Order by:
Sh.Amrinder Singh Sidhu, President.
1. The complainants have filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that the complainant has purchased the policy from the Opposite Parties for USD 50000 (United State Dollar) vide certificate No.SXI400152 date of issue: 19.06.2018 commencing dated 20.06.2018 to 05.08.2018 against the paid up premium of USD 2500/-. Further alleges that the complainant had gone to abroad on 19.06.2018. The complainant had diagnosed for left MLA stroke and remained under medical treatment William Osler Health Systems, Etobjiooke General Hospital 101 Humber College, Toronto and was admitted on 28.06.2018, where the treating doctor opined large left MCA territory infarction. No large frank haemorrhages. MRI is more sensitive to the sequelae of minor haemorrhages and in this regard the information was duly given to the Opposite Parties. Thereafter, the complainant lodged the claim of her reimbursement under the policy, but the Opposite Parties did not pay any heed to the request of the complainant despite various requests and reminders and at last repudiated the claim of the complainant without application of mind arbitrarily and illegally. As such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) To direct the Opposite Parties to pay the amount of Rs.11 lakhs on account of compensation on account of medical expenditure incurred for treatment alongwith interest @ 12% per annum from the date of payment to the hospital till its final realization and also to pay Rs.50,000/- as compensation for causing her mental tension, harassment and agony and also to grant any other relief to which this District Consumer Commission may deem fit be granted.
Hence, the present complaint.
2. On notice, Opposite Party No.1 appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the claim of the complainant is not payable as per the terms and conditions of the policy. As per the terms the company shall pay or reimburse to the insured/ insured person emergency medical assistance required on account of any disease/ illness contracted or injury sustained on contracted whilst on a trip upto the limit of sum insured as specified in the schedule of the policy and the deductible in respect of this benefit will be applicable for e ach and every claim separately & shall be of an amount as specified in the policy schedule. Moreover, the company shall not be liable to make any payment to any pre existing condition, unless the medical assistance provided abroad involves unforeseen emergency measures to save the insured/ insured person’s life. As per the verification of claim documents it reveals that the complainant was diagnosed for left MCA stroke and the complainant is known case of Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD) and the treatment taken by the complainant is related to past medical condition. As per the policy, any pre existing ailment coverage is applicable only in life threatening and lifesaving conditions, therefore any episode related past medical and its complications is covered only in life threatening and lifesaving condition, whereas in the present case, there was no record that the treatment taken by the complainant was life saving. Therefore, the present complaint is liable to be dismissed. Moreover, as per the terms and conditions of the policy, pre existing coverage in case of life threatening situation is covered upto 20% of Emergency Medical Expenses or USD 50000 whichever is less. Therefore, the liability of the answering Opposite Party is not more than 20% of the Emergency Medical Expenses. On merits, it is submitted that the answering Opposite Party received the claim intimation with regard to the treatment taken by the complainant at William Osler Health Systems, Etobjiooke General Hospital 101 Humber College, Toronto and the complainant submitted the relevant medical record in support her claim and after verification of the claim documents, it is found that the complainant as having past medical history of Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD) and was on regular medication. The treatment given to the complainant was related to the past medical condition for which she was suffering, therefore the claim of the complainant was repudiated vide letter dated 05.11.2018 as per the terms and conditions of the policy and hence there is no deficiency in service on the part of Opposite Parties.
3. Opposite Party No.2 not appeared despite due service, hence, Opposite Party No.2 was proceeded against exparte vide order dated 20.09.2019 of this District Consumer Commission.
4. In order to prove her case, the complainant tendered into evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C25.
5. On the other hand, to rebut the evidence of the complainant, Opposite Party No.1 also tendered into evidence affidavit of Sh.Rishi Kant Ex.OP1/1 and copies of documents Ex.OP1/2 to Ex.OP1/19 and closed the evidence on behalf of the Opposite Parties.
6. We have heard the ld.counsel for the parties and also gone through the documents placed on record.
7. Ld.counsel for the complainant has reiterated the averments as narrated in the complaint and contended that first of all, the written version filed on behalf of Opposite Parties has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. Further more at the time of issuance of the said policy to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. Further contended that the complainant had to go abroad, and to secure his life from medical treatment, she purchased Overseas Travel Insurance policy from the Opposite Parties for USD 50000 (United State Dollar) vide certificate No.SXI400152 date of issue: 19.06.2018 commencing dated 20.06.2018 to 05.08.2018 against the paid up premium of USD2500/-. Further contended that the complainant had gone to abroad on 19.06.2018. The complainant had diagnosed for left MLA stroke and remained under medical treatment William Osler Health Systems, Etobjiooke General Hospital 101 Humber College, Toronto and was admitted on 28.06.2018 and remained there upto 04.07.2018, where the treating doctor opined large left MCA territory infarction. No large frank haemorrhages. MRI is more sensitive to the sequelae of minor haemorrhages and in this regard the information was duly given to the Opposite Parties. Thereafter, the complainant lodged the claim of her reimbursement under the policy, but the Opposite Parties did not pay any heed to the request of the complainant despite various requests and reminders and at last repudiated the claim of the complainant without application of mind arbitrarily and illegally and there is deficiency in service on the part of the Opposite Parties.
8. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground the claim of the complainant is not payable as per the terms and conditions of the policy. As per the terms the company shall pay or reimburse to the insured/ insured person emergency medical assistance required on account of any disease/ illness contracted or injury sustained on contracted whilst on a trip upto the limit of sum insured as specified in the schedule of the policy and the deductible in respect of this benefit will be applicable for e ach and every claim separately & shall be of an amount as specified in the policy schedule. Moreover, the company shall not be liable to make any payment to any pre existing condition, unless the medical assistance provided abroad involves unforeseen emergency measures to save the insured/ insured person’s life. As per the verification of claim documents it reveals that the complainant was diagnosed for left MCA stroke and the complainant is known case of Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD) and the treatment taken by the complainant is related to past medical condition. As per the policy, any pre existing ailment coverage is applicable only in life threatening and lifesaving conditions, therefore any episode related past medical and its complications is covered only in life threatening and lifesaving condition, whereas in the present case, there was no record that the treatment taken by the complainant was life saving. Therefore, the present complaint is liable to be dismissed. Moreover, as per the terms and conditions of the policy, pre existing coverage in case of life threatening situation is covered upto 20% of Emergency Medical Expenses or USD 50000 whichever is less. Therefore, the liability of the answering Opposite Party is not more than 20% of the Emergency Medical Expenses. It is submitted that the answering Opposite Party received the claim intimation with regard to the treatment taken by the complainant at William Osler Health Systems, Etobjiooke General Hospital 101 Humber College, Toronto and the complainant submitted the relevant medical record in support her claim and after verification of the claim documents, it is found that the complainant as having past medical history of Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD) and was on regular medication. The treatment given to the complainant was related to the past medical condition for which she was suffering, therefore the claim of the complainant was repudiated vide letter dated 05.11.2018 as per the terms and conditions of the policy and hence there is no deficiency in service on the part of Opposite Parties.
9. Perusal of the contention of the ld.counsel for the complainant shows that the written version filed on behalf of Opposite Parties has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. The Opposite Party is limited Company and written version has been filed on the basis of special power of attorney given to ld.counsel for the Opposite Party. In this regard, Hon’ble Supreme Court of India in a judgment (2011)II Supreme Court Cases 524 titled as “State Bank of Travancore Vs. Kingston Computers India Pvt. Ltd.” and in para no.11 of the judgment, has held that
“the plaint was not instituted by an authorized person. On the plea that one authority letter dated 02.01.2003 was issued by Sh. R.K.Shukla in favour of Sh. A.K.Shukla. Further plaint failed to place on record its memorandum/articles to show that Sh. R.k.Shukla has been vested with the powers or had been given a general power of attorney on behalf of the Company to sign, verify and institute the suit on behalf of the Company.”
Similar proposition came before the Hon’ble Delhi High Court in “Nibro Ltd. Vs. National Insurance Co. Ltd.”, 2 (2005) 5SCC 30 that the
“bear authority is not recognized under law and ultimately, it was held that the plaint was not instituted by an authorized person. Here also appellant has not placed on record any resolution passed by any Board of Director in favour of Mr. Soonwon Kwon and that he was further authorised to delegate his power in favour of any other person. Further there is no memorandum/articles of the Company to show that Mr. Soonwon Kwon is one of the Director of the Company. In the absence of that evidence on record we cannot say that the special power of attorney given by Director Soonwon Kwon is a competent power of attorney issued in favour of Sh. Bhupinder Singh. In the absence of any resolution of the Company or any memorandum/articles of the Company to show that Sh. Soonwon Kwon is Director and that he was further authorised to issue power of attorney in favour of Sh. Bhupinder Singh.”
Recently our own Hon’ble State Commission, Punjab Chandigarh in FAO No.1235 of 2015 decided on 25.01.2017 in case titled as L.G.Electronics India Private Limited Vs. Sita Ram Chaudhary also held that the plaint instituted by an unauthorized person has no legal effect.
10. For the sake of arguments, for the time being, if the written reply filed by Opposite Party No.2 to 4 is presumed to be correct, it is not disputed that the complainant had to go abroad, and to secure his life from medical treatment, she purchased policy from the Opposite Parties for USD 50000 (United State Dollar) vide certificate No.SXI400152 date of issue: 19.06.2018 commencing dated 20.06.2018 to 05.08.2018 against the paid up premium of USD 2500/-. Further contended that the complainant had gone to abroad on 19.06.2018. The complainant had diagnosed for left MLA stroke and remained under medical treatment William Osler Health Systems, Etobjiooke General Hospital 101 Humber College, Toronto and was admitted on 28.06.2018, where the treating doctor opined large left MCA territory infarction. No large frank haemorrhages. MRI is more sensitive to the sequelae of minor haemorrhages and in this regard the information was duly given to the Opposite Parties. On the other hand, the Opposite Party though admitted that as per the verification of claim documents it reveals that the complainant was diagnosed for left MCA stroke and the complainant is known case of Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD) and the treatment taken by the complainant is related to past medical condition. As per the policy, any pre existing ailment coverage is applicable only in life threatening and lifesaving conditions, therefore any episode related past medical and its complications is covered only in life threatening and lifesaving condition, whereas in the present case, there was no record that the treatment taken by the complainant was life saving. Therefore, the present complaint is liable to be dismissed. Moreover, as per the terms and conditions of the policy, pre existing coverage in case of life threatening situation is covered upto 20% of Emergency Medical Expenses or USD 50000 whichever is less. Therefore, the liability of the answering Opposite Party is not more than 20% of the Emergency Medical Expenses. But we do not agree with the aforesaid contention of the ld.counsel for the Opposite Party.
11. The only ground for repudiation of the claim is that the complainant has concealed his ailments while obtaining the insurance policy as he was suffering from Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD). However, onus was upon the opposite party to prove whether the complainant has suffered from Hypertension, Diabetes Mellitus, Dyslipidemia, Asthma, Chronic Kidney Disease (CKD). But, however, the opposite party has not produced on record any previous medical record of the complainant that she ever took or underwent medical treatment of the aforesaid disease prior to the taking of the policy nor the opposite party has filed affidavit of any doctor/medical expert to prove that the patient was being treated by him for the aforesaid diseases prior to the taking of the policy. It has been held by the Hon'ble Punjab State Consumer Disputes Redressal Commission in case National Insurance Company Limited and Another Vs. Balwinder Singh 2012(1) CLT 34 that as regards pre-existing disease i.e. suppression of material fact, the appellants have not produced any evidence to prove that before the purchase of the policy, the insured/respondent had taken any treatment from any doctor or any hospital and the insured/respondent had the knowledge that he was suffering from the heart disease and concealed this fact from the appellants at the time of issuance of the mediclaim policy. In the absence of any reasonable evidence the insurance company was not correct in repudiating the claim under the policy. Same view has been taken by the Hon'ble National Commission in case Tarlok Chand Khanna Vs. United India Insurance Co.Ltd. 1(2012) CPJ 84 (NC). Moreover, hypertension and Diabetes Mellitus are no longer the material diseases as millions of people in this country are afflicted with these ailments. We draw support from II(2008) CPJ 213 wherein Hon'ble Mr. Justice S.N. Aggarwal and Mrs. Jasbir Kapoor member have held in an appeal titled as Life Insurance Corporation of India Vs. Sushma Sharma in para 18 of the judgement as follows:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days 9 of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
12. Moreover there was no bar on the Opposite Party to get the thorough medical check up at the time of issuance of the policy. The Opposite Party was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party firstly by repudiating the claim lodged by the complainant and secondly by cancelling the mediclaim policy of the complainant is illegal and void and against the principles of natural justice. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC) is fully attracted. It was held that
“Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This „take it or leave it‟, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
12 “It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.”
13. In similar set of circumstances, Hon’ble State Commission, Punjab Chandigarh in Consumer Complaint No.582 of 2019 (Avtar Singh Mann v. Bajaj Allianz General Insurance Co. Ltd. & Ors.) decided, vide order dated 29.10.2019, rejected the plea of the Insurance Company that the ailment, for which the complainant was admitted in the hospital in Canada, was the result of disease of Hypertension. The complaint was allowed and the opposite parties were directed to pay the insurance claim, along with interest and compensation etc. The opposite parties preferred an appeal (First Appeal No.477 of 2020) against that order before the Hon’ble National Commission, which has been dismissed in limine, vide order dated 17.08.2020. Thus, the order passed by this Commission in the above noted case has been affirmed by the Hon’ble National Commission.
14. Moreover, even non-disclosing of insured being a patient of Hypertension/diabetes did not amount to suppression of material facts they being a lifestyle diseases, so as to entitle the insurer to repudiate the claim, as held by our own High Court in case “Veena Sharma v. Life Insurance Corporation of India” 1999 (1) R.C.R. (Civil) 646.
15. Furthermore, in these days, Hypertension is considered as normal wear and tear. Hon’ble Delhi State Consumer Disputes Redressal Commission, New Delhi in case Life Insurance Corporation of India v. Sudha Jain 2007(2) CLT 423 has drawn conclusions in para 9 of the order and the relevant clause is 9(iii), which is reproduced as under:-
“9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.”
16. Further in Civil Writ Petition No.20040 of 2008 decided on 17.12.2008 (Max New York Life Ins. Co. Ltd. v. Insurance Ombudsman, Chandigarh & Anr.), our own High Court held that Hypertension is a disease, which could escape attention of a person and is required to be diagnosed by experts. Hon’ble Supreme Court in case P. Vankat Naidu Vs. Life Insurance Corporation of India & Anr. IV (2011) CPJ 6 (SC) 6 held in Paras No.6 and 7 as follows:
“6. We have heard learned counsel for the parties and carefully perused the record. In our view, the finding recorded by the District Forum and the State Commission that the respondents had failed to prove that the deceased has suppressed information relating to his illness was based on correct appreciation of the oral and documentary evidence produced by the parties and the National Commission committed serious illegality by upsetting the said findings on a wholly unfounded assumption that the deceased has suppressed information relating to hospitalization and treatment.
7. Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment. Therefore, the National Commission was not justified in interfering with the concurrent finding recorded by the District Forum and the State Commission by making a wild guesswork that the deceased had suppressed the facts relating to his illness.”
- It also needs to be mentioned that when the policy is issued to the insured, prior investigations regarding health of the insured are duly done by the Insurance Company. If the complainant was suffering from hypertension or any other diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant. Hon’ble National Commission in Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd. I (2016) CPJ 613 (NC) held that hypertension is common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. In paras No.8 to 10 it was held as follows:
“8. Learned Counsel for the respondent has contended that as per the terms and conditions of the insurance contract, the Insurance Company was not required to reimburse the petitioner complainant for expenses incurred by him on pre- existing disease. Learned Counsel has argued that from the medical report of the petitioner, it is clear that the petitioner was suffering from hypertension prior to the purchase of the insurance policy and since hypertension has a direct nexus with heart ailment, the respondent Insurance Company was justified in repudiating the insurance claim in view of the exclusion clause which excluded the expenses incurred on pre-existing disease.
- We do not find merit in the above contention. On perusal of the copy of the medical report of the petitioner dated 4.6.2010 issued by Dr. David P. Lipkin as also the letter of
the doctor dated 7.6.2010 addressed to Dr. M. Fertleman of Wellington Hospital would show that as per the observations of Dr. David P. Lipkin, the petitioner had a previous history of hypertension and he was on BP medicine Telmisartan. The above referred reports do not mention that the petitioner disclosed any previous history of heart problem. Therefore, the only fact established by the above reports is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified.
- Learned Counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hypertension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the heart problem suffered by the petitioner was caused by pre existing hypertension. There is no merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected.”
18. It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.
19. The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored. On this point, recently Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.50 of 2019 titled as Bajaj Allianz General Insurance Vs. Arjun Singh decided on 04.03.2021 also held so.
21. In view of our above discussion as well as the law laid down in the above noted authority, it is held that the genuine claim of the complainant was wrongly, illegally and arbitrarily repudiated by the opposite parties in whole. The opposite parties are liable to pay the amount of medical expenses incurred by the complainant on her treatment in the aforesaid Hospital in abroad as per the terms of the policy.
22. Now come to the quantum of compensation. It is not disputed that as per the certificate of Insurance, the complainant was insured and medically covered in case of Life threatening situation upto 20% of Emergency Medical Expenses or US50000 whichever is less. However, the complainant in complaint has claimed the amount for reimbursement of her bills amounting to Rs.11 lakhs, but perusal of the documents (copies of the medical record and bills Ex.Ex.C18, Ex.C19, Ex.C22 and Ex.C24) shows that the complainant has spent 11818 USD on her treatment and as per the policy document Ex.C2 produced by the complainant herself, it shows that pre-existing coverage in case of Life threatening situation is covered upto 20% of Emergency Medical Expenses or US50000 whichever is less. Hence, in view of this, the complainant is at the most entitled 20% of the expenses i.e. USD 2363.60 (20% of USD11818) and as such the complainant is liable to reimbursement of the medical expenses incurred on her treatment upto the extent of USD 2363.60.
23. Resultantly, we allow the complaint of the complainant partly and Opposite Parties are jointly or severally directed to pay the amount of 2363.60 USD or to pay the equivalent amount in Indian currency (by calculating the currency rate as on the date of payment), to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 21.12.2018 till its final realisation. Opposite Parties are also directed to pay compensation to the complainant for causing her mental tension and harassment to the tune of Rs.10,000/- (Rupees ten thousands only) and Rs.10,000/- (Rupees ten thousands only) as litigation expenses. The compliance of this order be made by Opposite Parties within 45 days from the date of receipt of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
24. Reason for delay in deciding the complaint.
This complaint could not be decided within the prescribed period because the government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.
Announced in Open Commission.
Dated:20.12.2021.
