DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/195/2020

Date of Institution : 09.09.2020

Date of Decision : 06.12.2023

Jaswinder Kaur Passi wife of Teja Singh resident of Balianwali, District Bathinda.    

                  …Complainant

Versus

1. Gupta Tour and Travel, Sadar bazar Near Bhagat Singh Chownk, Barnala through its managing director/proprietor. 

2. Bajaj Allianz General Insurance Company Limited, SCO 147 Ferozgandhi Market, Ludhiana 141001 through its manager. 

3.    Bajaj Allianz General Insurance Company Limited, GE PLAZA, Air Port Road Yerawada, Pune, 411006 through its managing director.  

              …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. P.S. Kaushal Adv counsel for complainant.

Opposite party No. 1 exparte.

Sh. N.K. Garg Adv counsel for opposite parties No. 2 & 3.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

3.Sh. Navdeep Kumar Garg : Member

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

    The complainant Jaswinder Kaur Passi filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Gupta Tour and Travel and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that complainant had to go Norway to visit her daughter as such complainant got her travel/health insured from the opposite parties No. 2 & 3 through opposite party No. 1 and choosed plan TRAVEL ELITE SILVER (US$ 50,000) and paid Rs. 2,881/- as premium vide which TRAVEL ELITE SILVER (US$ 50,000) policy schedule of policy No. OG-19-1203-9910-00000700 was issued to complainant by the opposite parties No. 2 & 3 through the opposite party No. 1 for period from 10.6.2018 to 5.9.2018. It is further alleged that the complainant has been go to Norway for the period 23.6.2018 to 12.9.2018, where complainant got health complications and treated for HYPERGLYCEMIA, as such complainant remained admitted in the Vestre Viken, drammen Sykehus, Medcine 2, 3004 Drammen hospital from 30.8.2018 to 2.9.2018 at Norway and had to pay Norwegian Krone 43,862/- that comes to the tune of around 3,42562/- Indian Rupees. It is alleged that after arrival, the complainant brought this fact into the knowledge of opposite parties and lodged claim before them but the opposite parties No. 2 & 3 told the complainant to provide the number of documentation and to provide attending physician statement form, which is to be filled by the attending doctor and there after without any cogent reason repudiated the claim of the complainant only by saying that “that you have consulted for the treatment of Diabetes Mellitus/Kidney Failure and received medical records suggested insured was suffering from Diabetes Mellitus since 3.5 years and is on continues treatment for the same” and policy does not cover any pre-existing medical condition whereas complainant had no such medical complication at the time of her departure or getting herself insured from the opposite parties. It is further submitted that complainant is an illiterate lady and at the time of charging premium from the complainant no such conditions were disclosed to complainant nor any policy qua the terms and conditions of insurance, was issued to complainant. It is further submitted that no such medical record was provided by the complainant to opposite parties No. 2 & 3, as such it has no effect qua the rights of complainant. The said claim has not been disbursed to the complainant till now despite repeated requests made by the complainant and personal visits to the office of opposite parties No. 2 & 3. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1)The opposite parties may kindly be directed to disburse the aforementioned amount of Rs. 3,42,562/- alongwith upto date interest @ 18% per annum from the date of lodging the claim to the complainant. 

2) To pay Rs. 2,00,000/- on account of compensation for mental agony and harassment and Rs. 50,000/- as litigation expenses.

3. Notice was served to opposite party No. 1 on 22.9.2020 but the opposite party No. 1 failed to appear and was proceeded against exparte vide order dated 19.10.2020. 

4. Upon notice of this complaint, opposite parties No. 2 & 3 appeared and filed written reply taking preliminary objections that the present complaint is a gross abuse of process of law and it absolutely false, frivolous and vexatious and no cause of action has been arose to the complainant and the same is liable to be dismissed. The complainant has suppressed material facts and not approached with clean hands. Further, an intricate question of law and facts are involved in the present complaint which requires voluminous documentary evidence for determination of dispute at hand etc. 

5. On merits, it is admitted that complainant Jaswinder Kaur obtained travel Elite Silver Policy from the opposite parties having No. OG-19-1203-9910-00000700 for the period from 10 JUN-2018 to 5-Sep-2018 or date of return whichever is earlier and vide which the complainant had opted to get covered herself for medical expenses upto US$ 50,000 with deductible of USD 100 and beside this, complainant also got insured herself under various heads which are reflected in the policy schedule and paid total premium of Rs. 2,881/- by the complainant under this policy. It is further alleged that this policy has been issued on the information provided to answering opposite parties and policy is not valid if the information provided is incorrect. This policy also does not cover any pre-existing medical condition/injury/illness/deformity and complications arising from them that are declared or undeclared. The policy coverages are as per the policy terms and conditions mentioned in the Travel Kit provided with the policy schedule. It is further alleged that the alleged claim of the complainant was duly processed by the answering opposite parties and as per medical record of the complainant the complainant has consulted for the treatment of Diabetes Mellitus and Kidney Failure, who was suffering from Diabetes Mellitus since 3.5 years and is on continues treatment for the same, which is prior to the inception of policy, Current ailment is pre-existing medical condition. Policy does not extend coverages for pre-existing ailment and its complications as per exclusion clause of the policy. There is evidence of material suppression by non disclosure of material fact i.e. pre-existing ailment which in itself is a violation of principle of insurance as well as terms and conditions of policy and declaration made thereof before the insurance policy. This policy does not cover any pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared. Hyperglycemia is most commonly caused by diabetes mellitus and hyperglycemia is usually caused by low insulin level. It is further submitted that the amount of USD 100 is required to be deductible from the claim amount. Other allegations of the complainant are denied and it is also denied that there is deficiency in service and unfair trade practice on their part and lastly prayed for the dismissal of complaint. 

6. In support of her complaint, the complainant tendered into evidence her own affidavit Ex.C-1, copy of insurance policy Ex.C-2, copy of certificate issued by hospital Ex.C-3, copy of request letter Ex.C-4, copy of hospital stay claim Ex.C-5, copy of deficiency reminder Ex.C-6, copy of repudiation letter Ex.C-7, copy of passport Ex.C-8, copy of Adhaar Card Ex.C-9, copy of sale deed Ex.C-10 (containing 10 pages) and closed the evidence. Ld. Counsel for complainant on 8.11.2021 has suffered the statement that I do not want to file any rejoinder on behalf of complainant. 

7. To rebut the case of the complainant the opposite parties No. 2 & 3 tendered into evidence affidavit of Saurabh Khullar Ex.O.P.2.3/1, affidavit of Dr. Ravindra Ex.O.P.2.3/2, copy of policy Ex.O.P.2.3/3 (containing 5 pages), copy of terms and conditions Ex.O.P.2.3/4 (containing 38 pages), copy of repudiation letter Ex.O.P.2.3/5, copy of medical treatment record as Ex.O.P.2.3/6 (21pages), copy of certificate dated 27.6.2019 Ex.O.P.2.3/7, copy of letter dated 6.5.2019 (containing 2 pages) and closed the evidence.  

8. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by the parties have also been gone through.  

9. Ld. Counsel for the complainant argued that the complainant had to go Norway to visit her daughter and got her travel/health insured from the opposite parties No. 2 & 3 through opposite party No. 1 and choosed plan TRAVEL ELITE SILVER (US$ 50,000) and paid Rs. 2,881/- as premium vide which TRAVEL ELITE SILVER (US$ 50,000) policy schedule of policy No. OG-19-1203-9910-00000700 which was issued to complainant by the opposite parties No. 2 & 3 through the opposite party No. 1 for period from 10.6.2018 to 5.9.2018 (Ex.C-2). It is further argued that the complainant got health complications and treated for HYPERGLYCEMIA, and remained admitted in the Vestre Viken, drammen Sykehus, Medsine 2, 3004 Drammen hospital from 30.8.2018 to 2.9.2018 at Norway (Ex.C-3) and had to pay Norwegian Krone 43,862/- that comes to the tune of around 3,42562/- Indian Rupees (Ex.C-5). It is further argued that after arrival, the complainant brought this fact into the knowledge of opposite parties and lodged claim before them but the opposite parties No. 2 & 3 told the complainant to provide the number of documentation and to provide attending physician statement form, which is to be filled by the attending doctor and there after without any cogent reason repudiated the claim of the complainant only by saying that “that you have consulted for the treatment of Diabetes Mellitus/Kidney Failure and received medical records suggested insured was suffering from Diabetes Mellitus since 3.5 years and is on continues treatment for the same, which is prior to the inception of policy. Current ailment is pre-existing medical condition. Policy does not extend coverage for pre-existing ailment and its complications as per below exclusion clause” (Ex.C-7). It is further argued that complainant is an illiterate lady and at the time of charging premium from the complainant no such conditions were disclosed to complainant nor any policy qua the terms and conditions of insurance, was issued to complainant. It is also argued that no such medical record was provided by the complainant to opposite parties No. 2 & 3, as such it has no effect qua the rights of complainant. It is further argued that the said claim has not been disbursed to the complainant till now despite repeated requests made by the complainant and personal visits to the office of opposite parties No. 2 & 3, as such the above said act of the opposite parties amounts to deficiency in service and unfair trade practice.

10. Ld. Counsel for the opposite parties No. 2 & 3 argued that the complainant Jaswinder Kaur obtained travel Elite Silver Policy from the opposite parties having No. OG-19-1203-9910-00000700 for the period from 10 JUN-2018 to 5-Sep-2018 or date of return whichever is earlier and vide which the complainant had opted to get covered herself for medical expenses upto US$ 50,000 with deductible of USD 100 and beside this, complainant also got insured herself under various heads which are reflected in the policy schedule and paid total premium of Rs. 2,881/- by the complainant under this policy (Ex.O.P.2.3/3). It is further argued that this policy has been issued on the information provided to the  opposite parties and policy is not valid if the information provided is incorrect and this policy also does not cover any pre-existing medical condition/injury/illness/deformity and complications arising from them that are declared or undeclared and the policy coverages are as per the policy terms and conditions mentioned in the Travel Kit provided with the policy schedule. It is further argued that the alleged claim of the complainant was duly processed by the opposite parties and as per medical record of the complainant the complainant has consulted for the treatment of Diabetes Mellitus and Kidney Failure, who was suffering from Diabetes Mellitus since 3.5 years and is on continues treatment for the same, which is prior to the inception of policy, Current ailment is pre-existing medical condition and policy does not extend coverages for pre-existing ailment and its complications as per exclusion clause of the policy. There is evidence of material suppression by non disclosure of material fact i.e. pre-existing ailment which in itself is a violation of principle of insurance as well as terms and conditions of policy and declaration made thereof before the insurance policy. This policy does not cover any pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared. Hyperglycemia is most commonly caused by diabetes mellitus and hyperglycemia is usually caused by low insulin level. It is further submitted that the amount of USD 100 is required to be deductible from the claim amount. It is further argued that the claim of the complainant repudiated by the opposite parties vide letter dated 23.8.2019 Ex.O.P.2.3/5 by mentioning the clause 2.4.12 i.e. “Any medical condition or complication arising from it which existed before the commencement of the policy period, or for which care, treatment or advice was sought, recommended by or received from a Physician”.

11. It is admitted case between the parties that the complainant had to go Norway to visit her daughter and got her travel/health insured from the opposite parties No. 2 & 3 through opposite party No. 1 and choosed plan TRAVEL ELITE SILVER (US$ 50,000) and paid Rs. 2,881/- as premium vide which TRAVEL ELITE SILVER (US$ 50,000) policy schedule of policy No. OG-19-1203-9910-00000700 which was issued to complainant by the opposite parties No. 2 & 3 through the opposite party No. 1 for period from 10.6.2018 to 5.9.2018. 

12. The case of the opposite parties No. 2 & 3 is that as per the medical record of the complainant the complainant has consulted for the treatment of Diabetes Mellitus and Kidney Failure, who was suffering from Diabetes Mellitus since 3.5 years and is on continues treatment for the same, which is prior to the inception of policy. Current ailment is pre-existing medical condition and policy does not extend coverages for pre-existing ailment and its complications as per exclusion clause of the policy. Further there is evidence of material suppression by non disclosure of material fact i.e. pre-existing ailment which in itself is a violation of principle of insurance as well as terms and conditions of policy and declaration made thereof before the insurance policy. So, this policy does not cover any pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared. It is also the case of the opposite parties that  Hyperglycemia is most commonly caused by diabetes mellitus and hyperglycemia is usually caused by low insulin level. To prove their case the opposite parties No. 2 & 3 have placed on record affidavit of Dr. Ravindra Ex.O.Ps.2.3/2. We have gone through the affidavit of above said doctor and are of the view that the same is without mentioning educational qualification or designation as well as address of the doctor, as such the same is not admissible in the eyes of law. Further, the opposite parties have placed on record copy of certificate dated 27.6.2019 Ex.O.Ps.2.3/7 vide which it is written that  Jaswinder Kaur Passi is suffering from Diabetes and is under my treatment since last about 3.5 years. But in support of this certificate Ex.O.Ps.2.3/7 no affidavit of treating doctor has been placed on record by the opposite parties. The opposite parties have failed to place on record proposal form. Moreover, the opposite parties have also failed to prove the fact that the terms and conditions were duly supplied to the complainant alongwith policy by producing any evidence about the receipt or mode of delivery.  

13. So, from the perusal of record it is proved that the complainant has taken treatment from Vestre Viken, drammen Sykehus, Medcine 2, 3004 Drammen hospital from 30.8.2018 to 2.9.2018 at Norway and paid 43,862 Norwegian Krone. It is also proved fact that the amount of USD 100 is required to be deductible from the claim amount as mentioned in the policy (Ex.C-2 & Ex.O.Ps.2.3/3 at Page No. 3). Further, there is nothing produced on record from the side of opposite parties that the medical examination of the insured was got conducted by the insurance company at the time of issuing policy, even the complainant was about 58 years of age at that time. It is the duty of the insurance company to conduct the thorough medical examination of the complainant, who has attained the age of about 58 years. Therefore, it is proved on record that the complainant is entitled to the amount which was spent i.e. Norwegian Krone 43,862/- (as per Ex.C-5) by her on treatment in the above said hospital minus  100 USD (as per policy Ex.C-2 & Ex.O.Ps.2.3/3). 

14. Ld. Counsel for the complainant has relied upon the judgment in case titled United India Insurance Co. Ltd. & Anr. Vs S.M.S. Tele Communication & Anr. III (2009) CPJ (NC), vide which it was observed that being aware of the existence of policy, is one thing, and being aware of the contents and meaning of the clauses of the policy, is another. It is, therefore, held that it was the bounded duty of the opposite parties, to supply the terms and conditions of the policy, to the complainant immediately, after the premium was paid paid by him. In this case, neither the terms and conditions same were supplied to the complainant, nor the same were explained to him, nor exclusion clauses were made known to him. Due to this reason, there was deficiency in service, in rendering service, on the part of the opposite parties. 

15. Ld. Counsel for the complainant further relied upon the judgment of Hon'ble Chandigarh State Consumer Disputes Redressal Commission (Union Territory) Complaint Case No. 234 of 2017 D/d 22.3.2018 in case titled Manish Goyal Vs Max Bupa Health Insurance Company Limited and others. 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.  

16. Ld. Counsel for complainant has also relied upon the judgment In R.P. No. 4461 of 2012 in case titled Neelam Chopra Vs Life Insurance Corporation of India & Ors., decided on 8.10.2018 (NC) vide which it was held in Para No. 11 that;-

“From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims”. 

17. The Ld. Counsel for complainant further relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and  others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums. 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 company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.

18. So, from the above discussion, it is established that the claim of the complainant was repudiated by the insurance company on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite parties No. 2 & 3. Therefore, the present complaint is partly allowed against the opposite parties No. 2 & 3 and the same are directed to pay Norwegian Krone 43,862/- minus 100 USD as per policy (as per the INR (Indian Rupees) exchange rate which was prevailed at the time of payment of the medical bill) alongwith interest @ 7% per annum to the complainant from the date of filing of the present complaint till realization. The opposite parties No. 2 & 3 are further directed to pay Rs. 5,500/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.

19. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

20. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       6th Day of December, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member

 

(Navdeep Kumar Garg)

Member