Per Shri Pradeep G. Kadu, Hon’ble President

        This is an action under Section 35 of Consumer Protection Act 2019 the briefly stated case is as follows:

1)      The Complainant is an adult Indian inhabitant, residing in Mumbai. In or around January 2020, the Complaint and his wife, Mrs. Chhaya Ajmera, planned to travel to the United States of America (USA) from 5^th February 2020 to 21^st March 2020. Complainant  and his wife accordingly availed the services of the Opposite Party by acquiring an overseas travel insurance policy from the Opposite Party.

2)      On 4^th March 2020, the Complainant during his stay in US was at his sister’s house in Atlanta, USA, when he experienced sudden and unexpected Illness. The Complainant was immediately taken to the Northside Hospital in Atlanta, USA and was provided Emergency Care, and was eventually discharged on 9^th March 2020.

3)      During the course of Hospitalization, the Complainant was verbally informed by the Northside Hospital that the Cashless Facility was approved by the Opposite Party, and thus continued with the treatment.

4)      Meanwhile, the Complainant, through his wife, contacted the Opposite Party on the contact number provided in the Policy documents, and intimated the Opposite Party of the claim, by providing the necessary particulars as were sought for. Further, the Complainant did regular follow up  and exchanged e mails with the opposite party to fulfill the necessary requirements for sanctioning of the insurance claim.

5)      In or around January 2021, the Complainant, being aggrieved by the Opposite Party’s rejection of the claim to the extent of the Sum Insured, filed his complaint before the Ombudsman. On 18^th February 2021, the Ombudsman refused to entertain the Complaint on the ground that the claim for compensation was more than Rs.30,00,000/-

6)      As complainant not satisfied with the order of the ombudsman filed the said complaint with this Hon commission on account deficiency of service by opposite party towards the complainant.

7)      The Complainant submits that the Opposite Party took nearly 6 months to settle the claim of the Complainant. This has affected his credit score of the Complainant and causing grave mental trauma and harassment to the Complainant. The Complainant submits that the Opposite Party’s delay in settling the claim of the Complainant is not only a breach of Clause 4.5(xi) of the Policy Terms & Conditions, but also a clear deficiency in service on party of the Opposite Party.

Learned advocate Shri Sunni Shah on behalf of the complainant and Mrs Siddhi Sawant on behalf of the opponent represented their respective clients and submitted affidavit of evidence and written arguments. We heard both parties at length. Mrs Siddhi sawant submitted pursis that her written argument to be considered as oral argument whereas Adv Sunni Shah argued the matter on behalf of Complainant. We have perused  various documents submitted by both parties.

Contentions of the Complainant

Complainant during his arguments mainly emphasised on the following points,

1)      The Complainant’s Claim was during the Period of Insurance: The Period of Insurance was from 05.02.2020 to 21.03.2020. The Complainant was hospitalized for Emergency Care for treatment of TIA on 04.03.2020 and discharged on 09.03.2020. The Opposite Party has not disputed this fact.

2)      The Complainant’s Claim is covered under Clause 2.1.1. (A) of the Policy Terms and Conditions. The Complainant is entitled to be indemnified for the entire Sum Insured: The Complainant’s Claim was pertaining to Hospitalization Expenses for In-Patient Care. The Complainant was hospitalized for Emergency Care for TIA suffered during the Period of Insurance, and thus his Claim is covered under Clause 2.1.1. (A) of the Policy Terms and Conditions. The Sum Insured under the Policy is USD 100,000/-. The Opposite Party has not disputed this fact.

3)      The Complainant’s Claim is not attributable to his Pre-Existing Disease. The Opposite Party could not have deducted the Claim under Clause 2.1.1 (F) of the Policy Terms and Conditions:

1. The Complainant’s Claim was in relation to the Hospitalization Expenses incurred for Emergency Care for treatment of TIA. The Complainant had never previously suffered from TIA before. The Opposite Party has not disputed this fact.
2. The Complainant’s Claim ailment of TIA was not attributable to PED of hypertension, diabetes, angioplasty or kidney transplant. The Complainant relies on Dr. Prashant Rajput’s Certificate dated 24.05.2021 [Exhibit U/ page 94 of the Complaint]. The Opposite Party’s reliance Dr. C H Asrani’s Certificate dated 15.11.2021 is misconceived as he merely opines that hypertension and diabetes mellitus are risk factors for TIA and on that basis states that TIA was attributed to PED of hypertension and diabetes mellitus. Dr. C H Asrani has no expert qualification for treatment of TIA.
3. The Complainant relies upon the following judgments in support of its submission that diabetes and hypertension have been considered by courts in India to be lifestyle diseases and are mere risk factors and cannot be considered as pre-existing disease to deny the claim of the insured:
   1. Hari Om Agarwal v. Oriental Insurance Co. Ltd., AIR 2008 Del 29 (para.21-23)ii.
   2. Neelam Chopra v. Life Insurance Corporation of India, MANU/CF/0698/2018iii.
   3. National Insurance Company Ltd. v. Jatinder Singh, MANU/CF/0005/2021 iv.
   4. Manmohan Nanda v. United India Assurance Co. Ltd., (2022) 4 SCC 582 (para-73-75)
4. Further, the Complainant’s prior history of hypertension, diabetes and angioplasty is anyways not covered under the definition of Pre-existing Diseases under Clause 1.53 of the Policy Terms and Conditions, as the Complainant did not have any ‘signs or symptoms, and/or diagnosed, and/or received Medical Advice/ treatment’ within 48 months to the first policy issued by the Company’.
5. Thus, the Complainant’s ailment of TIA cannot be said to be attributable to PED of diabetes, hypertension, angioplasty or kidney transplant. The Opposite Party, thus could not have been deducted the Complainant’s Claim under Clause 2.1.1. (F) of the Policy Terms and Conditions, to only 10% of the Sum Insured. The Opposite Party ought to have indemnified the Complainant for the entire Claim amount up to the Sum Insured.

4)      The Opposite Party delayed in settlement of the Complainant’ Claim: The Complainant submits that the Claim was lodged and the documents were submitted with the Opposite Party in March 2020. The Opposite Party did not settle or respond to the Claim till 16.09.2020, despite multiple follow up by the Complainant. As per Clause 4.5 (xi) of the Policy Terms & Conditions, ‘The Company shall settle any Claim within 30 days of receipt of all the necessary documents/ information as required for settlement of such Claim and sought by the Company’. The Opposite Party took nearly 6 months to settle the claim of the Complainant.

5)      Complainant on 6^th June 2024 made additional submission related to his claim and submiited that he restricts his claim further as

STATEMENT OF REIMBURSEMENT CLAIMED BY COMPLAINANT

Note:

1. Prayer clause (a) of the Complaint does not survive.
2. With reference to prayer clauses (b) and (c), the Complainant restricts its claim to USD 7,484/- towards reimbursement for the payments made towards the above Bills with interest at 18% p.a. from respective dates of payment. Prevailing exchange rate as on 27.05.2021 i.e. date of filing of Complaint was 1 USD = Rs.72.70.
3. The Complainant also prays for reliefs in terms of prayer clauses (d) and (e).

Contentions of the Opposite Party

1)      Opposite party relied on the submissions made in their written argument. Opposite party maintains that Ombudsman has refused to entertain the complainant on the grounds that the claim for compensation was more than Rs.30 lakh.

2)      Further opposite party submitted that complainant has failed to mention about his medical history and has not mentioned any of the disease/ medical illnesses in the list of diseases/ illnesses, thereby breaching the terms of the policy.

3)      Opposite party states that, complainant was admitted to the hospitalisation on 4 March 2020 in North side Hospital, Atlanta, where he was diagnosed with Transient cerebral ischaemic attack ( TIA), Chronic kidney disease, atherosclerosis heart disease of native  coronary artery without angina pectoris and chronic heart disease.

4)      With regards to this, opposite party took an expert opinion in which it was mentioned that the present ailment of the complainant is attributed to his pre-existing disease of hypertension, diabetes, angioplasty, and kidney transplant. Hence, as per the expert opinion received by the opposite party from Dr C.H.Asrani, that all of the current presenting complaints of insured are attributed to his pre-existing clinical conditions of hypertension and diabetes mellitus, history of angioplasty and renal transplant.

 5)     As per the terms and conditions of the policy as mentioned in the policy certificate, the liability of the respondent company is up to 10% of sum insured in case of life-threatening disease with 100 USD as deductible.

6)      Therefore, the cashless request was duly approved and settled for an amount of, 9900 USD in accordance to policy terms and conditions. Hence, there is no deficiency in service on the part of the respondent company and the claim was duly approved and paid in accordance to policy terms and conditions.

7)      In support of his argument Opposite party relied on following citations

1. SGS India vs Dolphin International Ltd LL 2021 SC 544
2. Ravneet Singh Bagga V KLM royal Dutch Airlines (2000)1 SCC 66
3. Indigo Airlines V Kalpanarani Debbarma (2020) 9 SCC 424
4. Oriental Insurance Co Ltd V Sony Cheriyan (1999) 6 SCC 451
5. General Assurance Society Ltd v Chandumull Jain and Anr (1966) 3 SCR 500

Observations and Conclusions

After going through all the submissions made by both parties and after perusal of records made available, we have following observations in the said case.

1. The present claim is regarding the policy taken by complainant as overseas travel insurance policy from the opposite party ie Care Health Insurance Ltd.
2. The name of the policy is gold WW, single. Some insured under the policy is  USD 100000/-.
3. Complainant had disclosed pre-existing diseases as hypertension, diabetes, and angioplasty.
4. The issue involved in the dispute is the less amount of claim sanctioned by the opposite party to the complainant while he was hospitalised during his travel abroad.
5. Opposite party claims that they have sanctioned the complainants claim, as per the terms and policy of the said insurance policy. Complainant on the other hand submits that his claim is sanctioned incorrectly by taking rescue of different clause of the policy which is unjustified. According to the complainant  the  said claim should have been sanctioned as per the clause 2.1.1.A of the said policy. However opposite party wrongfully applied clause 2.1.1.F of the policy and sanctioned the said claim under 2.1.1.F which reimburses only 10 % of the insurance claim.

Considering these facts, in order to understand the issue involved, we need to peruse respective clauses of the insurance policy submitted by both the parties. The relevant clauses referred by both the parties are

2.1.1.A

2.1.1.F 

1.53

6. It is true that during the period of insurance, the complainant had to undergo emergency medical treatment on account of a sudden and unexpected stroke which is identified as is transient ischemic attack. (TIA).
7. Discharge documentation of the North Side hospital in Atlanta, USA. It is mentioned that reason for hospitalization was mentioned as, transient right side, weakness, aphasia, which are symptoms of an illness called TIA.
8. Further, the hospital course clearly mentions that patient noticed on the morning of arrival to the emergency room. He had weakness in the right lower extremity, resulting in his leg, giving out.  Shortly after that, he developed right facial stiffness and expressive aphasia and difficulty understanding, ambulance was called and while patient was en route to the emergency room, symptoms all resolved. Patient was continued on aspirin and Plavix. He had an MRI Office brain, which showed no acute intra cranial abnormalities, but some old left lacuna infection, moderate chronic small vessel estimate disease

9. In the discharge document submitted by the complainant Discharge diagnosis mentions 

1. Trans ischaemic attack.
2. Chronic kidney disease stage two
3. Hyperlipidaemia
4. Diabetes, type two insulin dependent
5. Coronary artery disease

10. Complainant relied on the certificate obtained from global hospitals of Dr Prashant Rajput, dated 24 May 2021. This certificate mentions that the said patient was diagnosed as transient ischemic attack,(TIA), which is a cerebrovascular accident, ( CVA.) This is a new problem, not attributable to his heart disease.
11. However, it is not confirm whether Dr Rajput has referred the documents of treatment which complainant got during his hospitalisation in USA. …
12. On the other hand, opposite party relied on the certificate of Dr C.H.Asrani, who is an expert, as claimed by opposite party, submitted that, all of the current presenting complaints of insured are attributed to his pre-existing clinical conditions of hypertension and diabetes mellitus and past history of Angioplasty( with atherosclerosis heart disease,)and renal transplant (with CKD).
13. After comparing these opinions with the records available about treatment, we observed that the complainant is a known case of heart ailments as well as diabetes. Complainant has revealed this fact in the policy as PED. (Preexisting Diseases ) 
14. As discussed earlier complainants discharge diagnosis shows various aliment which relates to heart disease, kidney and diabetes mellitus.  As per the treatment report and documents, complainant was identified during the treatment that he suffered with Transient Ischaemic Attack (TIA).

According to medical terminology TIA is a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or the eye, sometimes as a pre curser of a stroke. This can cause sudden symptoms like those of a stroke.

The common risk factors for all TIA include diabetes, hypertension, age, smoking, obesity, alcoholism, unhealthy diet, psychosocial stress, and lack of regular physical activity.

Chronic kidney disease stage 2 

In Stage 2 CKD, the damage to your kidneys is still mild, and you have an eGFR between 60 and 89. Your kidneys are still working well, but at this stage, you will have signs of kidney damage. A common sign of kidney damage is protein in your urine.

Hyperlipidemia

A condition in which there are high levels of fat particles (lipids) in the blood.

Examples of lipids include cholesterol and triglycerides. These substances can deposit in blood vessel walls and restrict blood flow. This creates a risk of heart attack and stroke.

Causes of Hyperlipidemia

In most patients, hyperlipidemia has a polygenic inheritance pattern, and manifestations of the disorder are largely influenced by secondary factors such as (central) obesity, saturated fat intake, and the cholesterol content within a person's diet.

Diabetes type 2 insulin dependent 

Type 2 diabetes is a chronic disease. It is characterized by high levels of sugar in the blood. Type 2 diabetes is also called type 2 diabetes mellitus and adult-onset diabetes. That's because it used to start almost always in middle and late adulthood.

Coronary artery disease 

Coronary artery disease, also called CAD, is a condition that affects your heart. CAD happens when coronary arteries struggle to supply the heart with enough blood, oxygen and nutrients. Cholesterol deposits, or plaques, are almost always to blame.

Most often, atherosclerosis causes coronary artery disease. Atherosclerosis occurs when a waxy substance called plaque builds up in your coronary arteries. Over time, the plaque build up narrows your coronary arteries and restricts blood flow.

Complainant has disclosed some of the diseases in his list of PED while applying for the policy. Few of the pre-existing diseases mentioned in the discharge diagnosis are not disclosed while applying for the impugned policy. Although issue involved here is not related to non disclosure of PED, the mute question is that the complainant is already suffering from these diseases and the Certificates issued by Doctor Prashant Rajput confirms that he is under treatment for the same under him. Here one thing to be noted that the discharge diagnosis mentions multiple ailment of the complainant. The discharge report is silent on the point of cause of TIA to the concern patient. However medications, mentioning of various ailment of the complainant in discharge diagnosis, expert report of Dr Asrani on behalf of opposite party before Ombudsman and explanations described in earlier paras  about the pre-existing ailments of the complainant  indicates that the TIA is attributed to the pre-existing diseases of the complainant. The argument by opposite party regarding complainants suffering of TIA is associated with PED during the abroad travel of the complainant has a force as it is supported with the expert opinion of Dr C H Asrani based on the perusal of medical treatment documents of the complainant. Hence we are of the concerned opinion that complainants argument that his sudden illness diagnosed as TIA  during abroad travel is not associated with PED lacks merit and hence we are unable to accept it. Considering all the relevant facts and perusal of records we form a concerned opinion that the complainants claim is rightly sanctioned by opposite party vide clause 2.1.1.F of the insurance policy. Thus the complainant’s claim deserves to be dismissed. Hence, the Order.

ORDER

1. The Consumer Case No.CC/101/2021 stands dismissed.
2. No order at costs.
3. The copy of order be sent to both the parties free of costs.