Bajaj Allianz General Insurance Company Limited V/S Dalip Singh - Consumer Court Case

Chandigarh

DF-II

CC/1040/2019

Dalip Singh - Complainant(s)

Versus

Bajaj Allianz General Insurance Company Limited - Opp.Party(s)

Gaurav Bhardwaj Adv.

18 Jun 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint No	:	1040 of 2019
Date of Institution	:	15.10.2019
Date of Decision	:	18.06.2021

Dalip Singh s/o Sh.Balwant Singh, aged 84 years, R/o H.No.318, Phase-7, SAS Nagar, Mohali.

…..Complainant

Versus

1] Bajaj Allianz General Insurance Company Limited, Finserv Building, A Wing, 2^nd Floor, Sr. No.208/B-1, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar, Pune 1411014, Maharashtra through its Managing Director/Authorised Signatory

2] Bajaj Allianz General Insurance Company Limited, SCO No.156, 157, 158 & 159, 2^nd Floor, Sector 9, Chandigarh through its Branch Manager.

3] Sh.Liakat Bajaj, Executive, Bajaj Allianz Insurance Company Limited, SCO No.156, 157, 158 & 159, 2^nd Floor, sector 9, Chandigarh.

….. Opposite Parties

BEFORE: SH.RAJAN DEWAN PRESIDENT

SMT.PRITI MALHOTRA MEMBER

SH.B.M.SHARMA MEMBER

Argued by :- Sh.Gaurav Bhardwaj, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OP

PER PRITI MALHOTRA, MEMBER

Briefly stated, the facts of the case are that the marriage of the elder grandson of the complainant was fixed at Melborune (Australia) on 25.05.2019, to be solemnized from 22.05.2019 to 25.05.2019. After receipt of the transit/visitor vista from the respective Embassies, the complainant and his son planned to visit Melbourne and Auckland for participating in the marriage ceremonies. It has been averred that before actual performance of the air journeys, he got himself travel/medically insured with OPs by paying Rs.17471/- towards premium of the insurance policy. It is also averred that the complainant attended all the marriage functions and enjoyed well with family members. It is stated that in the 3^rd week of June, 2019, the complainant started feeling shortness in breath while walking and gas problems and accordingly approached local G.P. (General Practitioner), Dr. Rajneesh Sharma, M.D. Bishop Medical Centre, East Tamaki Aucklnad on 26.06.2019 and was diagnosed as shortness of breath likely heart failure, thus was referred to New Zealand Government Middlemore Hospital, Auckland where he remained admitted upto 03.07.2019 for treatment. Later on, he was examined by Dr.Rajneesh Sharma on 06.07.2019 and was found to be fit for travelling back to India and he returned back to India on 09.07.2019 by boarding the flight from Auckland on 08.07.2019. It is stated that the doctor charged NZ$130f for his examination on two different dates i.e. 26.06.2019 and 06.07.2019 @ NZ$65 each. It is also stated that after discharge, Government Middlemore Hospital, Auckland raised the bill dated 09.07.2019 for NZ @ 10714.17 and the said amount was to be paid by the insurance company but the same was not paid. It is pleaded that after discharge from the hospital, the complainant preferred the insurance claim with the OPs on account of rescheduling of flight which resulted into additional payment of NZ$143.78 as also the expenses involving medical examination/treatment at the clinic of Dr.Rajneesh Sharma, GP and the Government Middlemore Hospital, Auckland. It is also pleaded that the OPs segregated the flight rescheduling claim and repudiated the same vide letter dated 19.07.2019 on the ground that the flight rescheduling could only be permissible on account of the limited grounds as specified in the insurance policy and not otherwise. It is averred that the complainant had got his return flight rescheduled only under the highly compelling circumstances because of his sudden illness as he did not intend to take any sort of risk by staying back in Auckland as per his original schedule which was upto first week of September, 2019 & particularly when his son who had accompanied him from Mohali to Auckland had already returned back to India. The complainant submitted the claim along with the requisite documents/forms but the same was repudiated vide letter dated 04.08.2019 (Ann.C-13) on the ground that the alleged diagnosed medical condition was pre-existing to the policy as the record reveals past medical history of congestive heart failure, hypertension, gout and gord. It is asserted that the Middlemore Hospital, Auckland has inadvertently made a mention in the discharge summary regarding past medical history and upon reference by the complainant, the hospital authorities referred the said issue to the Medical Team which examined and treated the complainant for re-investigation and resolution of the concern and after reinvestigation, they come to the conclusion that the mention of words “congestive heart failure, under sub head of ‘Past Medical History in the discharge summary was an error of documentation on their part and as such the complainant sent an email dated 28.08.2019 attaching with detailed communication dated 28.08.2019 and revised discharge summary dated 26.08.2019. Subsequently, he took up the matter with the OPs vide his email dated 29.08.2019 for reconsideration of the decision but they refused to reconsider the same. It is asserted that the OPs have wrongly and illegally repudiated the claim. Hence, this complaint has been filed alleging the said act of OPs as gross deficiency in service.

2] The OPs have filed reply and while admitting the factual matrix of the case, stated that the complainant had opted Travel Prime Holiday Silver Policy bearing No. OG-20-1149-9915-00000733 for the period from 21.05.2019 to 17.09.2019 or date of return of insured, whichever is earlier. However, liability if any, is strictly as per terms and conditions of the policy (Ann. R-2). It is pleaded that they received a request for expenses incurred for the trip curtailment by the complainant and for the expenses incurred by him on his treatment taken from the hospital at abroad namely Bishop Medical Centre and Middlemore Hospital at Auckland for Dyspnoea/Exacerbation of Heart Failure Fluid Overload and he provided the medical documents for processing the claim under the policy. It is stated that as per analysis of claim documents especially Discharge Summary issued by the Middlemore Hospital, the complainant had consulted for the treatment of Dyspnoea/ Exacerbation of Heart Failure- Fluid Overload. It is also stated that the Medical records received states past medical history of Congestive Heart Failure, Hypertension, Gout and GORD (Gastro-esophageal reflux Disease); which is pre-existing to the policy. It is further stated that the current ailment is known complication of existing medical conditions i.e. Congestive Heart Failure and Hypertension which he is having prior to the starting of the policy and the policy does not extend coverage for pre-existing ailment whether it is declared or undeclared while opting the policy, therefore, the claim of the complainant is not payable as per Section 3 of the policy and claim falls under the Standard Travel Prime Exclusion. According to the OPs, the claim has been rightly repudiated vide Repudiation letter dated 04.08.2019 (Ann.R-4). It is also pleaded that the claim of the complainant for the expenses incurred in rescheduling of his flight by paying additional charges to the Malaysian Air Lines is also not payable as per terms and conditions of the policy. It is stated that the reason for the curtailment of the trip due to illness of the complainant is also not covered under the scope of policy. Denying rest of the allegations and pleading no deficiency in service, the OPs have prayed for dismissal of the complaint.

3] Parties led evidence in support of their contentions.

4] We have heard the ld.Counsel for the parties and have gone through the entire record as well as perused the written arguments.

5] The facts relating to the complainant’s visit to Melbourne (Australia) and Auckland (New Zealand) after getting himself medically insured with OPs vide Policy Ann.C-3 effective from 21.5.2019 to 17.9.2019; treatment taken by him at Bishop Medical Centre and Middlemore Hospital at Auckland during the currency of insurance policy; curtailing/rescheduling of his return journey due to health issue; lodging of claim with OPs for reimbursement of medical expenses incurred by him during said policy period as well as claim for curtailing/rescheduling of his return journey as well as repudiation thereof by OPs, are admitted between the parties.

6] The issue in dispute which forced the complainant to file the present complaint is the repudiation of both the claims raised by the complainant i.e. for reimbursement of medical expenses incurred on his treatment overseas as well as the amount for trip curtailment charges for his earlier return journey.

7] The thorough perusal of the record reveals that the OPs had repudiated the medical reimbursement claim of the complainant in respect of the treatment taken at abroad, claiming that the complainant took the treatment for his pre-existing disease, which is not covered under the policy in question and also declined the claim for trip curtailment charges stating that the curtailment of trip due to illness of the complainant/insured is not covered under the policy terms & conditions.

8] The meticulous reading of the record reveals that the OPs while rejecting the claim of the complainant for medical reimbursement solely relied upon the Discharge Summary issued by Middlemore Hospital, Auckland wherein it has been recorded that the complainant is having past history of ‘congestive heart failure’. It surprised the complainant that in his Discharge Summary wrongly it has been mentioned that he has been suffering from ‘congestive heart failure’ and in order to get the same rectified, he duly wrote an email to the said Hospital for re-examination of his record (Ann.C-14). In response to the said email, the case of the complainant was reexamined by the said Hospital by referring it to its medical team and after reexamination, it was found that inadvertently there was wrong mentioning of ‘congestive heart failure’, whereas the complainant has no past history of the kind and it has duly been conveyed vide email dated 28.8.2019 (Ann.C-16). We prefer to reproduce the relevant contents of the said reply of the Middlemore Hospital, Auckland (Ann.C-16 Page-44) as under:-

“On the discharge summary, we documented that Mr Singh had a ‘past medical history’ of Congestive Heart Failure. After further and careful review of our clinical notes, we can confirm that this was an error in documentation as there was no prior history of cardiac disease or symptoms of this reported by the patient, and clearly not noted on the list of post medical history provided by the referrer to the hospital. We have offered further investigation with a transthoracic echocardiogram during the admission as this appeared to be the first presentation however Mr Singh would like to have these investigations performed in his home country.

Xxxxx

We have amended the discharge summary (attached) to correctly reflect the above. We sincerely apologies for the inconvenience caused.

Xxxxxx

Once again I apologies for the errors in documentation and for the distress caused for you by this. I do hope that this letter provides you with reassurance that your concerns have been listened to and that you are now able to sort out the issues with your insurance claim. Providing best care to all the patients and their families in every department is a high priority at Counties Manukau Health. If you have any further concerns, you can contact us via email at

9] From the reply as reproduced above, it is abundantly clear that complainant never suffered from the disease i.e. ‘congestive heart failure’ as alleged by the OPs. With the above said reply by the treating hospital, the amended Discharge Summary was also sent. It is evident on record that after receiving the reply (as reproduced above) as well amended Discharge Summary (Ann.C-17), the complainant forwarded the same to the OPs for reconsideration, but the OPs again vide letter dated 18.9.2019 (Ann.C-19) hook on to their earlier stand of repudiation of the claim with regard to medical reimbursement of complainant ignoring the amended Discharge Summary issued by the Treating Hospital/ Middlemore Hospital, Auckland.

10] We are of the considered view that the repudiation as conveyed by OPs vide email dated 18.9.2019, is illegal, highly unjustified and uncalled for. In the repudiation letter (Ann.C-19), the OPs again focused on the alleged previous history of ‘congestive heart failure’, ‘hypothecation etc.’; which has already been clarified by the treating hospital by issuing amended Discharge Summary (Ann.C-17). This repudiation conveyed by the OPs reflects not only the arbitrary functioning of the OPs, but also reveals the callous attitude and ineffective working of the officials of the Ops for not dealing the claim afresh taking into consideration the fresh documents so furnished by the claimant/ complainant along with suitable clarification.

Also the OPs in their turn failed to bring on record any document showing that the complainant was having any pre-existing disease, as alleged or as to the observation made by the OPs in their repudiation letters.

11] Further, the plea of the OPs that the complainant was also having past history of hypertension and as such is not entitled for claim is also not tenable.

The Hon’ble Supreme Court in the case Biman Krishna Bose Vs. United India Insurance Company, civil Appeal No.3438 of 1995, has held that that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance Company. Moreover hypertension is not a material disease which is fatal in itself.

The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Cahnder Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension is a common ailment and it can be controlled by medication – Claim was wrongly repudiated.”

The Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission, while adjudicating the matter on this substantial issue of repudiation of claim on the basis of suffering from Hypertension of insured person, has categorically ruled that Hypertension is not a material disease and is manageable by medication/meditation, change of life style etc. and as such, cannot be a ground for rejection of genuine claims.

In the same manner, the claim of the complainant for the medical reimbursement is clearly made out in the present complaint.

12] So far as the claim of complainant with regard to trip curtailment is concerned, it is revealed that the complainant got his return flight rescheduled due to his sudden illness as he did not intend to take any sort of risk by staying back in Auckland as per his original schedule which was upto Sept., 2019. In our considered opinion, the OPs wrongly rejected the trip curtailment claim of the complainant for the reasons recorded hereafter.

13] Going through the original policy documents placed on record by the complainant as Ann.C-3, it shows that the Trip Curtailment claim is also covered under it. However, the said claim of the complainant (trip curtailment claim) has been rejected by the OPs vide Ann.C-11 dated 19.7.2019 on the ground that his claim does not fall in such conditions, which are not part of the policy issued to the complainant. In our view, such a stand of the OPs has no authentic base as neither the OPs have placed on record those terms & conditions of the policy provided to the complainant nor the same have been made part of the record before us for the reasons best known to the OPs. Moreover, a very strange fact has been noticed that the original policy issued to the complainant as placed on record as Ann.C-3 mentions the date of issuance as 17.5.2019, whereas the document placed on record by the OPs as Ann.R-2 as policy document (photocopy) shows the date of issuance of policy as 28.6.2019. OPs failed to justify the repudiation of the claim regarding trip curtailment charges.

14] Taking into consideration the above discussion and findings, we are of the opinion that it is highly unjustified on the part of OPs to repudiate the genuine claims of the complainant, which act not only amounts to deficiency in service but also proves unfair trade practice resorted to by the OPs. Thus, the complainant is fully entitled for reimbursement of medical expenses incurred by him overseas as well as for trip curtailment charges, which has been incurred by him. Therefore, the present complaint stands allowed against OPs No.1 & 2 and the Opposite Parties No.1 & 2 are directed as under:-