1.      This consumer complaint has been filed under section 21(a)(i) of the Consumer Protection Act, 1986 (in short, the ‘Act’) against the opposite party alleging deficiency in service in the repudiation of her claim as the nominee under the travel insurance policy obtained by her late husband, Sanjay Kumar. 

2.      The complainant states that her late husband had obtained policy no. OG-17-1101-9910-00007858 Insurance Plan – Travel Elite Gold for USD 2,00,000/- for the period 05.08.2016 to 25.08.2016 from the opposite party. The insured travelled to Vietnam on 05.08.2016 and was hospitalized on 08.08.2016 in Cho Ray Hospital, District 5, Ho Chi Minh City, Vietnam where he expired on 17.08.2016. His dead body was repatriated to India with the assistance of the Indian Consulate General in Vietnam through Intercontinental Co. Ltd. to India for the last rites. A claim under the insurance policy was submitted by her to the opposite party as she was not in a position to meet the expenses for the transportation of the body.  Despite several efforts the opposite party had repudiated the claim. The complainant is before this Commission with the prayer to:

(a)    allow the complaint of the complainant under section 21(a)(i) of the Consumer Disputes Redressal Act

(b)     direct the respondent no.1 to release the insurance amount vide policy No. OG-17-1101-9910-00007858 Insurance Plan – Travel Elite Gold for a sum to the tune of USD 2,00,000.

(c)     any other relief which this Hon’ble Court may deem fit and proper also be passed in favour of the complainant

3.      The complaint was resisted by the opposite party through a written statement. It was denied that the complainant had any cause of action because the insured had pre-existing illnesses and therefore due to the exclusions under the policy the insured was not eligible for the benefits under the policy. It is contended that (i) the medical records submitted by the insured clearly indicate that he had a history of Diabetes Mellitus, heart failure, chronic kidney failure and stroke which were ailments prior to the taking of the policy and the hospitalisation of the insured was on account of complications of the pre-existing medical conditions; (ii) terms and conditions of the policy do not extend coverage for pre-existing ailments and complications as per clause 2.4 and 2.2.12; (iii) this Commission in Pankaj Parasher Vs. ICICI Prudential Life Insurance Co. Ltd. decided on 11.04.2017 has held that the repudiation of the claim was correct since the petitioner had pre-existing diabetes which had been denied in the proposal form; (iv) that the claim was for USD 2,00,000 or approximately Rs 1.34 crores which was misguided since insurance is a contract of indemnity of loss and does not entitle the claimant to seek re-imbursement of loss; and (v) the medical discharge summary refers explicitly to past ailments. Therefore, it is averred that the repudiation was correct. 

4.      Complainant filed a rejoinder and parties led their evidence on affidavit. Opposite parties 2, 3 and 4 were excluded from the array of parties. I have perused the material on record and considered the arguments advanced by the learned counsels.

5.      Learned counsel for the complainant argued as per the complaint that the deceased insured was hospitalized and eventually expired in hospital while in Vietnam and his remains had to be expatriated to India with the assistance of the Consul General of India. The coverage under the policy was for a sum of USD 2,00,000 and, therefore, this amount has been claimed, which, according to the complainant, she is entitled to. The argument of the opposite party is that the claim falls under the exclusionary clauses of the policy relating to pre-existing illnesses and, therefore, the policy does not place any obligations on it and the claim is clearly misconceived and has rightly not been accepted. 

6.      Based on the record, it is evident that the expenditure on the insured’s treatment was USD 561.85 and on the transportation of the dead body was USD 7500 i.e. a total of USD 8061.85. The opposite party has disallowed this amount on the ground that (a) the claim was for USD 2,00,000 which was the maximum amount of coverage under the policy and (b) the claim was not admissible since the hospitalization and consequent transportation of the dead body was due to pre-existing illnesses as per the medical discharge report making the policy void ab initio.  The reliance of the opposite party on Pankaj Parasher (supra) does not appear relevant to this case as the facts are distinguishable as in that case the proposal form had been found to have wrongly declared that the complainant did not suffer from Diabetes Mellitus II. In the instant case, no evidence relating to the proposal form has been brought on record. Therefore, the reliance on this Commission’s judgment is of no help to the opposite party.   

7.     However, from the material on record, it is manifest that the medical discharge report dated 01.09.2016 of the Cho Ray Hospital, Ministry of Health, Vietnam states that:

“Medical History: Diabetes type 2, Heart failure, Chronic kidney disease, Stroke”

The contention of the opposite party that the insured had pre-existing medical ailments is based on this document.

8.      The opposite party also relies on the following provisions of the policy:

Standard Travel Policy Exclusions

2.4     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 however 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.

In the light of the medical discharge report, which records the pre-existing ailments specifically, the repudiation of claim by the opposite party/insurance company on the ground that it was specifically excluded under the policy cannot be found fault with.

9.      The cause of death of the insured according to repudiation letter was:

Coma after cardio-respiratory arrest. Heart failure, ischemic cardiomyopathy. Diabetes mellitus type II. Chronic kidney disease.

The repudiation letter of the opposite party dated 01.02.2018 reads as under:

“Insured was hospitalized for the treatment of heart failure due to coma after cardio respiratory arrest. Heart failure ischemic cardiomyopathy, diabetes mellitus type II and chronic kidney disease.

Medical records received are suggestive of past medical history of diabetes mellitus, heart failure, chronic kidney failure and stroke which is pre-existing to the policy.

Current ailment in question for which treatment was given is a medically accepted complication of pre-existing medical conditions. Policy terms and conditions do not extend coverage for pre-existing ailment and its complications as per below exclusion clause.” 

In view of the above, the exclusion clauses of the policy have been rightly applied by the opposite party in the repudiation of the claim.

10.    In view of the discussion above, repudiation of the claim is found to be based on the terms and conditions of the policy. The insured was hospitalized due to pre-existing medical ailments and succumbed due to complications arising from it. The opposite party cannot be faulted for disallowing the claim since the policy terms excluded it. The complaint is found to be without merits and is accordingly disallowed. There shall be no order as to costs. All pending IAs also stand disposed of.