Chandigarh

DF-II

CC/41/2021

Ms Paramjit Kaur Cheema - Complainant(s)

Versus

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

Jasneet Kaur Adv

14 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	41/2021
Date of Institution	:	21.01.2021
Date of Decision	:	14.05.2024

 

                                       

                       

Mrs.Paramjit Kaur Cheema w/o (Late) Brig AS Cheema (Retd.), Aged about 59 years, 36 Hakikat Road, Jalandhar Cantt, Jalandhar, Punjab-144005 Presently residing at: #1533, ATS Golf Meadows (Prelude) Dera Bassi, Barwala Road, Zirakpur, Punjab - 140507.

...Complainant

Versus

1.     Future Generali India Insurance Company Limited Through its Managing Director Indiabulls Finance Centre Tower Registered Office: 3, 6th Floor, Senapati Bapat Marg Elphinstone Road (W) Mumbai-400013

Also at:

Unit Nos. 801-802, 8th floor, Tower C, Embassy 247 Park, L.B.S. Marg, Vikhroli (West), Mumbai-400079

2.     Future Generali India Insurance Company Limited Through its Regional Head, Chandigarh SCO-4 & 5, 2nd Floor Sector 8-C, Madhya Marg Chandigarh-160017

3.     Europ Assistance India Pvt. Ltd., 7th Floor, Star Hub, Bldg. No. 2, Near ITC Maratha Hotel, Sahar, Andheri East, Mumbai, Maharashtra - 400059

…. Opposite Parties.

BEFORE:
	SHRI AMRINDER SINGH SIDHU,	PRESIDENT
	SHRI B.M.SHARMA	MEMBER
PRESENT:-
	Ms.Jasneet Kaur, Counsel for the complainant Sh.Ambuj Shukla, Adv. Proxy for Sh.Rajesh Verma, Counsel for OPs No.1 and 2 OP No.3 exparte

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.), LLM, PRESIDENT

1.         The complainant has filed the present complaint under Section 34/35 of the Consumer Protection Act, 2019, as amended up-to-date alleging therein that she was desirous to visit her daughter and her family between September 2019 to December, 2019 and as such she purchased “Future Travel Suraksha Policy No.T0659693 vide from 27.09.2019 to 25.12.2019 against the premium of Rs.5902/-.  Unfortunately on 22.12.2019, she suffered from an excruciating pain attack in her abdomen and had to be presented to the University of Cininnati Medical Centre’s Emergency Room for abdominal epigastria pain on an emergency. On 24.12.2019, an emergency procedure for removal of her gall bladder was performed through laparoscopic cholecystectomy and discharged on the subsequent day. The diagnosis revealed that the complainant had gallstone Pancreatitis which was due to presence of gall bladder stones as a result of which she had to undergo a gall bladder for removal surgery. The complainant submitted the cashless travel insurance form through email on 30.12.2019 for all claims related to date of service i.e. 22.12.2049 to 25.12.2019. However after repeated follow up for more than six moths, the claim was repudiated vide email dated 11.07.2020 on the ground of non-disclosure of material facts. The complainant also served a legal notice dated 14.12.2020 upon the OPs and the same was replied in evasive manner.  It has further been stated that there was no connection/relation between the present diagnosis and any past medical history.  Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint seeking directions to the OPs to process the cashless claim of the complainant and to pay the compensation for mental agony and physical harassment as well as litigation expenses.
2.         In their written version, OPs No.1 and 2 while admitting the factual matrix of the case have pleaded that  the contract of insurance is a contract of good faith on the part of the parties to the contract. It has further been stated that from the medical record, it is proved that the complainant was suffering from gal stone pancreatitis for a long time, which is a pre-existing disease prior to the policy and the current ailment of the complainant is a complication of the medical condition of gal stone pancreatitis etc. prior to taking of the policy and the policy conditions do not extend coverage for preexisting ailments and its complications. It has further been stated that the claim was repudiated vide letter dated 11.07.2020 on the ground that the complainant was having medical history of chronic cholecystitis and acid peptic disease as per the terms and conditions of the policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on their part, the OPs prayed for dismissal of the complaint.
3.         The complainant filed replication to the written reply of OPs No.1 and 2 and controverted their stand and reiterating his own.
4.         Despite due service through registered post, OP No.3 failed to put in appearance and as a result thereof it was ordered to be proceeded against exparte vide order dated 28.02.2022.
5.         The parties filed their respective affidavits and documents in support of their case.
6.         We have heard the Counsel for the contesting parties  and have gone through the documents on record.
7.         Undisputedly, the complainant was covered under the policy in question when she took the treatment for removal of the gall bladder in abroad. From the documentary evidence on record, it is observed that the complainant suffered an excruciating pain attack in her abdomen and had to admit in the University of Cininnati Medical Centre’s Emergency Room for abdominal epigastria pain and on 24.12.2019, an emergency procedure for removal of her gall bladder was performed through laparoscopic cholecystectomy and discharged on the subsequent day.
8.          The claim was repudiated by the OPs only on the ground that the complainant has failed to disclose the medical history of chronic cholecystitis and acid peptic disease at the time of taking the insurance policy. It has been argued on behalf of the OPs that the emergency procedure was a result of the continuation, progression, aggravation, exacerbation of the undisclosed pre-existing problem of chronic cholecystitis.  Hence, the claim was rightly repudiated. However, the attending doctor in the Case Evolution Report attached with the complaint as Annexure B has specifically observed that the emergency procedure which was carried out upon the complainant has neither any bearing on nor did signifies any pre-existing disease.  Further Dr.Mohinish Chabbra in his opinion dated 29.07.2020 (Annexure H) has observed that upon his continuous examination of the complainant since the year 2009, there has been no instance where any evidence of gallbladder stones could be detected in her reports or tests.  Thus, we have no hesitation in our mind to observe that the complainant was not undergoing any active treatment or under any medication for alleged pre-condition that is gastritis and hence, the complainant cannot be deemed to be under any positive knowledge of such ailment sickness of injury which required medical attention whilst on tour abroad.  Pertinently, there is no conclusive diagnosis of “Cholecystitis” and the same were only suggestive. Hence, the claim of the complainant was wrongly repudiated by the OPs.
9.         In New India Assurance Co. Ltd. Vs. Arun Krishan Puri, III(2009) CPJ 6 (NC), it was held that onus to prove the pre-existing disease of the insured at the time of taking the policy lay on the insurer. Further in the absence of verification of discharge summary by the doctor, who treated /issued the same, no reliance can be placed on it. In the absence of such evidence, the repudiation of the claim by the OPs cannot held to be justified.
10.         It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. 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., III (2008) CPJ 63 (SC) is fully attracted, wherein 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.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.

                In similar set of facts the 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:-

          “It seems 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.

                In view of the above discussion, we hold that the OPs-Insurance Company have wrongly and illegally rejected the claim under the policy.

11.         Consequently, the present complaint deserves to be partly allowed and the same is accordingly partly allowed. The OPs No.1 and 2 are directed to process all the cashless claims submitted by the US Medical Providers or by the complainant for claim reference No.M137863.13 covered under the “Future Travel Suraksha Policy No.T0659693.
12.         This order be complied with by the OP(s) No.1 and 2, within 45 days from the date of receipt of its certified copy.
13.         The complaint qua OP No.3 stands dismissed.
14.         The pending application(s), if any, stands disposed of accordingly.
15.         Certified copies of this order be sent to the parties as per rules. The file be consigned.

Announced in open Commission 14.05.2024
	Sd/- (AMRINDER SINGH SIDHU) PRESIDENT
	Sd/-
	(B.M.SHARMA) MEMBER