BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.163 of 2016

Date of Instt. 07.04.2016

Date of Decision: 20.05.2019

Ramesh Kumar, aged 63 years, s/o Late Sh. Roshan Lal, Surya Dye and Chemicals, Shop No.5, Near Devi Sahay Senior Secondary School, Basti Sheikh Road, Jalandhar.

..........Complainant

Versus

1. Apollo Munich Health Insurance Company Limited, Branch Office EH 198, First Floor, Satnam Complex, B. M. C. Chowk, GT Road, Jalandhar-Through its Branch Manager.

2. Apollo Munich Health Insurance Company Limited, (Claims Department) Plot No.277, Udyog Vihar, Phase II II. Gurgaoen- 122006 (Haryana).

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: Smt. Harleen Kaur, Adv Counsel for the Complainant.

Sh. V. K. Gupta, Adv Counsel for the OPs No.1 & 2.

Order

Karnail Singh (President)

1. The complainant Ramesh Kumar has filed the instant complaint, wherein alleged that he obtained Easy Travel Individual Insurance Policy for a period of sixty days effective from 27.11.2015 to 25.01.2016 for traveling abroad i.e. Australia, from OP No.1. The signatures on dotted lines on printed blank proposal form in mechanical and routine manner were taken at the time of insuring the complainant and the blank columns of printed proposal form and other related form would be filled in completed by authorized agent of OPs as per practice prevalent in insurance field. The complainant had perfect good health profile, insurability, lived without the aid of medication, active life style and was not ever hospitalized, rather participated in day to day activities of his business. He had no trace of any physical impairment and disease at that time. OP No.1 accepted risk of under Easy Travel Individual Insurance Policy. The complainant paid premium in the sum of Rs.5999/- as consideration for peril covered under insurance policy. The complainant has been insured under mediclaim health insurance policy for the last many years since 2012 by OPs.

2. That the OP No.1 did not issue/deliver policy documents except the schedule of insurance policy, though it was mandatory and obligatory upon the OPs to issue policy document, which expresses/represents a contract of insurance between the insurer and the insured. The terms and conditions, Exclusion Clauses were not communicated, explained, made known to the complainant and were not part of insurance policy. The OPs have agreed and under taken to indemnify/reimburse medical expenses for illness/sickness, accident sustained or contracted within the period of insurance risk coverage under the insurance policy to the complainant. Accordingly, the complainant has got the right of indemnification/reimbursement for all medical expenses incurred and for any loss or damages covered during the term of policy period of the complainant.

3. That the complainant proceeded to Melbourne in Australia on 27.11.2014 and returned to India on 29.01.2015. During the stay at Malbourne, the complainant had a complaint of minor problem with nose. On evaluation and clinical examination, he was treated for that minor problem suffered by the complainant. The complainant on returned to India lodged a claim for reimbursement of medical treatment expenses and medicine incurred there for total amount of 1479.17 Australian Dollar to OP. To utter surprise and dismay of the complainant, OP No.2 repudiated mediclaim, vide email dated 04.09.2015, on the pretext that the complainant known case of Hypertension, Diabetes and Obstructive Sleep Apnea (OSA). The reputation of claim is wrong, erroneous and perverse as well as unjust, arbitrary made in bad faith by misapplication of independent mind on conjectures and surmises without any valid justification whatsoever and is not sustainable in the eyes of law. The claim is not hit by such hidden clause of the policy and does not apply to the case of the complainant as OP has failed to indicate any evidence whatsoever except putting forth lame excuse and illogical plea of such alleged pre-existing disease prior to or at the time of taking Overseas Travel Insurance Policy. The OP is guilty of deficiency in rendering service negligence and unfair trade practice in unilateral, arbitrary, malafide repudiation of claim on whims and fancy and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the claim of expenses for medical treatment i.e. 1479.17 (Dollars) of Australia or equivalent to Indian rupees along with interest @ 12% per annum and further OPs be directed to pay compensation of Rs.20,000/- for causing mental tension and harassment and further OPs be directed to pay Rs.10,000/- as litigation cost.

4. Notice of the complaint was given to the OPs, who appeared through its counsel and filed joint reply, whereby contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed. It is further alleged that the complainant has not approached this Forum with clean hands. The complainant has suppressed various material facts in the present complaint. Hence, the complaint is liable to be dismissed. It is further alleged that there is no deficiency in service or negligence or unfair trade practice on the part of the answering OP which brings the present case adjudicable before this Forum. It is further averred that the complainant has concealed the material facts and further submitted that on 18.02.2015, the reimbursement claim of the complainant was received with final claimed amount USD 1012.51 or Rs.56735.68. Post reviewing the documents it was observed that complainant had taken four consultations on 10.12.2014, 14.01.2015, 20.01.2015 and 22.01.2015 overseas. He had provided invoices for the above mentioned dates and medicine bills. However, the medical record was not provided. It is submitted that medicine bills provided include the medicines for DM, HTN, IHD, anti anxiety and antibiotics. During the claim process overseas medical record is also received from Dr. Pallavi Sharma, however the previous medical history as required by the answering from the local doctor was not provided by the complainant despite the repeated requests and remainders. It is submitted that after observing these claim documents and medical records it was observed that the complainant is suffering from obstructive sleep apnea. He was evaluated and investigated and diagnosed with deviated Nasal Septum (DNS) with Turbinate Hypertrophy and Rhinitis Medicamentosa. He was managed conservatively by the treating doctor and was advised to undergo FESS Surgery. From the overseas medical records, it is evident that the complainant is known case of hypertension, diabetes and obstructive sleep Apnea and this past medical history was not disclosed by the complainant to the answering OP at the time of submitting the proposal form and as such, the claim of the complainant has been rightly repudiated. On merits, it is admitted that the complainant got insurance policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

5. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA and Supplementary affidavit of the complainant Ex.CB alongwith some documents Ex.C-1 to Ex.C-14 and closed the evidence.

6. Similarly, counsel for the OPs tendered into evidence affidavit as Ex.OPA along with some documents Ex.OP-1 to Ex.OP-7 and closed the evidence.

7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

8. As the facts has been already elaborated in detail and therefore, just to avoid repetition, we directly come to the issue in dispute i.e. whether the medical insurance claim of the complainant has been rightly or wrongly repudiated by the OPs. In order to observe these questions, we have to scan the repudiation letter, which is brought on the file by both the parties i.e. complaint as well as OP. Complainant produced the same as Ex.C-1, whereas the OP produced the said repudiation letter as Ex.OP-6 dated 04.09.2015. After going through the repudiation letter, we observed that the medical insurance claim of the complainant has been rejected by the OP on the ground of non-disclosure of material information i.e. pre-existing disease and in order to establish that there was a pre-existing disease to the complainant i.e. prior to inception of the policy i.e. 27.11.2015, the date of the commencement of the policy is very well mentioned in the Schedule - Easy Travel Individual Policy Ex.C-2, the OP has brought on the file a report of Dr. Ben Dixon, ENT Surgeon of Australia, forwarded the said report to Dr. Pallavi Sharma, wherein the history of the complainant is very well mentioned i.e. age as well as medical problem i.e. Obstructive Sleep Apnea and also reported that he is suffering from some frontal and vertex headache and he is also having a history of notable for type II diabetes and hypertension. The said report is dated 20.01.2015, whereas the insurance policy obtained by the complainant on 27.11.2015 to 25.01.2016, means prior to obtaining the policy, the complainant was suffering a problem of Sleep Apnea, type II diabetes and hypertension and also having some frontal and vertex headaches, but the said diseases were not disclosed by the complainant at the time of inception of the policy. The OP has also brought on the file copy of insurance policy Ex.OP-2 having two leaves and on the second leave, there is apparent signature of the complainant is available and above his signature there is a declaration given by the complainant in regard to his previous any ailment or getting any treatment. So, it clearly established that the complainant has concealed the pre-existing disease, if so, then the complainant is not entitled for the relief claimed and in support of this, we like to refer a pronouncement of Hon'ble Supreme Court, cited in 2009(9) JT 82, titled as “Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.”.

9. In view of the above detailed discussion, we find that the claim of the complainant has been rightly repudiated by the OP on a solid ground and thus, we do not find any substances in the argument of learned counsel for the complainant, therefore, the complaint of the complainant is dismissed with no order of cost. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.

10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Jyotsna Karnail Singh

20.05.2019 Member President