Punjab

Ludhiana

CC/19/507

Gurcharan Singh - Complainant(s)

Versus

Religare Health Insurance Co.Ltd - Opp.Party(s)

sukhwinder Singh Adv.

25 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 507 dated 31.10.2019.                                                        Date of decision: 25.07.2022.

 

Gurcharan Singh Deol aged about 62 years son of Sh. Nirbhai Singh resident of H. No.427-F, Shaheed Bhagat Singh Nagar, Pakhowal Road, Ludhiana-141013, Punjab                                                                                                                                                                                         ..…Complainant 

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Manager/Authorized Signatory Religare Health Insurance Company Limited SCO 13, Shanghai Tower, Feroze Gandhi Market, Ludhiana, Punjab-141001.                                                                                   …..Opposite party 

Complaint under Section 2, 12 and 14 of the Consumer     Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Gurcharan Singh Deol in person.

For OP                           :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainant is that on 11.03.2019 the complainant visited Vancouver, Canada from 11.03.2019 to 11.06.2019. Prior to proceeding to Canada, the complainant obtained international travelling insurance policy bearing No.13834845 from the OP which was valid from 11.03.2019 to 02.05.2019 which was later on extended to 26.07.2019. At the time of purchasing the policy, the complainant disclosed all the material facts regarding the status of his health and also provided all the documents to the OP. At the time of taking the policy, the complainant was hale and hearty and was not suffering from any heart or other disease of any kind including hypertension and dyslipidemia. It is further alleged that during his stay at Vancouver, Canada the complainant felt uneasiness and pain in the chest. He was taken to Delta Hospital, Delta City, Vancouver where he was treated by the staff of the hospital and remained in the hospital for a period of 3 hours. After that the complainant was discharged from the hospital. The complainant spent an amount of 1400 dollars on his treatment. The complainant further purchased medicine for an amount of 30 dollars. As per the insurance policy, the OP was bound to reimburse all the medical expenses incurred by the complainant during his stay in Canada. After returning to India, the complainant approached the OP for reimbursement of the medical expense incurred by him on his treatment in Canada  but the claim was dismissed on false and frivolous grounds. This amounts to deficiency of service on the part of the OP. Even a legal notice dated 17.09.2019 served upon the OP failed to evoke a positive response. Hence the complaint whereby it has been requested that the OP be directed to reimburse the amount of Rs.80,000/- equal to 1430 dollars incurred on his treatment in Canada along with compensation and litigation expenses of Rs.20,000/-.    

2.                The complaint has been resisted by the OP. In the written statement filed on behalf of the OP, it has been, inter alia, pleaded that the complaint is not maintainable and has been filed just to extract money from the OP. According to the OP, the policy bearing No.13834845 under the name of ‘Explore Canada’ was issued to the complainant for a total sum insured of USD 100000. The policy was effective from 11.03.2019 to 02.05.2019. The complainant is admittedly a diabetic. The complainant lodged a claim regarding his admission and treatment at Delta Hospital. The OP sent a query letter dated 26.06.2019 and subsequent reminder dated 06.07.2019 to the complainant asking him to provide the claim duly filled and signed on claim Form-A along with previous treatment record for diabetes and chest pain before travelling to Canada with record of any medication taken by the complainant in respect of diabetes. Later on, the OP came to know that the complainant was a severe case of HTN since October 2018 and diabetic since 2011. However, these facts were not disclosed to the OP at the time of inception of the policy. Therefore, in view of the terms and conditions of the policy, the claim was repudiated vide letter dated 26.07.2019. It has further been pleaded that as per the complicated chronic disease certificate dated 02.02.2011 issued by Medicine Department, Rajendra Hospital Patiala, the complainant was suffering from type-II diabetes mellitus and dyslipidemia and as per the chronic disease certificate dated 31.07.2018 also issued by Rajendra Hospital, Patiala, the complainant is said to be a patient of type-II DM and hypertension. It has further been pleaded that as per the prescription slip dated 20.02.2019, the complainant has been taking medicines tablet Ramitorva for blood pressure and tablet Lipitor for cholesterol. Therefore, he was not entitled for the claim which has been rightly repudiated. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, the complainant has submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C25 and closed the evidence.

4.                On the other hand, the counsel for the OP tendered affidavit Ex. RA of Sh. Tejinder Singh, Manager (Legal) of OP along with documents Ex. R1 to Ex. R12 and closed the evidence.

5.                We have heard the counsel for the parties and have gone through the record carefully.

6.                During the course of arguments, the counsel for the complainant has contended that the claim has been wrongly rejected. According to the counsel for the complainant, the complainant was not suffering from any pre-existing disease. Moreover, the complainant was medically fit before issuance of the policy and, therefore, the claim has been rejected on false and frivolous grounds which clearly amounts to deficiency of service on the part of the OP.

7.                On the other hand, the counsel for the OP has argued that the claim has been rejected strictly in accordance with the terms and conditions of the policy vide repudiation letter 26.07.2019. The counsel for the OP has further referred to a certificate Ex. R8 and Ex. R9 wherein it is clearly mentioned that the complainant was suffering from diabetes and dyslipidemia since the year 2011 and HTN since 2018. The counsel for the OP has further contended that the complainant has been taking the medicine also for the treatment of these diseases whereas this fact was not disclosed at the time of taking the policy and as such, the claim has been rightly repudiated for non-disclosure of pre-existing illness of HTN and dyslipidemia.    

8.                We have thoughtfully considered the above contentions raised by the counsel for the parties and gone through the record.

9.                In this case, the claim in respect of overseas medical insurance lodged by the complainant in respect of his treatment in Delta City Hospital Vancouver Canada has been repudiated vide letter Ex. R7 dated 26.07.2019 on the basis of clause 5.1 of the policy and further on the ground that the complainant did not disclose that he was suffering from HTN since October 2018 and dyslipidemia since 2011. In para no.3 of the complainant, the complainant has stated that he had disclosed all the particulars regarding the status of his health and had also provided the documents regarding his check-up report to the OP. The complainant has further claimed that at the time of purchasing the policy, the complainant was hale and hearty and he was not suffering from any heart disease or any other disease including the HTN and dyslipidemia. However, in the certificate Ex. R8 Complicated Chronic Disease Certificate issued by Rajendra Hospital, Patiala, it is clearly mentioned that the complainant has been suffering from type-II diabetes mellitus and dyslipidemia and the certificate is stated to be valid from 02.02.2011 to 01.02.2016. Similarly, in the chronic disease certificate Ex. R9 which is valid from 31.10.2018 to 30.10.2023, it is mentioned that the complainant has been suffering from type-II diabetes mellitus and hypertension since 31.10.2018. It is further evident from the medical prescription Ex. R10 that the complainant has been taking tablet of hypertension etc. These documents clearly belie the claim of the complainant that prior to taking the policy he was hale and hearty and was not suffering from any disease such as hypertension or dyslipidemia. This clearly amounts to violation of terms and conditions of the policy more particularly clause 5.1 of the policy Ex. R3. Even otherwise, it has been held by the Hon’ble Supreme Court of India in in Satwant Kaur Sandhu Vs New India Assurance Co. Ltd. Civil Appeal No.2776 of 2002 decided n 10.07.2009 that the contract of insurance is a contract of utmost good faith and the insurers is under an obligation to disclose all the facts which are known to him and non-disclosure of the information regarding pre-existing diseases is a valid and justifiable ground for repudiating the claim. In the instant case also, since the complainant did not disclose about the pre-existing disease of hypertension and dyslipidemia for which he has been suffering from since prior to taking the policy in question. Therefore, it has to be held that the claim has been rightly repudiation. Thus, no case of deficiency of service on the part of the OP is made out.

10.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:25.07.2022.

Gobind Ram.

Gurcharan Singh Vs Manager Religare Health Ins.                    CC/19/507

Present:       Complainant Sh. Gurcharan Singh Deol in person.

                   Sh. G.S. Kalyan, Advocate for OP.

                  

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:25.07.2022.

Gobind Ram.