BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.44 of 2017
Date of Instt. 16.02.2017
Date of Decision: 19.06.2019
Iqbal Singh Aged 43 years son of Late S. Amrik Singh alias Amrik Singh Pardesi r/o 1568, Banbury, Dr. San Ramon, CA-94582, through his special attorney S. Gurdev Singh, Advocate son of S. Basant Singh R/o 275-C, B. R. S. Nagar, Ludhiana.
..........Complainant
Versus
1. M/s Universal Sompo General Insurance Co. Ltd., SCO-4, 2nd Floor, PUDA Complex, Near Ladowali Road, Opposite D. C. Office, Jalandhar through its Branch Manager.
2. M/s Universal Sompo General Insurance Co. Ltd., through its Managing Director, Unit 401, 4th Floor, Sangam Complex, 127, Andheri Kurla Road, Andheri (East) Mumbai-400059.
3. M/s Heritage Health TPA Pvt. Ltd. through its Managing Director, Elite Auto House, 54-A, Ground Floor, (Rear Side), Andheri-Kurla Road, Chakala, Mumbai-400093.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Hukum Chand, Adv Counsel for the Complainant.
Sh. VK Gupta, Adv Counsel for the OPs No.1 & 2.
OP No.3 exparte.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant through his attorney Sh. Gurdev Singh, Adv, wherein alleged that the complainant is the son of insured Amrik Singh @ Amrik Singh Pardesi. The father of the complainant Amrik Singh @ Amrik Singh Pardesi along with his wife Mohinder Kaur decided to visit America just to see his son Iqbal Singh and his family and accordingly, prior to proceed to USA, the deceased insured Amrik Singh Pardesi took a worldwide insurance policy under Silver Plan from OP No.1 and issued by OP No.2 for a premium of Rs.13,153/- and policy number is 2984/20101471/00/000. At the time of issuance of the insurance policy, Late S. Amrik Singh @ Amrik Singh Pardesi was hale and hearty, and he had absolutely no problem or disease of any sort even prior to this Late Amrik Singh Pardesi was not suffering from any disease and was not taking any medical help from any one here in India. Accordingly, the deceased Amrik Singh Pardesi along with his mother Mohinder Kaur left for USA on 02.09.2014 through All Nippon Airways. During his stay in USA, all of sudden on 12.12.2014 deceased Amrik Singh Pardesi had massive heart attack and he was brought to hospital, but he was dead due to massive heart attack, leaving behind the complainant and his wife Mohinder Kaur. The father of the complainant was got admitted in the Critical Care Unit of San Ramon Emergency Physicians, where he was declared dead and an amount of US$ 4400.64 were paid as per the bills to the hospital towards medical and ambulance services. The complainant also spent an amount of US $ 3510 towards the cremation charges. In all the complainant had to pay US $ 7910.64 total equivalent to the Indian Currency amounting to Rs.5,25,000/- approximately.
2. Thereafter, the complainant filed an insurance claim alongwith submitted bills of the hospital, but OP refused to accept the claim on whimsical and flimsy grounds and as such, the OPs rejected the claim of the complainant illegally, vide letter dated 29.04.2015. The deceased/Amrik Singh Pardesi had never suffered from any such disease and the rejection of the claim is nothing, but an illegal decision of the OP and as such, the instant complaint filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the claim amount of Rs.5,25,000/- alongwith compensation of Rs.10,00,000/- with interest @ 15% per annum on the aforesaid amount to be paid till the date of payment.
3. Notice of the complaint was given to the OPs, but despite service OP No.3 did not come present and ultimately, OP No.3 was proceeded against exparte, whereas OPs No.1 and 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost. It is further averred that the complainant has not approached this Forum with clean hands rather the complainant has suppressed the material facts in the present complaint. Hence, the present complaint is liable to be dismissed on this ground only. It is further alleged that there is no deficiency in service or negligence or unfair trade practice on the part of the Ops, which brings the present case adjudicable before this Forum under Consumer Protection Act. It is further alleged that the claim case of the complainant was rejected by the OP No.3, vide rejection letter dated 29.04.2015 and the reason for rejection of the claim was that the deceased insured concealed the previous ailment at the time of obtaining the policy. It was noticed by the OP that the father of the complainant was suffering from Acute Myocardial Infarction and passed away during his trip abroad and even the death certificate reveals the cause of death Acute Myocardial Infarction. The past medical history shown Hypertension, Diabetes and Dyslipidemia, Athrosclerotic Coronary Artery Disease from years. As per the policy terms and conditions Section-1, Pre-Existing Disease not covered and the relevant policy conditions are stated that the complainant is not entitled for the insurance claim and further submitted that there is no deficiency in service on the part of the answering OPs and the claim of the complainant has rightly refused. It is further submitted that the present complaint is an abuse of judicial process and is filed with an oblique motive of undue enrichment at the cost of answering OP. On merits, it is admitted that the father of the complainant got insurance policy prior to proceed USA and further admitted that the claim submitted by the complainant qua his father is rightly repudiated. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. In order to prove the case of the complainant, the Special Attorney of the complainant tendered into evidence his duly sworn affidavit Ex.CA alongwith some documents Ex.C-1 to Ex.C-17 and closed the evidence.
5. Similarly, counsel for the OPs No.1 and 2 tendered into evidence affidavit Ex.OPA alongwith some documents Ex.OP-1 to Ex.OP-7 and closed the evidence.
6. We have heard the arguments from learned counsel for the respective parties and also gone through the case file very minutely.
7. It is very much admitted that the father of the complainant Amrik Singh @ Amrik Singh Pardesi obtained insurance policy under Silver Plan from OPs after making the payment of premium and thereafter, the father of the complainant Amrik Singh @ Amrik Singh Pardesi, along with his wife Mohinder Kaur proceeded to USA and where the father of the complainant Amrik Singh died due to massive heart attack and thereafter, insurance claim of his father was filed by the complainant, but the same was rejected by the OPs, vide Repudiation Letter Ex.C-7 dated 29.04.2015 on the ground that there was pre-existing disease to the insured Amrik Singh @ Amrik Singh Pardesi, which was not disclosed by him at the time of filling of the proposal form and as such, as per Section-1 Health Cover, the OP/Insurance Company is not liable to pay the insurance claim of medical expenses, which arises out of the pre-existing disease and accordingly, by invoking of Section-1 Health Cover of terms and conditions, the claim of the complainant had been rejected.
8. Now ball came before us for concluding whether the OP has rightly attracted the terms and conditions, for that purpose, we have gone through the Repudiation Letter Ex.C-7 dated 29.04.2015, wherein the reason for rejection of the claim is only that there was a pre-existing disease to the insured Amrik Singh Pardesi. In order to prove that there was a pre-existing disease to insured Amrik Singh Pardesi, the OP first of all referred Death Certificate of insured Amrik Singh Pardesi, the same is Ex.OP-4, no doubt, in the Death Certificate, a cause of death has been mentioned Acute Inferior Myocardial Infarction as well as Coronary Artery Disease and also mentioned Hypertension, Diabetes etc. and similar reason has been mentioned in the Transit Letter Ex.OP-5 and on the basis of these two documents, the medical insurance claim of the complainant has been repudiated by mentioning the said pre-existing disease and further, the counsel for the OP referred Proposal Form Ex.OP-6, wherein at Page No.3, the reply given by the insured have been mentioned that he was not suffering from any disease or illness current or past and by evaluating these documents, the OPs make its mind that there is a pre-existing disease to the insured Amrik Singh Pardesi and thus, the complainant is not entitled for the medico insurance claim and accordingly, the same was rejected and further made reliance by counsel for the OPs upon a judgment of Hon'ble Apex Court, cited in Civil Appeal No.4261 of 2019, titled as “Reliance Life Insurance Co. Ltd. & Anr. Vs. Rekhaben Nareshbhai Rathod” and also made reliance upon a judgment of Hon'ble Apex Court, cited in 2009 (3) Apex Court Judgments (SC) 244, titled as “Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.”.
9. We have gone through the entire record as well as contents of the pleading of both the parties and find that the main reliance of the OP, to prove the pre-existing disease of the insured Amrik Singh Pardesi, is upon Death Certificate Ex.OP-4, Transit Letter Ex.OP-5 and Proposal Form Ex.OP-6 and accordingly, we feel necessity to thoroughly glance these documents and first of all, we find that the death certificate apparently based upon the treatment taken by insured from a hospital in USA and in the medical record, obviously it was mentioned that the insured Amrik Singh Pardesi was having a massive heart attack and also mentioned Acute Inferior Myocardial Infarction and also test was conducted and there-from Hypertension, Diabetes etc. was also located and accordingly, the same was incorporated in the Death Certificate, Transit Letter and we have to analyze whether the disease mentioned in these documents Ex.O-4 and Ex.O-5 as well as in the hospital record was also in existence at the time of taking insurance policy i.e. on 28.08.2014 or at the time of filling of proposal form, for that purpose, the OP has miserably failed to bring on the file any medical report, medical prescription or ECG, where-from we can ascertain that the insured Amrik Singh Pardesi was also having the said disease at the time of filling Proposal Form rather the medical record produced by the complainant Ex.C-17 dated 27.08.2014 means the same day on which the proposal form was filled, in the said medical record, the ECG was also conducted and all other tests of the insured Amrik Singh was also conducted, but nothing was found wrong qua insured Amrik Singh Pardesi. Similarly, we referred the Proposal Form Ex.OP-6 and the Medical Record Ex.C-17 as well as Proposal Form was make authenticated by the same doctor of the same hospital i.e. Guru Nanak Mission, Hospital and signature of the doctor Manish Aggarwal is also available on the Proposal Form at Page 3rd, wherein he categorically mentioned that the insured is fit for traveling and the said doctor also reported in second page that ECG print out with report carried out by Cardiologist, Fasting and Blood Sugar and Urine Sugar or Urine Strip Test Report etc. were also obtained and further reported in its certificate, by the doctor, any past history of disease, operation, accident, investigation etc. 'No', General examination 'Good', Systematic Examination 'OK', ECG 'Good'. From the above report of the doctor, we observed that the insured Amrik Singh Pardesi had not disclosed anything at the time of inception of the insurance policy and as such, the plea taken by the OPs that the insured had concealed the pre-existing disease, is not a true version rather the documents of the OP itself established that there was no pre-existing disease to the insured Amirk Singh Pardesi at the time of obtaining the insurance policy, if so, then the OP has no right to invoke Section-1 Health Cover terms and conditions of the insurance policy because the same are not applicable in the case of the complainant.
10. Further, if any disease arrested the insured Amrik Singh Pardesi, later on while he was in USA, then the same cannot be co-related as a pre-existing disease, it might be occurred first time in America, when he was diagnosed and got treatment. So, with these observations, we are of the opinion that the judgments referred by the counsel for the OPs are not helpful in the instant case, being not identical facts and thus, we reached to the conclusion that the complainant is entitled for the relief claimed.
11. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs No.1 and 2 are directed to pay medical expenses of insured Amrik Singh i.e. Rs.5,25,000/- to the complainant alongwith interest @ 12% per annum from the date of repudiation i.e. 29.04.2015, till realization and further OPs No.1 and 2 are directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.70,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
19.06.2019 Member President
