Nidhi Verma, Member
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 against the opposite parties on the allegations that the complainant had planned to go to abroad [UK] having his passport No.L2707285 and in order to insurance cover in abroad he approached opposite party No.1 at Amritsar office, which is the business partner and corporate agent of opposite party No.2 and a policy No.0216002616991737776 for period 03.12.2016 to 18.01.2017 was issued to the complainant by the opposite parties on receipt of premium from the complainant. Unfortunately on 9.12.2016 he felt stomach pain and he contacted at helpline number mentioned in the policy of opposite party and on their advise, the complainant went to Queen's hospital where he was treated on the basis of above policy and a bill of 775 pounds was prepared and issued, which was not charged from the complainant as the same was covered under the above insurance policy. The complainant was also remained admitted in hospital Wexham Park Hospital Wexham Street, Slough SL2 4HL for which a bill of 1162.25 pound was charged, which was also not charged from the complainant being covered under the policy. The complainant came back to India after his tour. Barking Havering & Redbridge NHS Trust submitted their hospital bills to the opposite parties for payment but the complainant was surprised to receive a letter from the said trust that payment of hospital bills of the treatment of the complainant in abroad have not been paid by the opposite parties. Barking, Havering & Rebridge NHS Trust informed that these bills have not been settled and they asked the complainant to settle within 7 days of the said letter and further threatened that it will be referred to a debt collection agency and the complainant will face litigation. Further threatened to invoke the immigration rules 320, 321, 321A and 322 in which a person with outstanding debts of over 1000 pounds for NHS treatment which are not to be paid within three months of invoicing, may be denied a further immigration application to enter in the UK. The complainant has prayed the following reliefs:-
(i)] The Opposite parties be directed to settle the claim of 775.50+1162.25 pounds that is INR-1,55,040/- approx. in favour of trust namely Barking, Havering & Redbridge NHS Trust, RF4 Receivables 6619 Shared Business Services, Phoenix House, Topcliffe Lane, Wakefiele WF3, 1WE immediately without late and also pay if any fine is imposed by the said trust; or in the alternative if the same amount is recovered from the complainant by the said trust then opposite parties be directed to pay the same to the complainant along with interest @12% p.a. on the said amount;
(ii) The opposite parties be directed to pay compensation of Rs.25,000/- for the mental tension, harassment and agony suffered by the complainant on account of deficiency in service on the part of the opposite parties.
(iii) Litigation expenses of the present complaint, as Commission deem fit, be also awarded in favour of the complainant in the interest of justice, equity and fair play.
3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the complainant has not come to this commission with clean hands, as the various material facts are concealed by him from this Commission. The complainant had obtained the Med. claim policy from the OP 1 vide No.0216002616991737776, who provides Global assistance service and ancillary products such as Trawell Tag and offers Travel insurance as an add-on benefits, it is corporate agent provide polices underwritten by OP2 with settled terms and conditions. As came into the knowledge of the OP1 from the instant complaint that complainant had filed his med-claim on the basis of above said policy with the OP2, which was rejected by the OP2 because as per the settled terms and conditions of the policy specifically stated in 12 (C) pre-existing condition: the pre-existing conditions means any sickness/illness, which existed prior to the effective date of this insurance including whether or not the insured person had knowledge the symptom were related to the sickness/illness. Complication arising from the pre-existing condition will also be considered part of pre-existing condition." It is mentioned over here that the complainant has neither approached nor made any correspondence with the OP1 in regard to his alleged med claim at any point of time, he directly approached to the OP2 & who after considering his case with their medical panel, rejected the claim of the complainant, whereas it was duty of the complainant to send the information to the OP No. 1 regarding his med claim, so the OP No. 1 has having no any type of liability regarding the alleged claim filed by the complainant or rejected by the OP No. 2, hence the complaint of the complainant may kindly be dismissed on this score alone against OP No. 1. The complaint of the complainant is not maintainable in the present form against the OP No. 1. No cause of action arose to the complainant against the O.P. No. 1 as the complainant filed their claims or made the correspondence directly with OP No. 2, who after considering the case of the complainant rejected his claim, which came into the knowledge of the OP No. 1 from the instant complaint. The complainant is estopped by his own act and conduct to file the present complaint, as he has having full knowledge regarding his pre-existing ailment but even then he intentionally filed the instant complaint, although the OP No. 1 has having no involvement at any point of time. Till day, the complainant neither approached nor informed his illness or made any correspondence with OP No. 1 and prayed for dismissal of the complaint.
4 The opposite party No. 2 appeared and filed written version and contested the complaint by interalia pleadings that the complainant has not come to this commission with clean hands, as the various material facts are concealed by him from this commission. The complainant had obtained the Med. claim policy from the OP 1 vide No.0216002616991737776, who is corporate agent provide polices underwritten by OP2 with settled terms and conditions of company. The complainant filed his med-claim on the basis of above said policy and after gone through the documents produced by the complainant, it has come into the knowledge of the OP2 that complainant has past history of renal calculus, which is pre-existing disease & not covered under the policy issued to the complainant by OP1 & thereafter opinion of the medical panel has also been sought in this contest & then the claim of the complainant was rejected by the OP2, who is custodian of public money. The detailed contents of condition of the policy as stated in 12 (c) pre-existing condition: the pre-existing conditions means any sickness/illness, which existed prior to the effective date of this insurance including whether or not the insured person had knowledge. The symptom were related to the sickness/illness. complication arising from the pre-existing condition will also be considered part of pre-existing condition." so the claim of the complainant has rightly been rejected by the OP2, which come under the condition as stated above, hence the complaint of the complainant may kindly be dismissed on this score alone against OP1. The complaint of the complainant is not maintainable in the present form against the OP1. The complainant is estopped by his own act and conduct to file the present complaint, as he has having full knowledge regarding his pre-existing ailment but even then he intentionally filed the instant complaint, hence the present complaint is liable to be dismissed on this score also. No cause of action arose to the complainant against the OP No. 2 because he has having fully aware about the terms and conditions of the policy as well as his pre-existing decease, so the present complaint is without any cause of action, as such the complaint of the complainant is liable to be dismissed against OP1 on this score alone. The present complaint filed by the complainant with malafide intension to indulge the OP in the unnecessary litigation. The opposite party No. 2 has denied the other contents of the complaint and prayed for dismissal of the same.
5 To prove his case, Ld. counsel for the complainant tendered in evidence affidavit of complainant Ex.C-1, copy of cover note Ex. C-2, copy of policy Ex. C-3, copy of bill dated 21.12.2016 amounting to 775.50 pond Ex. C-4, copy of the bill statement dated 21.12.2016 Ex. C-5, copy of the bill dated 30.12.2016 amounting to 1162.25 pond Ex. C-6, copy of demand notice sent by NHS Ex. C-7, affidavit of complainant Ex. C-8 and closed the evidence. Ld. counsel for the opposite party No.1 tendered in evidence affidavit of Karan Kapoor Branch Head Ex. OP1/1, copy of acknowledgement Ex. OP1/2. The opposite party No. 2 tendered in evidence affidavit of Sh. Surinder Singh Divisional Manager Ex. OP2/1, copy of letter dated 4.8.2017 Ex. OP2/2, copy of insurance cover Ex. OP2/3, copy of terms and conditions Ex. OP2/4.
6 We have heard the Ld. counsels for the parties and have carefully gone through the record.
7 In the present complainant, the complainant planned to go to abroad UK having his passport number L2707285 and in order to insurance cover in abroad he approached opposite party No. 1 at Amritsar office which is the business partner and corporate agent of opposite party No. 2 and policy number 02160026169917377764 for period 3rd December 2016 to 18th January 2017 was issued to the complainant by the opposite parties on receipt of premium from the complainant (Ex C-2 &C-3). On 9th December 2016 complainant felt stomach pain and he contacted at helpline number mentioned in the policy of opposite party and on their advice the complainant went to Queen's hospital where he treated on the basis of above policy and a bill of 775 pounds were prepared and issued which was not charged from the complaint as the same was covered under the above insurance policy (Ex C-43). The complainant was also remained admitted in hospital Wexham Park Hospital for which a bill of 1162.25 pound was charged ,which was also not charged from the complaint being covered under the policy (Ex C-6). Later Barking Havering & Redbridge NHS Trust Submitted their hospital bills to the opposite parties for payment but the complainant was surprised to receive a letter from the said trust that payment of the hospital bills of the treatment of the complainant in abroad have not been paid by the opposite parties. The complainant received the letter from the said trust regarding invoke the immigration rules 320,321,321A and 322.
8 OP No 1 stated in their written version that the complainant had obtained the mediclaim policy from the opposite party number 1 vide no. 0216002616991737776 who provides global assistance service and ancillary products such as trawell tag and offer travel insurance as an add on benefits it is corporate agent provide policy underwritten by opposite party 2 with selected terms and conditions. OP NO2 rejected the claim as per the settled term and conditions of the policy specifically stated in 12© pre existing conditions : The pre existing conditions means any sickness/ illness which existed prior to the effective date of this insurance including whether or not the insured person had knowledge the symptom were related to the sickness / illness. complications arising from the pre existing condition will also be considered part of pre existing condition ”.
9 Further, the complainant has neither approached not made any correspondence with the opposite party 1 in regard to his alleged mediclaim at any point of time he directly approached to the opposite party 2. Who after considering his case with their mediclaim panel rejected the claim of the complainant.
10 The OP No.2, stated in their written version that the complainant had obtained the mediclaim policy from the opposite party 1, Who is corporate agent provide policies under written by opposite party 2 with settled term and conditions of company. The complainant filed his mediclaim on the basis of above said policy and after gone through the documents produced by the complainant it has come into the knowledge of the opposite party No. 2 that complainant has post history of renal calculus, which is pre-existing disease and not covered under the policy issued to the complainant by opposite party 1 and thereafter opinion of the medical panel has also been sought in this contest and then the claim of the complainant was rejected by the opposite party 2. The detailed contents of condition of the policy as stated in 12© pre existing conditions : The pre existing conditions means any sickness/ illness which existed prior to the effective date of this insurance including whether or not the insured person had knowledge the symptom were related to the sickness / illness. Complications arising from the pre existing condition will also be considered part of pre existing condition ”. ( Ex OP2/4)
11 The complainant has placed on record documents which show that he had taken a travel insurance policy from OPs. While in UK, He had been hospitalized and remained admitted in the hospital and hospital had raised bill of 775.50+ 1162.25 pounds. Further, the complainant placed on record the Affidavit (Ex C-8) stated that – “I had no knowledge, I’m suffering from problem of renal calculus at the time of purchase health policy from opposite parties No. 1 and 2. I had no knowledge I’m suffering from problem of renal calculus at the time of goes abroad”. While OP No 2 , placed on record the letter dated 04.08.2017( Ex OP2/2) stated that :-
12 From the documents you submitted we learnt that you are suffering from the following complaints during your trip abroad:-
Present complaint : left sided colic
Diagnosis: left ureteric calculus
Past history: renal calculus
Policy exclusion : pre- existing condition and related ailment
On the basis of the above detail they rejected the medi-claim of the complainant :- that policy doesn’t cover any pre-existing disease and related complications. But on what ground they repudiated the claim , no record of medical history provided by the OP nor they clarified from where they get any information regarding renal calculus . Only providing terms and conditions plus writing letter is not sufficient to prove their point. We consider this as unfair trade practice which follows deficiency in service by repudiating just claim for medical expenses. The Indians when travel abroad obtained travel insurance policy in order to cover the medical expenditure if any as the healthcare expenditure is very costly in abroad. Refusing to reimburse medical expenditure or repudiating claim on the basis of pre- existing disease without seeking informed consent for the insurance contract is unfair trade practice on the part of OPs.
The opposite party No. 2 has not placed on record any document regarding the plea of pre-existing disease. How the opposite party No. 2 has reached to the conclusion that the complainant is suffering from renal calculus. No cogent documentary proof has been placed on record to establish the pre-existing disease. Not even a single document like the treatment record of any hospital from where the complainant was taking the treatment of renal calculus has been placed on record. In the absence of such document the opposite party No. 2 has not even brought the treating doctor in the witness box for the said disease and whether the complainant was taking the medicine for the alleged pre-existing disease. The opposite party No. 2 has miserably failed to prove that the complainant is suffering from any pre existing disease.
Parvin Damani vs Oriental Insurance Co.Ltd , revision petition no 1696 of 2005 decided on 3rd October 2006 by Honorable National Consumer Dispute Redressal Commission New Delhi, if the insured is not aware about the diseases he is suffering and not taken treatment for the same such a diseases cannot be considered as pre-existing diseases.
13 In view of the facts that no explanation has been furnished by the opposite parties, we hold that the opposite parties were deficient in rendering services to the complainant. The opposite parties ought to have released the claim amount of 775.50+1162.25 pounds which was the bill raised by the hospital.
14 In view of above discussion, the present complaint is allowed and the opposite parties are directed to make the payment off 775.50+1162.25 pounds that is INR-1,55,040/- approx. in favour of trust namely Barking, Havering & Redbridge NHS Trust, RF4 Receivables 6619 Shared Business Services, Phoenix House, Topcliffe Lane, Wakefiele WF3, 1WE. The complainant has been harassed by the opposite parties for a long time therefore, the complainant is also entitled to Rs. 15,000/- (Rs. Fifteen Thousand only) as compensation and Rs. 10,000/- (Rs Ten Thousand only) as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
21.10.2022
