Punjab

Ludhiana

CC/21/509

Dapinder Kaur - Complainant(s)

Versus

Future Generali India India Ins.Co.Ltd. - Opp.Party(s)

Sudesh Mahajan

02 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  509 dated 09.11.2021.                                       Date of decision: 02.09.2024. 

 

Dapinder Kaur Aged About 47 Years wife of Late Shri Jasbir Singh, resident of House No.17, Simran Colony, Ludhiana.                                                                                                                                             ..…Complainant

                                                Versus

Future General India Insurance Company Limited, Sandhu Tower, Second Floor, Feroze Pur Road, Ludhiana through its Manager.                                                                                                                    …..Opposite party 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Sudesh Mahajan, Advocate.

For OP                           :         Sh. Suresh Shounik, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant got medical insurance policy No.T0005797 from the OP having validity from 02.02.2021 to 31.07.2021. The complainant stated that when she was in Surrey BC Canada, she suffered some health problem and got herself admitted in Surrey Memorial Hospital for getting treatment being indoor patient from 26.06.2021 to 27.06.2021 as well as outdoor patient. She paid 6660 Canadian Dollar to the said hospital for treatment of the problem covered under insurance policy in question. The complainant further stated that the OP rejected the claim vide letter dated 08.09.2021 on the ground of concealment of the medical problem. However, she never concealed any problem at the time of getting insurance policy. According to the complainant, due to rejection of her claim she has suffered mental torture and agony for which the OP is liable to pay compensation. She ran from pillar to post to get her claim but the OP without any reason rejected her claim which amounts to deficiency in service on their part. In the end, the complainant has prayed for issuing direction to the OP to pay an amount of Rs.3,99,600/- equal to 6660 Canadian Dollar along with compensation of Rs.50,000/- and litigation expenses of Rs.22,000/-.

2.                The OP filed written statement and assailed the complaint by taking preliminary objections as well as submissions on the grounds of maintainability; the complaint being misconceived, vexatious, misleading; suppression of material facts; lack of cause of action etc. The OP stated that on the basis of duly signed proposal form submitted by the complainant, a insurance policy namely “Future Travel Suraksha Policy” having policy No.T0005797 on 27.01.2021 with risk commencement/effective date from 02.02.2021 valid up to 31.07.2021 was issued on premium of Rs.11,739/-. The OP further stated that it received a claim intimation bearing claim No.T0006864 dated 22.07.2021 from the complainant along with medical records to claim the sum insured under the policy post-treatment at Surrey Memorial Hospital, Canada due to alleged “Small Bowel Obstruction”  and she was admitted from 25.06.2021 to 27.06.2021. After scrutiny of the medical record and preliminary investigation of documents, it was held that the complainant was already suffering from “Diabetes Mellitus, Hypertension, Hyperuricemia, Dilated Cardiomyopathy with LVEF of 22-24%”. Further the complainant had undergone multiple surgeries in past such as “implantation of Pacemaker in 2020, hysterectomy in 2018 and cholecystectomy 10 years ago” and was under medication for “Complete Heart Block status post CRT-p implantation in 2020, Hysterectomy in 2018 and Cholecystectomy from last many years”. According to the OP, the complainant did not disclose all or any of the said disease in proposal form dated 27.01.2021 and she has concealed her past medical history. Further in the medical records of Surrey Memorial Hospital, Canada, vast medical history and undergoing of multiple surgeries in past of the complainant were recorded. Even the outpatient card of the complainant of Dayanand Medical College & Hospital, Ludhiana shows that on 21.01.2021 the complainant consulted at said hospital before traveling abroad and in the said outpatient card, the above said past medical history of the complainant was recorded.

                   The OP further stated that to ascertain the admissibility of her claim, investigated the medical documents produced by the complainant by Medical Expert Dr. Saurabh A Patel  which shows that the complainant was suffering from many disease since long which she had not disclosed at the time of inception of the policy.  As such, the claim of the complainant was repudiated due to non-disclosure of material and crucial information vide email dated 25.08.2021.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections and submissions. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of welcome letter dated 27.01.2021 as well as policy documents, Ex. C2 is the copy of medical record of the complainant of Surrey Memorial Hospital, Canada, Ex. C3 is the copy of OPD Card of DMC Hospital, Ludhiana, Ex. C4 is the copy of Discharge Summary of DMC Hospital, Ex. C5 is the copy of Email, Ex. C6 is the copy of invoice of Surrey Memorial Hospital and closed the evidence.

4.                On the other hand, the counsel for the OP tendered affidavit  Ex. R1 of Sh. Masiruddin Shaikh, Assistant Manager-Legal of the OP along with documents i.e. Ex. OP1 is the copy of policy schedule, Ex. OP2 is the copy of claim intimation form, Ex. OP3 is the copy of declaration form, Ex. OP4 is the copy of medical records of Surrey Memorial Hospital, Ex. OP5 is the copy of OPD card of DMC Hospital, Ex.OP6 is the copy of medical expert report, Ex. OP7 is the copy of terms and conditions, Ex. OP8 is the copy of repudiation letter/Email dated 25.08.2021 and closed the evidence.                    

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.                 

6.                The complainant obtained an insurance policy from the OP namely Future Travel Suraksha Individual _ TIW under Silver plan (Worldwide Including US & Canada) Ex. C1 = Ex. OP1 on 27.01.2021 covering herself having a coverage of 100000 USD on premium of Rs.11,740/-. The policy was valid from 02.02.2021 to 31.07.2021 and it was issued on the basis of information and declaration furnished by the complainant. The complainant went to Surrey BC, Canada where she suffered some health problem and was admitted in Surrey Memorial Hospital on 26.06.2021 and remained admitted till 27.06.2021 where she incurred 6660 Canadian Dollars (Rs.3,99,600/-) on her treatment. The complainant submitted her cashless claim with the OP along with documents vide Travel Insurance Claim Form Ex. OP2 but the OP after investigations, rejected the claim of the complainant vide Email dated 25.08.2021 Ex. OP8 by invoking policy terms and condition, Non-disclosure of pre-existing medical condition. The operative part of Ex. OP8 reads as under:-

“This is with reference to the Future Travel Suraksha Policy Cashless Claim registered with us under the above mentioned policy number.

You presented to emergency room of Surrey Memorial Hospital on 25th June 2021 with the background medical-surgical history of Diabetes Mellitus, Hypertension, Hyperuricemia, Dilated Cardiomyopathy with LVEF of 22-24%, Complete Heart Block status post CRT-p implantation in 2020, Hysterectomy in 2018 and Cholecystectomy. On evaluation; You were given the diagnosis of Small Bowel Obstruction secondary to most likely adhesions, which responded to medical management.

As on record; You have significant past pertinent medical history of Diabetes Mellitus, Hypertension, Hyperuricemia, Dilated Cardiomyopathy with LVEF of 22-24%, Complete Heart Block status post CRT-p implantation in 2020 and on continuing treatment for the same as well as past surgical history of Hysterectomy in 2018 and Cholecystectomy.

In spite of Your significant past pertinent medical history and on continuing treatment for the same as well as significant past surgical history, the same were neither disclosed nor were we contacted in view of the "disagreement-objection or any changes with respect to the information provided in the transcript/declaration" - which is evident in page 6/6 of Your Policy Schedule, reproduced below.

Dear DAPINDER KAUR,

We wish to inform you that the Insurance policy number T0005797 has been issued on the basis of the information and declaration given by you, the transcript whereof is mentioned below. In case of any disagreement or objection or any changes with respect to information mentioned below, we request you to please revert back within a period of 15 days from date of your receipt of this transcript or the policy start date whichever is earlier, failing which it will be deemed that you are satisfied with the correctness of the details mentioned below. Please be informed that this Policy shall be construed to be void ab initio/invalid in the event we find that you have not disclosed material or correct information required for the purpose of providing the below insurance cover and in case of any claim arising under the policy in such a scenario, we shall be under no obligation whatsoever to settle such claim to you and the premium paid by you under this policy shall stand fully forfeited.

Please refer question 19 and answer to that, where it is mentioned "No" and there was no correspondence from Your end with reference to the same.

In case of Disagreement or objection or any changes with respect to information and contents mentioned hereinabove, please contact our Help Line numbers & register your objections/changes/disagreement to the contents of this transcript or you may also send us email or written correspondence at the below address within a period of 15 days from date of receipt of this transcript or the policy start date whichever is earlier.

In accordance with the above Policy Terms & Conditions; we regret to inform you that your claim is inadmissible - stands denied.”

7.                Now the question arises whether the rejection of the claim on the ground mentioned therein is justified or not?

8.                In this case, the cashless claim in respect of Silver Worldwide medical insurance lodged by the complainant in respect of her treatment in Surrey Memorial Hospital, Canada has been repudiated vide Email Ex. OP8 dated 25.08.2021 on the basis of non-disclosure of pre-existing disease  as the complainant at the time of availing the insurance policy concealed the facts regarding her pre-existing diseases as diagnosed in OPD card Ex. OP5 of the complainant issued by Dayanand Medical College & Hospital, Unit – Hero DMC Heart Institute, Ludhiana vide which she was diagnosed of DM2, DCMP, LYEF 25%, Adenomyosis, CAG (N) Coronaries, P. Hysterectomy etc.  Further as per medical report Ex. OP6 of Dr. Saurabh A. Patel, Medical Department, EUROP Assistance India, the relevant portion of which is reproduced as under:-

“Diagnosis:

Small Bowel Obstruction Secondary to most likely adhesions - ICD 10:K56.60.

Chief Complaints: Reason for Consultation: History of Present Illness

Abdominal Pain, Nausea. LQ Abdominal Pain * 01 House PTA.

Preexisting/Past Medical History:

DM, HTN, Dilated Cardiomyopathy with LVEF 22-24% - CHB with Normal Coronaries noted in 2018 – Pacemaker Implanted in 2020, Last Check in January 2021, Hysterectomy in 2018 and Cholecystectomy in 10 years ago.

As per Claim Form:

HTN 03 years, DM 04 Years, CRT-P Implanted about 1.5 Years ago.”

It is further evident from the medical report Ex. OP6 that the complainant has been taking medicines for her above said ailments. This document clearly belies the claim of the complainant that prior to taking the policy she was not suffering from any pre-existing disease as in the declaration form Ex. OP3 the complainant has answered in negative to question No.19, which reads as under:-

“19. Do you have any pre-existing medical condition, Injury, physical deformity, at present or in the past?

No.”

This clearly amounts to violation of terms and conditions of the policy more particularly condition No.15 of the policy Ex. OP7, which is reproduced as under:-

                   “15. Disclosure of information norm:

The Policy shall be void and all premiums paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.”

Further the exclusion clause is reproduced as under:-

                   “Exclusions applicable to Section A

In addition to the General Exclusion listed we shall not cover any claim that is caused by or attributed to or in respect of

b. Benefits will not be available for any condition, ailment or injury or related condition(s) for which You have been diagnosed, received medical treatment, had signs and/or symptoms, prior to inception of Your first policy, until 48 consecutive months have elapsed, after the date of inception of the first Policy with Us.”

Even otherwise, it has been held by the Hon’ble Supreme Court of India in Satwant Kaur Sandhu Vs New India Assurance Co. Ltd. Civil Appeal No.2776 of 2002 decided n 10.07.2009 that the contract of insurance is a contract of utmost good faith and the insurers is under an obligation to disclose all the facts which are known to him and non-disclosure of the information regarding pre-existing diseases is a valid and justifiable ground for repudiating the claim. In the instant case also, since the complainant did not disclose about the pre-existing disease of diabetes mellitus, hypertension, Dilated Cardiomyopathy with LVEF 22-24%, CHB with Normal Coronaries noted in 2018 – Pacemaker Implanted in 2020, Last Check in January 2021, Hysterectomy in 2018 and Cholecystectomy in 10 years ago for which she has been suffering from since prior to taking the policy in question. On the basis of all above discussion, this Commission is of the view that the complainant has failed to prove that the repudiation of the claim by OP is patently illegal. Therefore, the complainant cannot be held entitled to the amount of 6660 Canadian Dollar equivalent to Rs.3,99,000/- in Indian currency in her treatment in Australia.

9.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.   

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:02.09.2024.

Gobind Ram.