Chandigarh

DF-I

CC/600/2022

Sarwan Singh Masoun - Complainant(s)

Versus

Care Health Insurance Ltd. - Opp.Party(s)

Sarwinder Goyal

01 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/600/2022
Date of Institution	:	15/06/2022
Date of Decision	:	01/04/2024

1. Sarwan Singh Masoun (aged about 80 years), s/o Khazan Singh, Travel Health Insurance Policy No.(34827383), H.No.852, Apex Dusangh Road Moga Bhagha Purana Bhagha Purana, Moga, Punjab-142001. Since Deceased, through following LRs/LHs.

2. Manjit Kaur w/o Late Sh. Sarwan Singh Masoun, Resident of H.No.852, Apex Dusangh Road Moga Bhagha Purana Bhagha Purana, Moga, Punjab-142001. Now residing at 4224, White Horn DR NE Calgary, Alberta T1Y5C5 Canada.

3. Dr. Navdeep Singh s/o Late Sh. Sarwan Singh Masoun, Resident of H.No.852, Apex Dusangh Road Moga Bhagha Purana Bhagha Purana, Moga, Punjab-142001. Now residing at 4224, White Horn DR NE Calgary, Alberta T1Y5C5 Canada.

4. Amardeep Singh S/O Late Sh. Sarwan Singh Masoun, Resident of H.No.852, Apex Dusangh Road Moga Bhagha Purana Bhagha Purana, Moga, Punjab-142001. Now residing at 9073E Manning Ave Selma, CA 93662 USA.

… Complainants

V E R S U S

1. Care Health Insurance Limited, SCO 56-57-58, 2^nd Floor, 9-D, Chandigarh, 160017 Through its Managing Director.

2. Insurance Ombudsman, Care Health Insurance Limited, SCO No.101-103, 2^nd Floor, Batra Building, Sector-17D, Chandigarh-160017.

3. The Manager, Care Health Insurance Limited, Unit No.604-607, 6th Floor, Tower C, Unitech Cyber Park, Sector 39, Gurgaon – 122001.

4. The General Manager/Authorised Representative, Falck Global Assistance. Through Care Health Insurance Limited, SCO 56-57-58, 2nd Floor, 9-D, Chandigarh, 160017.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Sarwinder Goyal, Advocate for complainants
	:	Ms. Niharika Goel, Advocate, proxy for Sh. Paras Money Goyal, Advocate for OPs 1,3 & 4 (through VC)
	:	Complaint against OP-2 dismissed as withdrawn vide order dated 20.3.2024.

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sarwan Singh Masoun (since deceased) through his LRs, complainants against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the son of the complainant is citizen of Canada and is working in a hospital there.  On 5.12.2021, the complainant alongwith his wife planned to visit Canada on visitor’s visa. Being allured by the agents of the OPs for purchasing health insurance policy, complainant purchased a Travel Health Insurance under Silver-WW IN US/Canada plan (hereinafter referred to as “Subject Policy”) valid w.e.f. 2.12.2021 to 1.12.2022 on payment of premium of ₹81,341/-.  Accordingly, as per their plan, both the complainant and his wife travelled to Canada on 5.12.2021. Both the complainant and his wife were healthy and they reached Canada, but, after one month i.e. in the month of January 2022 complainant fell ill and he visited Dr. Dubey, who advised him to go through multiple diagnostic tests like blood work, CT scan etc. The complainant had gone through the process of diagnosis and had spent an amount of ₹1,55,569/- regarding which he submitted claim form and documents with the OPs. Copies of documents alongwith medical treatment and bills are Annexure C-3. OPs had taken long time to settle the claim and in the meantime, complainant again fell ill and was taken to Peter Lougheed Centre Hospital at Calgary, Alberta, Canada on 16.3.2022 in ambulance where he was diagnosed with acute kidney injury and hyperkalemia and remained hospitalized there till 19.3.2022 for treatment.  Bills of the hospital, ambulance charges and other doctor charges to the tune of ₹7,47,820/- were again submitted to the OPs with claim form and copies of relevant documents relating to second claim are Annexure C-4.  However, OPs illegally and arbitrarily rejected the claim of the complainant vide letter dated 8.4.2022 (Annexure C-5) on the ground that the complainant was suffering from pre-existing disease and for non disclosure of material facts by him.  Immediately complainant objected the illegal rejection of his claim by sending letter (Annexure C-6) to the OPs through his son.  The treatment of the complainant was underway and he had undergone number of diagnostic tests, investigations and medications.  Thereafter, complainant was again hospitalized on 2.5.2022 and remained admitted there for five days and after clearance of the medical bills, complainant submitted the claim form and other medical record including bills (Annexure C-7 to C-9) with the OPs.  Out of the five claims detailed below, one claim is of the spouse of the complainant No.1 which is also pending with the OPs :-

Sr. No.	Date of submission of claim	Amount of claim in Dollars	Amount of claim in Rs.
1	March 08, 2022	2565.42	155569.00
2	March 28, 2022	14836.21	899679.00
3	May 10, 2022	2195.06	133110.00
4	May 14, 2022	16510.56	1001213.00
5	April 22, 2022 Manjit Kaur	835.10	50641.00

 

On seeing that the complainant was being provided lengthy treatment and was being hospitalized there on various occasions and also that the OPs have not settled the claim, the complainant shifted to India from Canada on 16.5.2022 as it was very difficult for him to afford the medical expenses in Canada.  Due to the compelling circumstances, complainant was brought to India by his wife, son and daughter in law by purchasing business class tickets for the complainant as he was not keeping good health at that time and an amount of ₹96,867.22 was spent for the purchase of return tickets.  In this manner, the act of the OPs in denying/rejecting the genuine claim of the complainant amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.

2. OPs 1, 3 & 4 resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and cause of action.  However, it is admitted that the subject policy was purchased by the complainant from the OPs and the same was valid w.e.f. 2.12.2021 to 1.12.2022.  It is alleged that, in fact, as complainant was suffering from various ailments before purchasing the subject policy and had not disclosed about the said ailments i.e. pre-existing disease having medical history of prostrate surgery, the claim of the complainant was rejected/repudiated vide letter dated 8.4.2022 (Annexure OP-11) on the ground of misrepresentation, mis-description and non-disclosure of material facts by him at the time of obtaining the subject policy.  It is further alleged that the insured vide email dated 27.4.2022 (Annexure OP-14) responded by submitting past medical record of Fortis Hospital.  However, it is not disputed that the aforesaid claims were lodged by the complainant with the OPs, but, alleged that the claims of the complainant were only denied on account of pre-existing disease from which he was suffering and also that he had not disclosed about the said disease at the time of purchasing the subject policy and the same is fundamental breach of the subject policy.   On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-2 in its letter/reply 29.6.2022 submitted that the Insurance Ombudsman is not an interested party as it had carried out its duties as per rules and prayed for deletion of its name.

However, subsequently, in view of the statement made by the advocate for the complainants, consumer complaint against OP-2 was dismissed as withdrawn vide order dated 20.3.2024 of this Commission.

4. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of OPs.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant No.1 namely, Sh. Sarwan Singh Masoun, who died during the pendency of the instant consumer complaint, (hereinafter referred to as “insured patient”) had had obtained the subject policy, covering the risk of one lac dollar each for himself and his wife, Mrs. Manjit Kaur Masoun and during their stay in Canada, insured patient had suffered from various ailments and was hospitalized on different dates and he had submitted medical bills from time to time alongwith the claim forms to OP-1 and the claims of the complainant were denied/rejected vide denial letter dated 8.4.2022 (Annexure C-5) on the ground of pre-existing disease and non-disclosure of material facts by the insured patient, the case is reduced to a narrow compass as it is to be determined if the OPs/insurers are unjustified in rejecting/denying the claims of the complainants and the complainants are entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainants, or if the OPs/insurers have rightly denied/rejected the claim of the complainants and the consumer complaint of the complainants being false and frivolous is liable to be dismissed, as is the defence of OPs. 
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the subject policy (Annexure C-1) clearly indicates that the same was valid w.e.f. 2.12.2021 to 1.12.2022.  Further, terms & conditions of the subject policy (Annexure C-2) defines the pre-existing disease as under :-

“1.62 Pre-existing Disease means any condition, ailment or Injury or related condition(s) for which the Insured Person had signs or symptoms, and/or were diagnosed, and/or received Medical Advice/treatment within 48 months to prior to the first policy issued by the Company.”

4. Perusal of the medical record annexed with the claim form (Annexure C-3 Colly. & Annexure C-4), clearly indicates that the insured patient had taken treatment in different hospitals at different times, during which he was also hospitalized and spent huge amount for his treatment.
5. Annexure C-5 is the claim denial/rejection letter dated 8.4.2022 which indicates that the claim of the complainants was denied/rejected on the ground that the insured patient had not disclosed about the pre-existing disease or illness or injury which he was suffering before purchasing the subject policy. The relevant portion of the letter is reproduced below for ready reference :-

 “We have reviewed the claim filed by you pertaining to Health Insurance policy (34827383) and hereby inform you that the claim is not payable as per policy terms and Conditions listed below:

• REASON = CLAUSE 2.1.4(II) ANY TYPE OF PRE-EXISTING DISEASE OR ILLNESS OR INJURY. THE POLICY SHALL BE VOID AND ALL PREMIUM PAID THERE ON SHALL BE FORFEITED TO THE COMPANY, IN THE EVENT OF MISREPRESENTATION, MIS-DESCRIPTION OR NON-DISCLOSURE OF ANY MATERIAL FACT BY THE POLICY HOLDER, INSURED OR ANY PERSON ACTING ON HIS/HER BEHALF.”

 

6. Annexure C-11 is copy of discharge summary issued by the Fortis Hospital, which indicates that the insured patient was diagnosed with BPH with urinary bladder calculus and during hospitalisation treatment was given to him through laser TURP + Laser CLT on 5.9.2016 and he remained admitted in the said hospital w.e.f. 5.9.2016 to 7.9.2016.
7. OPs/insurers in their written version under clause (d) (at page 4) have specifically stated that as per discharge summary dated 7.9.2016 of Fortis Hospital, Mohali, the insured patient was diagnosed with BPH (Benign Prostatic Hyperplasia) with Urinary Bladder Calculus and underwent laser TURP, being known case of BPH, which fact was not disclosed by him at the time of purchasing the subject policy and on that account the claim of the complainant was denied. 
8. However, when it has come on record that the subject policy was purchased by the complainant on 2.12.2021 i.e. after about 60 months of the previous treatment, which was taken by him in the year 2016, i.e. beyond the prescribed period of 48 months, it is safe to hold that the denial of the claim of the complainant by the OPs on the ground of non-disclosure of material facts qua pre-existing disease is against the terms & conditions of the subject policy and is illegal and arbitrary.
9. In support of his case, learned counsel for the complainants has relied upon the order dated 22.11.2007 passed by the Hon’ble Delhi State Commission in Oriental Insurance Co. Ltd. & Ors. Vs. Hans Raj Khurana, Appeal No.162 of 2004 in which it was held as under :-

        “Consumer Protection Act, 1986 Sections 2 and 14 Medical Insurance Claim - Medical claim was rejected by appellant/company on ground of ‘non-disclosure' of pre-existing disease - Surgery of gall bladder stones - At time of taking policy in question, there was no pre- existing disease since earlier operation was done seven years back - Failure to produce papers of previous illness - Held - If, same problem developed after seven years it cannot assume a character of pre-existing disease or non-disclosure of pre-existing disease - Facts and circumstances considered - Insurance company directed to pay Rs.45,007/- towards medical expenses and Rs.15,000/- towards mental agony and harassment - Appeal partly allowed.”

 

10. The learned counsel has further relied on the order dated 22.3.2018 passed by our own Hon’ble State Commission in Manish Goyal Vs. Max Bupa Health Insurance Company Limited in which it was held as under :-

B. Consumer Protection Act, 1986 Section 2(1)(g) Insurance claim - Rejected on ground that insured not disclosed the pre-existing disease and doctor recorded the past history of illness - Age of insured was more than 45 years at the time policy issued - No medical examination got conducted by Insurance Company - Held, if the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), by putting the insured to thorough medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability - Complaint partly allowed.”

 

11. In view of the foregoing discussion and the ratio of law laid down above, it is unsafe to hold that OPs/insurers were justified in denying/rejecting the claim of the complainants qua the subject policy and the present consumer complaint deserves to succeed. 
12. Now coming to the quantum of amount, since the complainants have proved the bills (Annexure C-3, C-4, C-7 and C-9) totaling to CAD 37926.54 (rounded off to CAD 37927) towards the expenses spent on hospitalisation/treatment of the insured patient, and the equivalent value of CAD 37927 in Indian currency comes to 37927 x 60 (i.e. average value of CAD in 2022) = ₹22,75,620/- and the subject policy further indicates 200 USD was deductible in case of in-patient and out-patient care, and the equivalent of the same in Indian currency comes to 200 x 78 (i.e. average value of USD in 2022) = ₹15,600/-, it is safe to hold that OPs/ insurers are liable to pay total amount of ₹22,75,620–₹15,600 = ₹22,60,020/- to complainants No.2 to 4 alongwith interest and compensation etc.
13. So far as prayer clause (iii) of the complainants regarding cost of air tickets alongwith other expenses is concerned, in view of the statement made by the advocate for the complainants on 20.3.2023, the same is disallowed, being not pressed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1, 3 & 4/insurers are directed as under :-

1. to pay ₹22,60,020/- to complainants alongwith interest @ 9% per annum from the date of denial/rejection of the claim i.e. 8.4.2022 onwards.
2. to pay ₹30,000/- to the complainants as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainants as costs of litigation.

5. This order be complied with by the OPs 1, 3 & 4 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.  It is, however, made clear that the aforesaid awarded amount shall be apportioned amongst the complainants in equal share.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

01/04/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member