T.B.Road, Palakkad – 1                                                -        Opposite parties   

(By Adv.Ullas Sudhakaran)                                            

O R D E R

            By  Smt.BHANUMATHI.A.K. MEMBER

The case of the complainant is as follows:

The complainant had availed a Travel Age Elite Silver Insurance Policy bearing No.OG-11-1513-9910-00000031 for a value of USD 50,000 from the 2^nd opposite party.  As per the terms and conditions of the above said policy  the opposite parties had assured the complainant that he will get benefit of the insurance coverage if he has to incur any medical expenditure in the United States.  The complainant went to United States  on 13/7/2010 for a period of two months.  The complainant felt some gastric problem and for the said  reason on 3/8/11  went to MINNESOTA GASTROENTEROLOGY P.A. for checkup and he was advised to stay  for observation.  For the said purpose the complainant paid an amount of 198 USD.  On 4/8/2010 the complainant felt suffocation and uneasiness for which he went to PARK NICOLLECT CLINIC, MINNEAPOLIS  and he was kept  under observation for which he had to pay 280 US Dollar.  After the observation and checkup the doctors advised him to go to hospital for further checkup.  As a procedure he was admitted in the Emergency Care unit and then shifted to hospital for further checkup.  The complainant informed the hospital authorities that he is having Travel Age Elite Silver Insurance Policy and they contacted the opposite parties.  Opposite parties informed the hospital authorities that the benefit of the said policy can be given to the complainant.  In total the complainant spent an amount of Rs.1573 US Dollar for the medical treatment.  The complainant placed  the claim before the opposite parties for the disbursement of the claim.  But it is getting delayed the complainant constrained to make payments as the hospital authorities were pressing for emergency payments of the bills.  The said payments were made by the complainant’s son-in-law named Mr.Manoj Unni  on line on  9/12/2010. The complainant got a letter from opposite party dated 12/11/2010 stating  that the claim put forward by the complainant was denied as the claim fall under ‘Non Disclosure of Material Information’ and              ‘Pre Existing condition’.  But the complainant had not undergone  any full fledged medical treatment for any  ailment.   The complainant was not hospitalized and had just done checkup to remove the doubt of any possibility of being cardiac problems.  The complainant  had never undergone any cardiac treatment or not a cardiac  patient even now. 

The complainant had received a cheque bearing No.502017 dated 23/12/10 for Rs.4522/- from the opposite parties which the opposite parties  posed to be full and final settlement of the claim.  The complainant doesn’t  proposes  to accept the said amount. 

Thus the complaint seeking an order directing the opposite parties to pay an amount of Rs.1573 USD or equivalent  of Indian Rupees and Rs.10,000/- as compensation  for mental agony with 12% interest and cost.

Opposite parties entered appearance and filed version with the following contentions.

Opposite parties admit the complainant had availed a Travel Age Elite Silver Insurance Policy No.OG-11-1513-9910-0000031 for a value  of USD 50,000 and that as per the terms and conditions of the above said policy the opposite parties had assured  the complainant that he will get benefit of the insurance  coverage for the medical expenditure  incurred by the complainant in the United States.  Opposite parties contents that the complainant had concealed the material information  regarding his ailments and treatments he was undergoing  at the time of availing  the policy exclusion clause 2.4.12, the opposite parties are of  no liability to make payments.  The complainant had a past medical history  of DM and Cardiac ailments and the said history has not been disclosed in the proposal form and then  the opposite parties  were prevented  from making a clear assessment of the risk to be insured and from taking decision on whether an insurance cover was to be given and if so, with relevant exclusion.  This amounts to “Non Disclosure of Material Information” and also pre-existing condition and the claim was rightly repudiated by the opposite parties. The denial of claim does not amounts to deficiency  of service on the part of the opposite parties.  The opposite party had admitted the claim of the complainant towards medical expenditure incurred by him  for constipation and a cheque bearing No.502017 for Rs.4522/- which the complainant was legally entitled was issued to the complainant.

Both parties filed their respective affidavits and Ext.A1 to A6 series were marked on the side of the complainant.Ext.A6 series marked with subject to proof.  Ext.B1 to B4  marked on the side of the opposite parties.

Matter heard.

Issues to be considered are

1)    Whether there is any deficiency in service on the part of opposite  parties ?

2)    If so, what is the relief and cost entitled to the complainant ?

Issue 1 & 2

The complaint is regarding the repudiation of the part of the claim amount claimed by the complainant.  The complainant had availed a Travel Age Elite Silver Insurance  Policy bearing No.OG-11-1513-9910-00000031 for a value of USD 50,000 which is marked as Ext.A1.  Opposite party also admits the same.  On 13/7/2010 the complainant went to the United States for a period of two months. The complainant felt some gastric problems and went to MINNESOTA GASTROENTEROLOGY P.A for checkup on 3/8/11.  The said date was written in the complaint as per the order in IA 247/11.  But it seems to be incorrect.  On verification  it is seen in the  amendment application the correct date is as 3/8/2010.  After observation  the doctors advised him to go hospital for further checkup.  As a procedure of the said hospital he was admitted in the Emergency Care Unit and he was shifted to hospital for further checkup.  The complainant spent an amount of 1573 USD  for the medical treatment.  Ext.A6 series shows the amount spent by the complainant.  But  it is marked as subject to proof. Complainant says that the Hospital authorities had contacted the opposite parties and  the opposite parties had informed  the hospital authorities that the benefit of the policy can be given to the complainant. No documents are produced to support the claim.

On 24/09/2010 the complainant sent claim form to the opposite parties.  On 9/12/2010 the complainant got a letter dated 12/11/10 from opposite parties stating that the claim stands denied as the claim fall under “Non Disclosure of Material Information” and also “Pre-existing condition”.

The complainant had received a cheque  bearing No.502017 dated 23/12/10 for Rs.4522/. No document is produced to show that whether the complainant accepted the same or not ?

The main contention of the opposite parties is that the complainant had concealed the material  information regarding his ailments and treatments he was undergoing  at the time of availing the policy from the opposite parties.  The policy was issued  by the opposite parties to the complainant based on the information provided by the complainant regarding his health condition in the Ext.B4 proposal form. The related column  of the proposal form submitted  by the complainant remain blank.  It doesn’t  mean that the complainant deliberately  concealed his material facts.  Complainant will not have knowledge about the seriousness of filling the column.  Complainant is not given   any false information regarding  his health.  At the time of issuing such  a policy the opposite parties have responsibility to make the complainant to fill the necessary column.   If the complainant had any intention to mislead the opposite parties he would not reveal the previous history in the claim form.  Ext.B2 does not reveal that in which period the complainant was under the treatment of Dr.Jayagopal at Lakshmi Hospital, Palakkad.

The complainant is claiming an amount of 1573 USD which he spent for treatment.  The repudiation  of the claim of the complainant is only in the basis of Ext.B4 is  not proper.  In Ext.B2 page No.4  Attending physicians statement also it is written as “is illness due to any pre-existing conditions ?” the answer is “yes”. So we are not in a position to attribute deficiency of service only on opposite parties. 

In the result we partly allow the complaint.  Opposite parties are jointly and severally directed to pay the half of the amount claimed by the complainant(i.e.786.5 US Dollar or equivalent of Indian Rupees) and Rs.1000/- (Rupees One thousand ) as cost of the proceedings. Order shall be complied within one month from the date of receipt of the order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of order, till realization.

Pronounced in the open court on this the 27^th day of  October 2011.                                                                                                                                                                                                        

   Sd/-

Seena.H

President

   Sd/-

Preetha G Nair

Member

    Sd/-

Bhanumathi.A.K.

Member

APPENDIX

Exhibits marked on the side of the complainant

Ext.A1 – Insurance Policy (original) issued by OP dated 12/7/10

Ext.A2 – Letter dated 12/11/10 sent by opposite party to the complainant

Ext.A3 –  Copy of lawyer notice dated 10/1/2011 sent by complainant to the

              opposite parties

Ext.A4 series  –  Postal receipts (2 nos)

Ext.A5 –  Postal acknowledgment  

Ext.A6 series – Photocopy of treatment record and payment details.

Exhibits marked on the side of the opposite party

Ext.B1 –  Certified true copy of policy issued to the complainant

Ext.B2 – Certified true copy of claim form   

Ext.B3 –  Certified true copy of receipt of payment given to the complainant

Ext.B4 –  Certified true copy of proposal form

Cost Allowed

Rs.1,000/- allowed as cost of the proceedings.