BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.160 of 2016
Date of Instt. 06.04.2016
Date of Decision: 10.07.2018
Lakhbir Singh aged about 60 years son of S. Dial Singh, resident of House No.101, Model Estate, Deep Nagar, Jalandhar Cantt.
..........Complainant
Versus
1. Reliance General Insurance, Policy Services Office, SCO-2, PUDA Complex, Ladhowali Road, Jalandhar through its Branch Manager.
2. Europ Assistance India Pvt. Ltd., 301-C Wing, Business Square, Andheri-Kurla Road, Chakla, Andheri East, Mumbai through its Managing Director.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. V. K. Singla, Adv Counsel for the Complainant.
Sh. Vikas Kumar Gupta, Adv Counsel for the OP No.1.
OP No.2 exparte.
Order
Karnail Singh (President)
1. The instant complaint is filed by the complainant, wherein alleged that the complainant purchased an insurance policy bearing No.2002552817113938 under the policy “Reliance Travel Care Insurance Policy-For Individual” in the month of April, 2015, which is valid from 23.04.2015 to 21.07.2015. The complainant was not having any pre-existing illness/injury prior to obtaining the policy. As per the chart showing the coverage of various diseases dental care expenses were also insured for a sum of USD Dollars 500 in the policy. The complainant went to Australia in the month of April, 2015 and remained in Australia upto 17.10.2015. When the complainant was in Australia, he suffered from a dental problem and had rushed to Dental Surgeon for immediate treatment and got the treatment as per the advice of the doctor on different dates. The complainant spent USD 345.00 on 27.06.2015, USD 337.00 on 30.06.2015 and USD 355 on 20.07.2015.
2. That the complainant returned to India on 17.10.2015 and approached the OPs on 05.11.2015 and lodged the claim incurred by the complainant for treatment while in Australia. But it is regretted that instead of sanctioning the claim, OP No.1 returned the claim on the flimsy grounds and asked for the copy of visa, doctor's consultation papers, result of investigation and past medical history for the treatment of tooth No.17. It is further clarified that when the policy was taken, there was no pre-existing illness, injury at all as the complainant was also examined by medical officer of the OP and more so a certificate issued by doctor Col. K. J. S. Rana, SM (Retd.) OIC ECHS Polyclinic, Jalandhar, clarify that no treatment for tooth No.17 was carried out. The complainant is an Ex-Army and is following the disciplines and rules.
3. That sufficient proof was given at the time of lodging of the claim, but the claim was not sanctioned and OPs unnecessarily demand documents such as result of investigation, copy of Visa etc., which were already brought to the notice of the OP. On 22.12.2015, an other letter from Dr. Ashutosh Misal from Europ Assistance India Pvt. Ltd., Mumbai was received by the complainant intimating that company shall not be liable to make any payment under this benefit in connection with or in respect of any expenses under Dental Treatment. The complainant approached the OP at his own level. The policy taken by the complainant was a perfect and clear cut speaking policy without any lacuna covering medical expenses including transportation evacuation and Repatriation, Dental Care expenses and other Diseases mentioned in the policy. Thereafter, the complainant got served a legal notice dated 21.02.2016 upon the OPs, but all in vain and as such, necessity arose to file the present complaint with the prayer that the OPs may be directed to admit the claim of the complainant and to pay 500 USA Dollars to the complainant along with interest @ 12% per annum from the date of receipt of the amount, till its realization and further OPs be directed to pay damages to the tune of Rs.50,000/- for causing unnecessary harassment, mental tension, physical pain etc. along with Rs.15,000/- as counsel fees and litigation expenses.
4. Notice of the complaint was given to the OPs, but despite service OP No.2 did not come present and ultimately, OP No.2 was proceeded against exparte.
5. OP No.1 appeared through its counsel and filed its written reply and 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. It is further alleged that the complainant has not approached this Forum with clean hands. Therefore, the complainant is not entitled for the relief claimed and even there is no deficiency in service or negligence or unfair trade practice on the part of the OP. It is further averred that the claim case of the complainant's was rejected by the OP No.2, vide rejection letter dated 22.12.2015 and the reason for rejection of the claim are duly mentioned therein. It is further submitted that as per record, complainant contacted Dr. Rodman Ip on 27th June 2015 with toothache and minor swelling related to tooth No.17. On evaluation, it was observed that his tooth No.17th was having temporary restoration form his earlier dental treatment related to the said tooth. There was very deep restoration closed to the pulp of tooth 17 and it was found that complainant is having irreversible pulpits and apical periodontists related to tooth No.17. From the medical records of the complainant, it was observed that complainant had received prior treatment for tooth No. 17 before the current overseas presentation. Hence, the current presentation was result, consequence, continuous, progression, aggravation of pre-existing dental pathology related to tooth No.17 and failure of your past dental treatment and as such, the complainant shall not be liable to make any payment under this benefit in connection with or in respect of any expenses whatsoever incurred by the insured person. On merits, it is admitted that the complainant got insurance policy and submitted a claim, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
6. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit Ex.CA along with some documents Ex.C-1 to Ex.C-10 and then closed the evidence.
7. Similarly, counsel for the OP No.1 tendered into evidence affidavit Ex.OPA along with some documents Ex.OP-1 to Ex.OP-18 and closed the evidence.
8. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
9. It is admitted that the complainant had got insurance policy “Reliance Travel Care Insurance Policy-For individual” from OPs, after making a payment of premium for the period 23.04.2015 to 21.07.2015 and thereafter, complainant went to abroad i.e. Australia in the month of April, 2015 and remained there upto 17.10.2015 and as per version of the complainant during that period, he got some dental problem and accordingly, he got treatment from Dental Surgeon and made payment USD 345.00 on 27.06.2015, USD 337.00 on 30.06.2015 and USD 355 on 20.07.2015 and then after coming back to India, he lodged a medical insurance claim on 05.11.2015, but the same was repudiated by the OP on a flimsy ground that there is a pre- existing problem to the tooth no.17 of the complainant.
10. To the contrary, the OP No.1 alleged that the complainant has got previous problem in his tooth no.17, which is clearly established from the medical record submitted by the complainant relating to Dr. Rodman of Australia. The complainant had temporary restoration in tooth no.17 prior to insurance coverage, but he did not disclose the same in proposal form at the time of inception of the policy. When the complainant himself did not disclose the disease for which a treatment is taken, was pre-existing as per medical record of the complainant and accordingly, as per terms and conditions of the insurance policy, the claim of the complainant was rightly repudiated.
11. We have sympathetically considered the respective version of both the parties and find that the complainant has categorically took a plea in his complaint in Para No.3 that when the policy was taken, there was no pre-existing illness, injury at all as the complainant was also medico legally examined by the medical officer of the OP and moreover, this plea of the complainant is also fortified from the documents placed on the file by the complainant himself i.e. certificate issued by the doctor, which is Ex.C-9, wherein he categorically reported that no treatment for tooth no.17 was carried out at ECHS Dental Centre, Jalandhar Cantt, as per Medical/Dental Records of this Centre. So, first of all, it is established by the dentist doctor that there is no pre-existing disease of tooth No.17 of the complainant and further when the complainant categorically alleged in the complaint that he was medico legally examined by the medical officer of the insurance company prior to inception of the policy and in reply to this para No.3, the OP has not denied rather gave evasive reply without touching the real points that whether the complainant was medico legally examined or not, so, when the specific reply is not come or given by the OP, then it presume that the factum so narrated in the complaint is admitted, so if the complainant was medico legally examined by the medical officer of the OP, then the OP cannot say at this stage that there was any pre-existing medical problem in tooth No.17 of the complainant and therefore, the insurance claim of the complainant has been wrongly repudiated by the OPs.
12. Furthermore, the complainant in order to establish on the file that he got a treatment from Dental Surgeon while in Australia, produced on the file Tax Invoice of the said doctor, which are Ex.C-3 to Ex.C-5, wherein the payment of USA Dollar have been shown, so if the complainant has got an insurance policy while going overseas and got treatment therefrom, then he is entitled for the said insurance claim and accordingly, we find much force in the substances of the learned counsel for the complainant and therefore, complaint of the complainant is partly accepted and OPs are directed to pay the insurance claim of 500 USA Dollar, to the complainant (by converting into Indian rupees, considering the rate of USA Dollar in the Indian Currency at the time of repudiation of claim i.e. 22.12.2015). The OPs are also directed to pay interest @ 12% on the aforesaid converted Indian Currency amount from the date of repudiation, till realization. OPs are further directed to pay compensation of Rs.20,000/- for mental harassment and also directed to pay litigation expenses of Rs.5000/-. 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.
13. 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 Harvimal Dogra Karnail Singh
10.07.2018 Member President
