12800 Australian Dollar towards the cost of his treatment at Hospital in Australia, along with 2967 Australian Dollars paid by him for various doctors/ hospital visits and medicines etc. pre & post the treatment. The Opposite Party has contended that its liability cannot in any circumstances be more than the items/treatments covered under the policy and beyond that nothing can be claimed. However, there is not even an iota of evidence, placed on record by the Opposite Party, to show how the aforesaid amounts claimed by the Complainant in respect of the treatment taken by him are not payable. Importantly, per Ex.OP-1/1, which is copy of the Reliance Travel Care Policy, placed on record by the Opposite Party itself, there is compulsory deductible of 50 USD in the claim of the Complainant as per the terms of the Policy. In this backdrop, we are of the concerted opinion that the Complainant is certainly entitled for 12800 Australian Dollar plus 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. 
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.  
13.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

	Sd/-	Sd/-	Sd/-
24/07/2019	[Dr.S.K.Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
	Member	Member	President
“Dutt”