Order-16.
Date-06/07/2017.
Shri Kamal De, President.
This is an application u/s.12 of the C.P. Act, 1986.
Complainant’s case in short, is that complainant purchased a travel insurance policy vide policy no.0G-16-2401-9310-00012540 from the OPs for the period from 14-12-2015 to 03-01-2016 for a premium of Rs.1,989/-. The complainant on 14-12-2015 travelled from Kolkata to Singapore. The date of return journey was on 03-01-2017 from Sidney to Singapore by Flight No.SQ232 and Singapore to Kolkata by Flight No.ML488. During the validity period of travel of insurance policy, that is, on 26-12-2015 at the time of arrival from Melbourne to Gold Coast the complainant suddenly felt unwell during flight journey and immediately he was taken under treatment to Tweed Hospital with Presyncopal episode on flight where he was given some medication along with some clinical examinations for the diagnosis of syncope. Under the instructions of the doctors the complainant was immediately admitted to the hospital for observation for 24 hours for medical attention. The complainant was, however, released against medical advice on 26-12-2015. After discharge the complainant intimated the OPs regarding his treatment and the OPs vide letter dated 28-12-2015 asked the complainant for papers of treatment for processing the claim of the complainant. The complainant submitted claim form vide letter dated 11-10-2016 with all medical treatment papers. OPs, thereafter, vide their letter dated 26-02-2016 repudiated the claim with a generic remark that the policy does not extend coverage for pre-existing ailment. The complainant, thereafter, vide emails dated 06-09-2016 and 03-10-2016 represented to the OPs to reconsider the claim but in vain. The complainant submits that he is in good health and has never fallen ill and never claimed insurance coverage for medical treatment under general medical insurance for the last 10 years. The complainant has alleged deficiency in service against the OPs. It is also stated that the repudiation is unreasonable and not valid in the eye of law. The complainant has prayed for direction upon the OPs to release the claim along with other reliefs. Hence, this case.
OPs 1 and 2 have contested the case in filing written version contending, inter alia, that the case is not maintainable either in law and in fact and is liable to be dismissed. It is stated that on 26-12-2015 the complainant felt unwell during the flight journey and had been admitted to hospital for observation but as he wanted to be discharged the hospital discharged him on the same day. The complainant later on submitted the claim intimation to the OPs on 28-12-2015. OPs asked the complainant to submit all treatment related documents. On receipt of the treatment related documents. The OPs observed that the complainant was having a pre-existing ailment like hypertension, diabetes mellitus and obstructive sleep apnea and, as such, the claim does not fall under the purview of travelling insurance policy issued by the parties. The OPs repudiated the claim under Exclusion No.2.4 and 2.4.12. It is stated that there is no deficiency of service on the part of the OPs. The OPs have prayed for dismissal of the case.
Point for Decision
- Whether the OPs are deficient in rendering service to the complainant?
- Whether the OPs have repudiated the claim arbitrarily?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have perused the documents on record i.e. Xerox copy of policy certificate, photocopies of journey e-tickets, photocopy of treatment sheet of the hospital, Xerox copy of letter dated 28-12-2015, Xerox copy of forwarding letter dated 11-01-2016, Xerox copy of letter of repudiation dated 26-02-2016, Xerox copies of emails on different dates, Xerox copy of general mediclaim policy being No.51170034152500000691 in the name of the complainant under OPs and other documents on record.
We have also seen the documents filed form the side of the OPs i.e. Xerox copy of travel insurance policy, Xerox copy of treatments and conditions of trael insurance policy, Xerox copy of repudiation letter dated 26-02-2016 and other documents on record.
We find that OP has repudiated the claim on the ground of pre-existing ailment like hypertension, diabetes mellitus and obstructive sleep apnea under Exclusion Clause NO.2.4 and 2.4.12. We have gone through the Exclusion Clauses, there is nothing there about ailment like hypertension, diabetes mellitus and obstructive sleep apnea. The Exclusion Clause 2.4.12 says “Any medical condition or complication arising from it which existed before the commencement of the policy period nor for which care, treatment or advice was sought recommended by or received from a physician”. OP has failed to produce before us any treatment sheet showing that the complainant was suffering from any of such disease. Seen the treatment papers on record as filed from the side of the complainant. It appears from the complainant’s progress note that he suffered from 68yo m with presynocopal episode on flight. The patient was also discharged against the medical advice on 26-11-2015. We find that the complainant was admitted to the hospital for events of high risk as observation for 24 hours under telemetry monitoring wherein the complainant had undergone the medical attention and diagnosis and there is nothing on treatment showing that he suffered from hypertension and diabetes mellitus. Moreover, the complainant has stated that he is otherwise in good health and has never fallen ill. We also find that the complainant maintains a mediclaim policy for the last 10 years under the OPs and has never claimed insurance coverage for medical treatment under its general medical insurance policy even for the last 10 years. We think that the OPs could not file any document to establish that the complainant suffered from any pre-existing disease like hypertension, diabetes mellitus, sleep apnea. The onus to prove that the complainant was suffering from pre-existing disease. As per settled law the onus is on the OP to entertain that the complainant suffering from the pre-existing diseases as alleged. We find that the OPs have not produced any credible documentary evidence in support of this case. We know that most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because insurance company relies on their Clause 2.4 or 2.4.12 of the policy in a mala fide manner to repudiate all the claims. In that case, no claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. We are fortified by the decision as reported in Tarak Ch. Khanna vs. United India Insurance Company dated 16-08-2011 by Hon’ble National Consumer Disputes Redressal Commission (Revision Petition No.686 of 2007). We think that OPs have not been justified in repudiating the claim of the complainant. The repudiation we think is bad in law.
Consequently, the case merits success.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the OPs.
OPs are directed to release an amount of Rs.20,148-24 as against the subject Travel Insurance Policy to the complainant apart from litigation cost of Rs.10,000/- within one month from the date of this order.
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision in C.P. Act.
