Chandigarh

DF-II

CC/82/2017

Sh. Sumesh Chander Khazanchi - Complainant(s)

Versus

M/s Future Generali India Insurance Company Ltd., - Opp.Party(s)

Ravinder Rana Adv. & Raj Karn Adv.

09 Dec 2017

ORDER

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

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Consumer Complaint  No	:	82 of 2017
Date  of  Institution	:	23.01.2017
Date   of   Decision	:	09.12.2017

 

 

 

 

Sumesh Chander Khazanchi aged about 66 years s/o Sh.Madan Gopal Khazanchi, R/o H.No.465, First Floor, Sector 20-A, Chandigarh   

             …..Complainant

Versus

1]  M/s. Future Generali India Insurance Company Ltd., Policy Servicing Office, SCO No.78-79, 2^nd Floor & 3^rd Floor, Sector 17-C, Chandigarh 160017 through its Branch Head.

2]  M/s. Future Generali India Insurance Company Ltd., Corporate & Registered Office: 6^th Floor, Tower-3, Indiabulls Finance Center, Snapati Bapat Marg, Elphinstone Road, Mumbai (Maharashtra) 400013 through its Managing Director.

3]  Europe Assistant Exclusions India Pvt. Ltd., C/o 301, ‘C’ Wing, Business Square, Andheri Kurla Road, Chakala, Andheri (East), Mumbai-400 093 through its Managing Director  

….. Opposite Parties  

 

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

                                SH.RAVINDER SINGH              MEMBER

 

 

For complainant(s)      : Sh.Ravinder Rana, Advocate.  

 

For Opposite Party(s)   : Sh.Rajesh Sharma, Adv. for OPs No.1 & 2.

  OP No.3 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant had gone abroad (USA) on 28.5.2014 to visit his son Bhuvan Khazanchi on Tourist Visa.  It is averred that while the complainant went abroad he was keeping good health and was taking aspirin only on the advice of doctors to control Arthritis Migraine.  The complainant also availed “Travel Suraksha-Individual” insurance policy from Opposite Parties No.1 & 2 dated 9.4.2014 for the period from 28.5.2014 to midnight of 23.11.2014 by paying requisite premium (Ann/C-1 & C-2).

         It is stated that during his visit to USA, on 17.7.2014 in the night, the complainant did blood vomiting and as such was rushed to The Elliot Health System Hospital (an empanelled Hospital), where the doctor diagnosed stomach Ulcer (Gastric Ulcer) and successfully done gastrointestinal and other services. The complainant paid the bill raised by the said Hospital to the tune of 10,239$, 880$ and 374 $, apart from spending 50.55$ on medicines.  Thereafter, the complainant submitted claim with OP Insurance Company, but the same was repudiated on 4.11.2014 on the ground of concealment of facts and also on the ground that the complainant is using Aspirin Medicine due to which the Ulcer was developed.  It is stated that on 11.11.2014 the Opposite Parties rejected the claim of the complainant on the same ground.  After that the complainant filed a Complaint No.102 of 2015 before this Forum, which was partly allowed vide order dated 29.3.2016 with directions to the Opposite Parties to settle the claim of the complainant within 30 days.  The appeal preferred by the OPs No.1 & 2 against the said order dated 29.3.2016 was dismissed by the Hon’ble State Commission, UT, Chandigarh vide order dated 25.7.2016.

         It is submitted that the OPs again vide undated letter (Ann.C-11) informed the complainant that his claim has been repudiated being not payable. Alleging the said repudiation of claim as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The OPs No.1 & 2 have filed joint reply and while admitting the factual matrix of the case, stated that the complainant suppressed the material fact with regard to his health and did not disclose the complete facts of his previous medical history of arthritis, migrane and treatment with anti-platelet agent aspirin in the proposal form (Ann.R-1).  It is stated that even the treatment record of the complainant of PGI, Chandigarh (Ann.C-14), which is prior to the issuance of policy, shows that the complainant was having chronic problem of headache/migraine with acute episodes since 2008 and was regularly taking treatment for the same and was also taking Aspirin since long time, but the said information was withheld by the complainant at the time of issuance of policy. It is submitted that the diagnosis of the complainant as per discharge card has attributed the current condition of the complainant to chronic therapy and due to anti-platelet & antithrombotic long term use. As such the complainant is not entitled to get any relief as the policy clearly provides that any claim arising or related to consequence of the pre-existing disease is excluded from the scope of policy cover. It is pleaded that the claim has rightly been repudiated. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the OPs.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the complainant in person, ld.Counsel for the OPs and have also perused the entire record.

 

6]       It is evident that the complainant purchased “Travel Suraksha-Individual” insurance policy from Opposite Parties No.1 & 2 dated 9.4.2014 for the period from 28.5.2014 to midnight of 23.11.2014 by paying requisite premium (Ann/C-1 & C-2).  Further, there is no denial that the complainant while his visit to USA on 17.7.2014 got admitted to Elliot Health System Hospital as he suffered from blood vomiting etc. and was diagnosed as a case of Stomach Ulcer (Gastric Ulcer). The complainant underwent treatment and during his hospitalization applied for cashless benefit, which was declined by the OP Insurance Company.  The complainant challenged that denial of the claim by filing complaint, which was contested as a pre-mature complaint and the OPs were directed to settle the claim of the complainant within the stipulated period mentioned in the order.  The filing of the present complaint is the outcome of the rejection of the claim formally lodged by the complainant after the passing of previous order dated 29.3.2016.

 

7]       The defence/written statement of the OP Insurance Company reflects that the claim lodged (which was formally lodged after the passing of order dated 29.3.2016) for the reimbursement of the expenditure incurred by the complainant for his treatment while his stay in Hospital Elliot Health System (USA), during the policy period, has been declined on the basis of the previous observations as were made while denying the cashless request of the complainant. 

 

8]       In this backdrop of the case, we have examined the ground taken by the OP Insurance Company for rejection of cashless facility as well as the rejection of claim lodged by the complainant. 

 

9]       It is revealed from Ann.C-7 dated 4.11.2014 that the claim of the complainant has been rejected on the ground that he has past medical history of Arthritis, Migrain and on continuing treatment with anti platelet agent-Aspirin.  It is also claimed that the ailment suffered by the complainant while his stay at USA, was the result of/consequence and was progression of ongoing anti platelet treatment for his past medical history of arthritis and migraine, which was not disclosed at the time of inception of the policy.

 

10]      In the outset, we are of the opinion that there is no medical literature or medical expert opinion on record from the side of the OP Insurance Company, to prove beyond any doubt their stand that the causation of Stomach Gastric Ulcer (which the complainant suffered while his stay in USA) was solely due to the continued intake of medicine ‘Aspirin’ by the complainant, as alleged. In common parlance, there are numerous factors responsible for the causation of the Gastric Ulcer and the medical record of the complainant on record does not support the stand of the OP Insurance Company that the complainant suffered such ailment due to the continued intake of Aspirin medicine. 

 

11]      Undoubtedly, the previous medical record of the complainant of earlier dates reveals that he was prescribed for ‘Aspirin’ for the treatment of headache/migraine suffered by him intermittently.  Further the ailment of gastric ulcer has no nexus with ailment of Headache or Migraine as suffered by the complainant and it is not one of the complication of the headache.  So, it cannot be claimed that it is outcome or is in consequence of any pre-existing disease, as alleged by the OP Insurance Company.

 

12]      For the sake of arguments, if we presume that the gastric ulcer caused was due to the regular intake of Aspirin medicine, even then the causation of gastric ulcer is only a side effect of the medicine Aspirin and has no direct nexus with his previous ailment of headache/migraine or arthritis.  The claim raised for the treatment of gastric ulcer is not a claim arising or related to consequence of the pre-existing disease which is excluded from the scope of policy cover. It is only the side effects of medicine for which the complainant cannot be blamed.  Had it been the case, he would have been advised not to continue with the medicine in future.  To the contrary, he was advised to hold Aspirin for shorter duration.  The opinion of the treating doctor of the Elliot Hospital (Ann.C-13 Page 51) is reproduced for the sake of convenience:-

         RE:  Sumesh Chander Khazanchi

     This patient should avoid NSAIDs which include names such as naproxen, ibuprofen, aleve, advil.

He will hold Aspirin until July 28 when it can be restarted.

He will take omeprazole over –the-counter daily along with carafate four times daily for the next month.

He is to seek immediate medical attention for worsening signs of anemia including shortness of breath, fatigue, weakness and of course any sign of rectal bleeding (dark stool or bright red).  Some dark stool for the next 2-3 days is normal.”

 

13]      From the above discussion, we can safely conclude that rejection of the claim solely on the basis of complainant’s taking Aspirin medicine for longer period, is not sustainable and is hereby held as illegal, untenable. Hence, the deficiency in service on the part of OP Insurance Company (OPs NO.1 & 2) is proved.

 

14]      So far as the allegation regarding concealment of pre-existing disease is concerned, the complainant was not subjected to any medical examination by the Insurance Company, while subscribing for the policy in question.  The age of the complainant at the time of availing the policy was 66 years and it was the duty of the Insurance Company to get the medical examination of the complainant before issuing the policy in his favour and could have investigated thoroughly. Now they cannot take any ground of pre-existing disease, after lodging of the claim by the complainant, for its rejection.  In addition, it is also observed that the terms & conditions of the policy placed on record by the OP Insurance Company, are nowhere recorded to be delivered to the complainant.   

 

15]      Keeping in view the above findings, we are of the opinion that the deficiency in service on part of OPs NO.1 & 2 is proved.  Therefore, the complaint is allowed with directions to OP NO.1 & 2 – M/s Future Generali India Insurance Company Ltd. to make payment of 11493.55$ to the complainant in Indian Currency taking the Indian currency value as on 17.7.2014 (date of admission), being the medical expenses incurred by him, along with compensation of Rs.10,000/- for causing mental & physical harassment and litigation cost of Rs.5,000/-, within a period of 30 days from the date of receipt of certified copy of this order.

         In case the Opposite Party No.1 & 2 failed to comply with the order within the above stipulated period, then they shall also be liable to pay additional compensatory cost of Rs.20,000/- to the complainant apart from the above relief.

 

16]      However, the complaint qua OP NO.3/Europe Assistant Exclusions India Pvt. Ltd. stands dismissed.

         Certified copy of this order be forwarded to the parties, free of charge. After compliance, file be consigned to record room.

Announced

9^th December, 2017                                                                           Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER