BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 49 of 2015

Date of Institution: 15-01-2015

Date of Decision: 18-08-2015

Pritam Singh son of S.Joginder Singh, resident of VPO: Fatehgarh Shukar Chak, Tehsil & District Amritsar.

Complainant

Versus

1. Bajaj Allianz General Insurance Company Limited, Registered Office at GE Plaza, Airport Road, Yerwada, Pune through its Principal Officer.
2. Bajaj Allianz General Insurance Company Limited, Branch Office at Ranjit Avenue, Amritsar.

Opposite Parties

Complaint under Consumer Protection Act.

Present: For the Complainant: Sh.S.K.Sharma, Advocate.

              For the Opposite Parties: Sh.R.P.Singh, Advocate.

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Pritam Singh under the provisions of the Consumer Protection Act alleging therein that he purchased policy from Opposite Parties  i.e. Plan Travel Age Elite Siler for US $ 50,000 bearing policy No.OG-14-1210-9910-00000798 for the period from 30.8.2013 to 25.2.2014 and paid the premium of Rs.13,915/-. Complainant alleges that during the course of validity of the said insurance policy, the complainant had gone to Melbourne on 30.8.2013 and there he suffered heart problem on 24.10.2013 and he was admitted in Dandenong Hospital Southern Health/ Monash Heart and he was treated there for his disease and a bill of $17481.50 (17481.50x60=Rs.10,48,890/-) was issued by the hospital authorities out of which $1000 was paid by the complainant leaving the balance of $16481.50 which was still to be paid to the hospital. Accordingly, the requisite documents of the insurance policy, hospital record and bills etc, were sent to the Opposite Parties for getting the insurance claim covered by the said policy, but the Opposite Parties  illegally, arbitrarily and malafidely rejected the claim of the insurance of the complainant due to the previous physician’s statement suggesting that  the complainant’s diabetes was the cause of his admission to Monash Medical Centre with an inferior Stemi and in this respect, Dr.Madhuni Herath of Monash Medical Centre Clayton had issued a letter to the claims officer of the Opposite Party on 24.3.2014 making it clear that  it was not the actual cause of his inferior STEMI which was the reason of his admission in the hospital. As such, the Opposite Party has no right to reject the insurance claim of the complainant on flimsy grounds. Complainant further alleges that on account of rejection of the claim of the complainant, the complainant had to pay the balance amount to the hospital and since he was unable  to pay the same, as such, he requested the hospital authorities to allow him installments of the balance amount which was allowed and he was asked to pay the balance amount of $16481.50 in 24 equal installments starting from 24.6.2014 which he has been paying regularly, under the compelling circumstances because the Opposite Party had refused to pay the claim amount.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the Opposite Parties  to pay the insurance claim amount of $17481.50 (17481.50x60= Rs.10,48,890/-) alongwith interest @ 18% per annum. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties appeared and filed written version in which it was submitted that the complainant has not come to this Forum with clean hands, therefore, he is not entitled to any claim. In this case as per documents, the complainant suffered heart attack during his visit in Melbourne, Australia and was admitted to hospital. As per the medical reports and  attending physician statement, the complainant was suffering from diabetes type-2 since three years, and further  attending physician has stated that present illness/ ailment is due to pre-existing condition. It is further submitted that as per the policy Exclusion clause 2.4, the company  shall be under no liability to make payment  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 physician. As per medical reports, discharge summary and attending physician statement, the complainant was suffering from diabetes type-2 since three years and further attending physician has stated that present illness/ ailment is due to pre-existing condition. So, in view of the policy, exclusion clause, the insured is not entitled to any claim. The complainant has breached the terms and conditions of the policy, therefore he is not entitled to any claim. Therefore, the claim of the complainant was rightly repudiated vide letter dated 12.2.2014. So far as letter dated 24.3.2014 issued by alleged Dr.Madhuni Herath of Monash Medical Care Clayton is concerned that is denied being wrong and incorrect as this was obtained from non-treating doctor for getting claim and same has been obtained after repudiation of the claim. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C7 and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Sh.Surpreet Kaur Ex.OP1,2/1, affidavit of Dr.Yogesh Kankariya Ex.OP1,2/2 alongwith documents Ex.OP1,2/3 to Ex.OP1,2/8  and closed the evidence on behalf of the Opposite Parties.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got policy bearing policy No.OG-14-1210-9910-00000798 from Opposite Parties  i.e. Plan Travel Age Elite Siler for the period from 30.8.2013 to 25.2.2014 for sum assured US $50,000 on payment of premium of Rs.13,915/-. During the validity of the said insurance policy, the complainant went to Melbourne on 30.8.2013 and there he suffered heart problem on 24.10.2013 and was admitted in Dandenong Hospital Southern Health/ Monash Heart and underwent treatment for this disease. Said hospital authorities issued bill of $17481.50 (17481.50x60=Rs.10,48,890/-) out of which $1000 was paid by the complainant to the said hospital authorities leaving the balance of $16481.50 which was still to be paid to the aforesaid hospital. The claim was lodged by the complainant with Opposite Parties, but the Opposite Parties repudiated the claim of the complainant on the ground that the complainant was suffering from diabetes which was the cause of his admission to the aforesaid Monash Medical Centre. In this regard, Dr.Madhuni Herath of Monash Medical Centre Clayton had issued a letter/ certificate to the claims officer of the Opposite Party on 24.3.2014 making it clear that  it was not the actual cause of his inferior STEMI which was the reason of his admission in the hospital, but inspite of that, the Opposite Parties  have wrongly rejected the insurance claim of the complainant. The aforesaid hospital authorities allow the complainant to pay the balance amount in installments which the complainant has been paying regularly, under compelling circumstances. Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the opposite parties.
7. Whereas the case of the Opposite Parties is that the complainant suffered heart attack during his visit in Melbourne, Australia and was admitted in the hospital. As per the history of the complainant recorded by that hospital, the complainant was suffering from diabetes type-2 since three years, and the present illness/ ailment is due to pre-existing condition and as per the policy Exclusion clause 2.4, the company shall be under no liability to make payment  in respect of any claim  directly or indirectly caused by, based on, arising  out of or howsoever attributable to any of the pre existing disease including diabetes and the present illness is due to pre existing condition, so under the policy exclusion clause, the claim is not payable to the complainant. Opposite Party further submitted that as per the standard travel policy exclusion clause  the company shall be under no liability to make  payment hereunder in respect of any claim directly or indirectly caused by, based on  by, based on, arising out of or howsoever attributes of pre existing disease and further  any medical condition of complication arising from it which existed before the commencement of policy period or from which care treatment or advice was sought, recommended by or received from the physician. As per the history recorded by the attending physician, the patient was suffering from Type 2 diabetes since 3 years and the present ailment was due to pre existing ailment. As per policy exclusion, the ailment/ illness  arising out of pre-existing ailment is not covered. Therefore, the claim of the complainant was righty repudiated  vide letter dated 12.2.2014 Ex.C3. As regard letter dated 24.3.2014 Ex.C4 issued by   Dr.Madhuni Herath of Monash Medical Care Clayton, said letter  has been obtained from non treating doctor for getting claim by the complainant and that too after the  repudiation of the claim. So, the claim of the complainant has been rightly repudiated by the Opposite Parties. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Parties.
8. From the entire above discussion, we have come to the conclusion that the complainant got policy Plan Travel Age Elite Silver bearing policy No.OG-14-1210-9910-00000798 Ex.C2 from Opposite Parties  valid  for the period from 30.8.2013 to 25.2.2014 for sum assured US $50,000 on payment of premium of Rs.13,915/-. During the validity of the said insurance policy, the complainant went to Melbourne on 30.8.2013 and there he suffered heart problem on 24.10.2013 and was admitted in Dandenong Hospital Southern Health/ Monash Heart Centre,where he was medically treated and the complainant had to pay bill of $17481.50 to the said hospital authorities as per bill Ex.C5.  The complainant paid   $1000 to the said hospital authorities leaving the balance of $16481.50 which was still to be paid to the aforesaid hospital by the complainant. The claim was lodged by the complainant with Opposite Parties alongwith all the relevant documents, but the Opposite Parties  repudiated the claim of the complainant vide letter Ex.C3 on the ground that physician’s statement suggested that complainant’s diabetes was the cause of his admission/ hospitalization at Monash Medical Centre with an inferior STEMI.  Opposite Parties  produced on record the attending physician’s statement as well as discharge summary of Monash Medical Centre Ex.OP1,2/3 in which the history of the complainant was recorded as Type 2 Diabetes Mellitus  and this fact has not been disclosed by the complainant at the time of taking policy. The complainant has produced on record a certificate/ letter from the aforesaid hospital authorities i.e. Monash Medical Centre, Clayton dated 24.3.2014 Ex.C4 in which Dr.Madhuni Herath of Monash Medical Centre Clayton has categorically  stated that  although they were aware of history of complainant of Type 2 diabetes mellitus and that it is a  risk factor for heart attacks, but  it wasn’t the actual cause of his inferior STEMI which was the reason for his admission in hospital in October, 2013. So, the hospital authorities have categorically mentioned that the history of Type 2 diabetes mellitus of the complainant was not the actual   cause of his inferior STEMI which was the reason for his admission in the aforesaid hospital. Not only this, the Opposite Parties  could not produce any previous medical record of the complainant that he was aware  of the disease Type 2 diabetes or that he was taking medicine for the treatment of the same nor the Opposite Parties  could examine any medical practitioner/ doctor who has treated the complainant for diabetes nor the Opposite Parties have filed any affidavit of any doctor who has medically treated the complainant for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest @ 9%. In the present case, the Opposite Parties  have simply relied upon the history of the complainant recorded at the time of his admission in Monash Medical Center Clayton in October, 2013.
9. In view of the above discussion, we are of the opinion that the Opposite Parties  have wrongly repudiated the claim of the complainant. Consequently, we allow the complaint with costs and the Opposite Parties  are directed to pay the amount spent by the complainant on his medical treatment i.e. US $17481.50 or equivalent in Indian currency, with in one month from the date of receipt of copy of this order failing which the complainant shall be entitled to interest @ 9% per annum on this amount from the date of filing of the complaint till the payment is made to the complainant. Opposite Parties  are also directed to pay litigation expenses to the complainant  to the tune of Rs. 2000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 18-08-2015.                                  (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member