Chandigarh

DF-II

CC/194/2017

Sohan Lal - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Sh. Rajiv Goel Adv.

07 Dec 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	194/2017
Date of Institution	:	27.02.2017
Date of Decision	:	07.12.2017

 

                                       

                                               

Sohan Lal Bhandari s/o Sh.Gurdas Ram r/o H.No.3605, Sector 32-D, Chandigarh

                                ...  Complainant.

Versus

1. United India Insurance Co. Ltd., Divisional Office No.16 Vulcan Insurance Building, 6^th Floor & Veer Nariman Road, Churchgate, Mumbai-400020 through its Divisional Manager.

 

2. United India Insurance Co. Ltd., SCO No.123-124, Sector 17-B, Chandigarh-160001 through Manager.

…. Opposite Parties.

 

BEFORE:  SHRI RAJAN DEWAN, PRESIDENT

SMT.PRITI MALHOTRA, MEMBER

 

Argued by:       

Sh.Rajiv Goel, Advocate for the complainant

Sh.Satpal Dhamija, Adv. for the OPs.

 

 

PER RAJAN DEWAN, PRESIDENT

1.         Briefly stated, the complainant took an Overseas Medi Claim Policy with date of commencement as 09.05.2016 to 01.08.2016 (Annexure C-1) from the OP.   He also averred that he held the said policies in the past years also. On 09.05.2016, he travelled from India on Air India Flight to UK as per program went to Calgary, Canada on 15.06.2016. On 19.06.2016, he felt shortness of breath and uneasiness and admitted to Alberta Health Services Emergency, where the doctors prescribed different blood and Gr test and also different medication and he was discharged after 6 hours. According to the complainant, he incurred in all $1384.72 towards his treatment.  Later on he arrived in UK where he felt the same problem and so he went to cardiologist at Clementime Churchill Hospital, London where the doctor recommended ECG Cardiography and he incurred 485 UK pounds vide invoice dated 15.07.2016 (Annexure C-5).  After seeing echo reports, Prof Roxy Senior recommended blood test and CT scan. He contacted the Insurance Company Branch in Spain who replied vide e-mail dated 07.07.2016 that he has to pay the invoice at the counter and they will reimburse the invoice later but as the expenses were beyond his reach and as such he proponed the ticket to India and returned on 11.07.2016.  It has further been averred that he submitted the insurance claim dated 01.08.2016 for reimbursement of $1384.72 Canadian Dollors+UK Pounds 485+224 (change of ticket from UK to India) but the same was illegally and arbitrarily repudiated vide letter dated 18.11.2016. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainant has filed the instant complaint.
2.         In their written statement, the OPs have not denied the factual matrix of the case. It has been pleaded that on scrutiny of the documents, the Medical Penal concluded that the complainant was diagnosed for hypertension and further found that there was past history of hypertension. Accordingly after due application of mind, the OPs repudiated the claim as per General Condition No.12(c) of the terms and conditions of the Insurance Policy.  It has further been pleaded that the OPs are not liable to pay the amount for the expenses incurred on the change of the ticket from UK to India as the ailment which has been observed as pre-existing. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
3.         We have heard the arguments advanced by both the sides and gone through the documentary evidence on record.
4.         The core question, which falls for consideration, is, as to whether, the repudiation of the claim of the complainant by the Opposite Parties, is justified.
5.         Having given our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer to the question posed has to be in negative. 
6.         The Opposite Party has expressed its inability to admit the liability of the Complainant and repudiated his claim vide letter dated 18.11.2016 (Annexure C-8) on the ground that the complainant has been treated for hypertension and is having past medical  history of hypertension by taking the shelter of General Condition No.12(c) of the policy.
7.         We have given our thoughtful consideration to the above submissions, but we are not impressed with the same   because a pre-existing can only be one for which the patient had undergone some treatment or been on regular medication.  That is not so in the present case as the OPs have not come forward with any cogent evidence in the shape of any previous hospital record/prescription to show that the complainant was ever diagnosed or visited any hospital/ clinic/ doctor with the aforementioned diseases/ ailments and was on regular medication. It is also not mentioned anywhere that the complainant was suffering from the hypertension since how long.  Still further, it cannot be denied that one can suffer from a disease suddenly without any symptom(s) or he/she may not be in a position to understand the symptom(s), but that does not in any way mean that he/she was suffering from some pre-existing disease.  It seems that the insurance companies (like the opposite party), with a view to deny even the rightful insurance claims of the persons (like the complainant), are taking a customary stand that the patient/claimant was suffering from some pre-existing disease. However such a stand, sans any cogent proof of the previous disease, is totally unethical and should be shunned with heavy hands. 
8.         In Tarlok Chand Khanna Vs. United India Insurance Co. Ltd., I (2012) CPJ 84 (NC), it was held by the National Commission that as per the settled law, the onus to prove that the Insured was suffering from preexisting disease was on the Insurer, which, in the instant case, the OPs failed to discharge. Further in SBI Life Insurance Company Ltd. Vs. Smt. D. Leelavathi & Anr., I (2012) (1) CPJ 490 (NC), the National Commission held that the allegation of pre-existing disease had to be proved by medical evidence, which in the instant case was lacking. In Sushil Kumar Jain Vs. United India Insurance Co. Ltd., I (2012) CPJ 204 (NC), it was held by the National Commission that the Insurer failed to produce any credible evidence including documentary evidence, or medical record, to show that the Insured had been treated for any pre-existing diseases. Similar is the situation, in the instant case, where, the OPs failed to bring, on record, the other medical record, to corroborate their plea. Further in Birla Sun Life Insurance Co. Ltd. Vs. Charakapu Chinna Rao, I (2012) CPJ 557 (NC), it was held by the National Commission that having used specific grounds, for repudiation of claim, it was necessary for the Insurer to produce supporting evidence.
9.         In these set of circumstances, it will not be wrong for us to ignore the contentions of the OPs on the basis of which the genuine claim of the Complainant was repudiated, as there is no proof to substantiate the same. The Complainant is thus held to be entitled to the reimbursement by the OPs to the extent of expenses borne by him as per Medical Policy (Annexure C-1) and there is no legal hitch for the same.
10.         However, the complainant is not entitled to expenses incurred by him on account of preopening the air ticket to India, as claimed by him under the mediclaim insurance policy. 
11.         In the light of above observations, the present complaint deserves to succeed and the same is allowed, qua them. The OPs are directed to:-

[a]            pay the claim of $1384.72 Canadian Dollars +485 UK Pounds, in Indian rupees by taking the currency value as on 01.08.2016 (i.e. date of submission of the claim), towards the medical expenses under the policy in question to the complainant. 

[b]            pay Rs.7,500/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[c]            pay Rs.5,500/- as cost of litigation;

12.           The above said order shall be complied within 30 days of its receipt by the OPs;  thereafter, they shall be liable for an interest @9% per annum on the amounts mentioned in per sub-para [a] & [b] above, apart from cost of litigation, from the date of this order, 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.

Announced

07/12/2017

Sd/-

(RAJAN DEWAN)

PRESIDENT

 

Sd/-

(PRITI MALHOTRA)

MEMBER