Paramjit Kaur, complainant has filed the present complaint against The Bajaj Allianz General Insurance Company Limited (hereinafter called, the OPs) U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short, the C.P.Act.) in which she has prayed that the opposite party be directed to pay the genuine claim of Rs.2,50,000/- (3500 pounds approx.). Opposite parties be further directed to pay Rs.50,000/- on account of causing physical and mental harassment alongwith Rs.20,000/-as litigation expenses.
2. The case of the complainant in brief is that she used to travel in foreign country i.e. United Kingdom and during every visit she got herself insured from opposite parties. Previously also during her visit to U.K., she got travel policy having no.OG-16-1202-9910-00003475 for a period from 13 Nov. 2015 to 11 March, 2016. During that period no claim has been raised as no problem occurred. Afterwards again while going to U.K. She got Travel Policy having no.OG-16-1202-9910-00002920 for a period from 30 Sept. 2016 to 27 Jan. 2017 from opposite parties after paying premium. During her stay at United Kingdom, she was hospitalized at U.K. on 11 January 2017 i.e. between the periods of policy and discharged on 13 January, 2017. She got treatment of Inferior ST Elevation Myocardial Infraction. She has next pleaded that the intimation has been duly given to the Insurance Company as the policy is cashless but the opposite parties failed to make the payment and wrongly repudiated her genuine claim vide letter dated 30 March,2017. The repudiation letter is illegal. Actually, she is not the patient of hypertension alleged by the opposite parties. Even the Hypertension has no link with the disease for which she has been medically treated and the disease is not preexisting one. In the month of September 2016 she got treatment of her Eyes from Satyam Prayogshala, Inside Dr.Om Parkash Eye Institute Pvt. Ltd. The Mall Amritsar and at that time before giving treatment, she got medically examined and found totally fit. Even her ECG at that time was totally Ok. The Insurance company wrongly repudiated her claim and are not making payment to the hospital authorities. Thus, there is no deficiency in service on the part of the opposite parties. Hence this complaint.
3. On notice, the opposite parties appeared through their counsel and filed their written reply taking preliminary objections that the present complaint filed by the complainant is gross abuse of process of law and is absolutely false, frivolous and vexatious; the complainant has suppressed material facts from this Hon'ble Forum and as such the complaint is liable to be dismissed; the complainant has not approached this Forum with clean hands and as such the complaint is liable to be dismissed, the complaint is bad due to acts, deeds, conduct and acquiescence of the complainant; as per the General Conditions of the Travel Age Policy, the claim of the complainant is not tenable if ailment for which the complainant is treated is due to complication of pre existing medical condition and as such policy does not extend the coverage for pre existing ailment and its complications as per below exclusion clause:
2.4 The company shall be under no liability to make payment care under in respect of any claim directly or indirectly caused by based on, arising out of or however attribute to any of the following:
2,4,12 Any medical condition of complication arising from it which existed before the commencement of the policy period or for which care, treatment or advise was sought, recommended by or received from a physician.
The claim of the complainant falls in the exclusions of the policy as such the claim of the complainant has been repudiated vide letter dated 30.3.2017 as per the terms and conditions of the policy as complainant was at fault for concealing the material facts at the time of getting policy and thus, the complainant was informed accordingly and there is neither any negligence nor deficiency in service nor any unfair trade practice on the part of the insurance company. On merits, it was submitted that the complainant got treatment for inferior St Elevation Myocardial Infraction. The claim of the complainant has been repudiated vide letter dated 30.3.2017 on the ground of concealment of pre-existing disease and the complainant concealed the fact that she was patient of hypertension. As such the claim has been repudiated as per pre existing diseases or the complication arising out of pre existing diseases does not cover within the purview of the terms and conditions of the policy. So there is no deficiency in service on the part of the opposite parties. The letter dated 30.3.2017 is legal and valid. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1, alongwith other documents Ex.C2 to Ex.C13 and closed the evidence.
- Counsel for the opposite parties tendered into evidence affidavit of Navjeet Singh Authorized Signatory Ex.OP1 alongwith other documents Ex.OP2 to Ex.OP17 and closed the evidence.
- We analytically observe with the judicial precision and find that the OP insurers have arbitrarily repudiated (vide Ex.OP14) the complainant’s health-insurance medical-treatment claim pertaining to the applicable Travel Age Health Policy. The present dispute was caused on account of the impugned repudiation of the complainant’s insurance claim for her medical treatment in U.K. by the OP insurers pertaining to her ‘hospitalization’ for the reason that the contacted aliment had been a pre-existing one and thus fell under the exclusion clause 2.4 and 2.4 12 of the related Policy; and the same were not disclosed in the related proposal form amounting to non-disclosure of material facts that were material to disclose. The OP insurers have based their above repudiation decision solely on the complainant’s ‘Admit-Card’ OPD summary (Ex.C9-p2/ Ex.OP10-p2) mentioning the History: Past H.T. (4 years) and Right Eye CS done in the year 2007; with no other evidence of whatsoever of any pre-existing disease. Further, there has been no other documentary evidence available and/or produced on the records of the present proceedings proving the presence/knowledge/symptoms of the ‘ailments’ (prior to the date of proposal/policy) for the medical treatment of which the present claim stood preferred.
- Thus, the alleged misrepresentation/concealment/non-disclosure of material facts etc do not stand proved. In such like repudiations the o. n. p. (onus of proof) always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”. The honorable National Consumer Commission has further elaborated the legal proposition in RP # 218 of 2008 titled United India Insurance Co. Ltd., vs. Anumolu Rama Krishan as: “7… Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be ‘silent diseases’ and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear….”. Even, the OP insurer’s refusal to ‘pre-authorizations’ requests by the treating hospitals are not justified and the subsequent demands of ‘non-descript’ and ‘non-exist’ imaginary documents are all the more un-sustainable. We also find that the present claim put forth by the complainant has been kept illogically deferred awaiting ‘settlement’ for collateral but arbitrary reasons. Even, the expert professional TPA (Third Party Administrators) opinion pertaining to pre-existing disease has been neither procured nor taken as an evidence of its ‘non-disclosure/suppression’ by the insured since she may not be “herself’ aware of the disease present in its latent hibernating state. Lastly, we find that the there has been no evidence on the proceeding’s records that the ‘terms and conditions’ of the applicable policy were ever communicated to the present complainant and as such these including its exclusion clauses cannot be made applicable to the detrimental settlement of the impugned claim. Moreover, the contents of Admit Card are as per the oral statement of the insured’s accompanying attendant and desires further corroboration to attain legal force. 8. We are further strengthened in our overall above legal contention by virtue of the NCDRC rulings as made out in 2017(1) CPJ 498, 2014(3) CPJ 552 and 2012(4) CPJ 839 that have lead us to adjudicate the present complaint in the instant way.
9 In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986.
10. We, therefore, partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ as per the governing ‘terms’ of the applicable Travel Age Health Insurance Policy (to its full benefits) to the present complainant besides to pay her Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the orders till actual payment.
11. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (Jagdeep Kaur)
January 15,2018. Member
*MK*
