Chandigarh

DF-II

CC/172/2018

Harbans Singh Palla - Complainant(s)

Versus

Future Generali India Insurance Company Limited - Opp.Party(s)

Manoj Lakhotia Adv.

06 Sep 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	172 of 2018
Date  of  Institution	:	20.03.2018
Date   of   Decision	:	06.09.2019

 

 

 

 

Harbans Singh Palla s/o Late Sh.Dalip Singh, aged about 72 years, Resident of House No.1516, Sector 51-B, Chandigarh.  

             ……..Complainant

 

Versus

 

Future Generali India Insurance Company Limited, SCO No.78-79, 3^rd Floor, Sector 17-C, Chandigarh.

 

………. Opposite Party

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

         SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Sh.Manoj Lakhotia, Adv. for complainant.

Sh.Rajesh Sharma, Adv. for Opposite Party

 

 

PER PRITI MALHOTRA, MEMBER

 

                                The case of the complainant in brief is that the representative of Opposite Party approached the complainant for providing medical insurance policy, to which complainant agreed.  It is averred that the representative of the OP Insurance Company, after due investigations and going through the entire medical records, past medical history with further enquiring about earlier insurance policies issued from time to time, obtained the signatures of the complainant and his wife on some papers/forms. The complainant paid a sum of Rs.23,552/- as premium and accordingly, medical Insurance policy ‘Future Travel Suraksha – Senior Citizen Insurance Policy bearing No.2016-T0443590-FTS for the period effective from 9.5.2016 to 29.9.2016 was issued  (Ann.C-1).  

         It is averred that the complainant during his visit to Sydney, Australia, all of a sudden on 1.6.2016 suffered acute abdominal pain and as such taken to Dr.Giridhar Parla at Blacktown NSW and then got admitted to Westmead Hospital on 2.6.2016. It is averred that after thorough investigation, the complainant was diagnosed with Acute Cholangitis (no predisposing factors), which required urgent intravenous antibiotics and Endoscopic Retrograde Pancreatography (ERCP).  The investigation further revealed a 10 mm stone was unable to be retrieved.  A sphincterotomy was performed and biliary stent was inserted. The complainant was again admitted to Hospital on 5.8.2016 for removal of biliary stent.  It is submitted that this was acute condition, which had no previous history.  It is also submitted that the complainant had to undergo the procedures as recommended by the doctors over there and had to remain admitted in ICU.  It is further submitted that the complainant was to remain hospitalized twice, firstly on 2.6.2016 and then on 5.8.2016 costing total expenses of $23,240.33 (Rs.11,85,291/-) on his treatment in Sydney, Australia. However, when the complainant lodged claim with Opposite Party for reimbursement of medical expenses, the same was repudiated on the ground that the complainant had past pertinent medical history of Hypertension, diabetes Mellitus, Coronary Artery Disease, Hyperlipidemia & had undergone open cholecystectomy to which there is no disclosure made at the time of policy inception (Ann.C-30).  It is pleaded that the complainant had disclosed each and every fact about his health, medical history to the Opposite Party while proposing for the policy. Hence, this complaint has been filed alleging the said repudiation as illegal and deficiency in service on the part of Opposite Party.

 

2]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that the insurance policy was issued on the basis of information provided by the complainant (Ann.R-1 to R-3). It is stated that the complainant had past medical history of Hypertension, Diabetes Mellitus, Coronary Artery Disease, Hyperlipidemia and having undergone open Cholecystectomy.  It is stated that the treatment record of complainant dated 31.12.2010 is consistent with acute Choledocholelithiasis – calculi in CBD (Ann.R-4).  It is also stated that from medical record of Gian Sagar Medical College & Hospital it is confirmed that the complainant had suffered with CBD stone (Ann.R-5).  It is submitted that from medical record of Fortis Hospital, it is also confirmed that the complainant underwent Open Cholecystectomy on 6.1.2011 (Ann.R-6).   It is also submitted that the complainant concealed his past medical history relating to his health & treatment, in the proposal form submitted with insurance company while taking insurance, therefore, his claim has rightly been repudiated. Denying other allegations and pleading no deficiency in service, the Opposite Party has prayed for dismissal of the complaint.

 

3]      The complainant filed rejoinder thereby reiterating the assertions as made in the complaint and controverting that of the Opposite party made in the reply.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       Admittedly, the complainant availed medical Insurance policy from Opposite Party i.e. ‘Future Travel Suraksha – Senior Citizen Insurance Policy’ bearing No.2016-T0443590-FTS for the period effective from 9.5.2016 to 29.9.2016 (Ann.C-1) for the coverage of his visit to abroad. It is not disputed that during the said coverage period, the complainant visited Sydney, Australia and there he was diagnosed with Acute Cholangitis (no predisposing factors) and on investigation revealed a 10 mm stone, resultantly, sphincterotomy was performed and biliary stent was inserted. It is also not disputed that the complainant got again admitted to Hospital there on 5.8.2016 for removal of biliary stent.  The medical expenses incurred by the complainant on the said treatment during the insurance coverage period are not disputed.

 

7]       The apple of discord between the parties is the rejection of the claim lodged by the complainant with Opposite Party for reimbursement of the medical expenses incurred during the said insurance period. The reason assigned by the Opposite Party qua rejection of the claim is that the complainant concealed material facts about his previous disease/ailments and thus he is guilty of suppression of facts which claimed to have justify the repudiation of claim as right.

 

8]       In our considered opinion, the stand taken by the Opposite Party is not convincing enough to justify the repudiation of the claim by the Opposite Party, which in turn, has failed to specify, by referring/producing any particular document(s) whereby the complainant was asked to disclose about his previous ailments/disease and the answers given thereat.  The copy of the two page proposal form annexed as Ann.R-1 by the OP's, has been printed in such a miniature form with distorted print that it is quite hard to even read out the details given in the said proposal form including the so called disclosures claimed to have been relied upon by the OP's which further claimed to have been wrongly filled & singed by the complainant while availing the policy in question. The only submission the Opposite Party made is that the complainant has concealed fact about his previous ailments pertaining to past medical history of Hypertension, Diabetes Mellitus, Coronary Artery Disease, Hyperlipidemia and having undergone open Cholecystectomy in the year 2011. 

 

9]       There is clear cut absence of any of the documents from the side of the Opposite Party to revealing any of the enquiry persuaded to know about the previous health status of the complainant, rather it has been averred by the complainant, by duly sworn affidavit, that he has been issued the present policy after having been made to undergo thorough medical examination by the Opposite Party; which divulges that the Opposite Party was having all the information & record regarding the health status of the complainant and only thereafter he was issued the policy in question.

         It is clear from the medical record placed on file that the complainant was earlier diagnosed with Acute Choledocholelithiasis-calculi in CBD and thereafter underwent Open Cholecystectomy i.e. complete removal of Gall Bladder by undergoing major surgery.  In our considered opinion, it is not, at all, difficult to ascertain by way of clinical & medical examination of the person/proposer concern about the surgery undergone by him/her, by medical experts deputed by the Opposite Party.  It is also worthwhile to mention that the complainant, was above 70 years of age, when he proposed & availed the policy in question.  Further, it is also well presumed that the Opposite Party being guided as per IRDA Guidelines, must have conducted thorough medical examination of the proposer/complainant before issuing policy in question and when once the policy has been issued, then it is under complete liability to reimburse the medical expenses incurred during currency of policy coverage. 

 

10]      In the given scenario, it is clear that the policy in question has been issued by the Opposite Party in favour of the complainant only when the Opposite Party has satisfied itself regarding health status of the proposer and thus, the Opposite Party cannot be allowed to wriggle out from their liability to reimburse to the insured/complainant the medical expenses incurred during insurance period.   

 

11]      In our opinion, the repudiation of genuine claim of the complainant is totally unsustainable against the established law as laid down by Hon’ble Supreme Court as well as National Consumer Disputes Redressal Commission. 

 

         The Hon’ble Supreme Court in the case Biman Krishna Bose Vs. United India Insurance Company, civil Appeal No.3438 of 1995, has held that that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance Company. Moreover hypertension is not a material disease which is fatal in itself.

 

        The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Cahnder Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension is a common ailment and it can be controlled by medication – Claim was wrongly repudiated.”  

         The Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission, while adjudicating the matter on this substantial issue of repudiation of claim merely on the basis of suffering from Hypertension of insured person, has categorically ruled that Hypertension is not a material disease and is manageable by medication/meditation, change of life style etc. and as such, cannot be a ground for rejection of genuine claims.

 

12]      The objection raised by the ld.Counsel for Opposite Party while arguing the case about this Forum having no pecuniary jurisdiction to decide the present complaint as the sum insured under the policy in question is more than 20 lacs, is not tenable.  The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in latest judgment passed in Consumer Complaint No.1704 of 2017 – Harbinder Pal Singh Vs. M/s Angel Infrastructure Pvt. Ltd. & Anr., decided on 9.3.2018, has held that only total sum which has been paid is to be taken into consideration for deciding the pecuniary jurisdiction and since, in the present complaint the amount sought to be paid by the Opposite Party & prayed for by the complainant, is less than Rs.20 lacs, hence this Forum has the pecuniary jurisdiction to try & adjudicate the present complaint.

 

13]      Taking into account the facts & circumstances and settled position of law, as discussed in the preceding paragraphs, the claim of the complainant for medical reimbursement of Rs.11,85,291/- is found to be genuine.  The Opposite Party is found to have indulged into unfair trade practice and deficient in rendering service for repudiating the genuine medical claim of the complainant on flimsy grounds. 

 

14]      In view of the above findings, the complaint is allowed with directions to the Opposite Party to reimburse an amount of Rs.11,85,291/- to the complainant with interest @9% p.a. from the date of repudiation i.e. 4.4.2017 (Ann.R-8) till payment, with compensation of Rs.20,000/- for causing mental agony, harassment, along with litigation cost of Rs.10,000/-, within a period of 30 days from the date of receipt of copy of this order. 

         Certified copy of this order be sent to the parties, free of cost. File be consigned to record room.

Announced

6^th September, 2019              

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER