Delhi

New Delhi

CC/503/2014

Nirankar Kishor Mathur - Complainant(s)

Versus

M/S. National Insurance Company.Ltd. - Opp.Party(s)

13 Jan 2020

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

                                                                (DISTT. NEW DELHI),

                                               ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                                          NEW DELHI-110001

 

          Case No.C.C.503/2014                                            Dated:

         In the matter of:

 

          Mr. Nirankar Kishore Mathur ( now deceased),

           S/o Sh. Late B.K. Mathur,

           R/o 146, Madan Lal Block,

             Asian Games Village,

                Delhi-110049.

            Through his legal heirs

 

1.   Dr. Shobha Mathur

R/o Noida

 

2.    Sh.Rajeev Kishore,

R/o Singapore

 

3.    Sanjeev Kishore,

R/o Daripally Odisha

…..Complainant

 

Versus

 

1. National Insurance Co. Ltd.,

Jeevan Bharati Building Tower-II,

Fourth Level, 124,

Connaught Circus,

New Delhi-110001.

 

2. Heritage Health TPA Pvt. Ltd.,

1102, Raheja Chambers, 11^th Floor,

Free Press Journal Road,

Nariman Point,

Mumbai-400021.

 

 

 

 

 

 

 

NIPUR CHANDNA, MEMBER

 

                                           ORDER

 

The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant(now deceased) had taken an Overseas Travel Insurance Policy.  It is alleged that in the month of February 2013, the DLA was to travel to Singapore to meet his son, as  he was 82 years old, as a mandatory requirement for travelling abroad,  the DLA(Deceased Life Assured) obtained an Insurance policy bearing No.25100/48/12/0570000044 dated 12.2.2013 from OP-1 valid from 20.02.2013 to 18.08.2013 for sum insured of USD 50,000/-.  

 

2.     It is alleged that the said policy was extended bearing No.80110315 valid from 19.8.2013 to 16.11.2013.  It is submitted that nearly after a stay of six months at Singapore, the DLA suffered  pain in the left shoulder and he was admitted in National University Hospital, Singapore where he was diagnosed with Non Q waive acute myocardial infarction.  It is alleged that the complainant was treated for 7 day(from 6.8.2013 to 13.8.2013) and was discharged on 13.8.2013.  It is further alleged that during the treatment it was found that the DLA suffered with low Hemoglobin  which led to lesser supply of blood oxygen to heart.   It is alleged that the deceased lodged the claim with OP-1 through OP-2 for reimbursement and submitted all the medical documents.  It is further alleged that claim was repudiated by OP-2 on the ground that  the DLA was suffering from pre-existing disease, therefore in terms of clause 10-C of the insurance policy, he is not entitled to the insurance claim.  It is further submitted that as per the discharge summary, the deceased did not suffer with any coronary heart disease but only suffered with low hemoglobin and the repudiation of the claim of the deceased is arbitrary and on frivolous ground, hence this complaint.

 

3.     Complaint has been contested by OP.  O.P appeared and filed its written statement. In its written statement O.P has alleged that the present complaint is  barred under clause 10(3) of Non Traditional Basis Overseas Mediclaim Policy.  Rule 10(3) of the Non Traditional Basis Overseas Mediclaim Policy, states that

 

Pre-existing condition

 

“Any pre existing medical condition ailments declared or undeclared will be excluded from the policy.  The coverage provided is subject to the details and declaration made by the proposal to the company and attached policy wording bearing.  Any pre-existing condition(s) as defined in the policy, the pre-existing condition means any sickness/illness, which existed prior to the effective date of this insurance including whether or not the insured person had knowledge that symptoms were related to sickness/illness.  Complications arises from a pre-existing condition will also be considered part of the pre-existing condition”.

 

 

4.     It is further alleged by the OP that the DLA  had not complied with the terms and conditions of the contract of insurance, therefore, complaint be dismissed.  It is further alleged that on scrutiny of the claim papers submitted by the DLA, it is observed that the DLA was treated for myocardial infraction.  It was also noticed that the DLA had past history of hypertension and diabetes and deceased had not disclosed his above past medical history while proposing insurance with the O.P. It is alleged that the claim was rejected under clause 10(3) of Non Traditional Basis Overseas Mediclaim Policy. It is further alleged that the deceased was intimated about repudiation of claim vide letter dated 6.02.2014. Hence the complainant is not entitled to any relief against the O.P and the complaint is liable to be dismissed with heavy costs.

 

5. Complainant has filed his affidavit affirming the facts alleged in the complaint.  Complainant has also filed copy of policy referred above, copy of discharge summary, copy of bill, copy claim form and True copy of repudiation letter dated 6.2.2014. On the other hand Shri A.S.N. Murti Diptt. Manager has filed affidavit in evidence on behalf of O.P testifying all the facts as stated in the written statement. Parties have also filed their respective written submissions.

 

6.     We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties.

7.     There is no dispute on the point that DLA had taken Overseas mediclaim policy referred above.

8.     There is no dispute on the point that the DLA was got admitted in the National University Hospital, Singapore and discharged summary of the hospital reveals that the deceased was admitted in the hospital on 6.8.2013 and he was discharged from the hospital on 13.8.2013  There is no dispute on the point that the DLA had spent a sum of USD 8605.13 in getting the treatment.

9.     The only question for consideration is whether repudiation of claim of the DLA by the OP  on ground of pre-existing disease was justified or not or whether the hypertension could be said to be pre-existing diseases or  whether the DLA  was a patient of abovementioned diseases prior to taking the policy in question .

10.      In this case the claim of the DLA was repudiated on the ground that he had pre-existing disease at the time of inception of the policy.  It is a settled proposition of law that the burden to prove undeclared pre-existing disease is upon the Appellant and they are required to discharge this burden by producing any cogent evidence on record.  Learned Counsel for the OP has failed to point out any piece of evidence which could prove that the deceased was suffering with any pre-existing disease.  The contention of the OP is that the deceased was suffering from hypertension(which is pre-existing disease) causing the present illness, hence, rightly repudiated.  Our attention is not drawn to any document which could even suggest that the deceased had this existing illness prior to taking the policy.  It is also a settled proposition that the pre-existing disease means the disease for which the insured had been hospitalized or undergone operation in near proximity to the Policy.  This view has been taken by this Commission in the case of Pradeep Kumar Garg vs National Insurance Company Ltd. [III (2008) CPJ 423]. 

11.    Claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the ' discharge summary' of the insured by invoking the ' exclusion clause' or non-disclosure of ' pre-existing disease' unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above.

12.    It may be stated here that in the present case there is nothing on record to prove the fact that prior to the issuance of the policy the complainant had taken treatment from any doctor or any hospital for the diseases Hypertension.

13.    The plea taken by O.P of suppression of material facts regarding hypertension for repudiating the claim of the DLA was not justified. OP had repudiated the claim of the complainant without any basis and on wrong assumption and in an arbitrary manner which amounts to deficiency in service on the part of the OP.   We therefore hold, OP guilty of deficiency in services and direct it as under:

i).     Pay to the complainant USD 8605.13  (to be calculated in Indian Rupees  @ prevailing in the year 2013) alongwith interest @ 9% from the date of filing of complaint i.e. 7.7.2014 till its realization.

ii)      Pay to the complainant a sum of Rs.20,000/- as compensation,  which will include the cost of litigation.

 

The order shall be complied within 30 days of the receipt of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post. File be consigned to Record Room.

 

Pronounced in open Forum on13/01/2020.

 

              

(ARUN KUMAR ARYA)

PRESIDENT

                             (NIPUR CHANDNA)                                                (H M VYAS)

                                   MEMBER                                                               MEMBER