BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint No. 191 of 2022.
Date of Institution : 24.03.2022.
Date of Decision: 20.02.2024.
Nand Lal Mehta son of Shri Jawahar Lal, aged about 72 years, resident of House No. 432, Gali No.2, Bansal Colony, Sirsa, Tehsil and District Sirsa.
….. Complainant
Versus
- Religare Health Insurance Branch Office at Building Galaxy Medicose Dabwali Road, Sirsa, H.O. Sirsa, Haryana through its Branch Manager.
- Religare Health Insurance Company Limited, Unit No. 604-607, 6th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurgaon- 122001 through its Managing Director.
….. Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019
BEFORE: SH. PADAM SINGH THAKUR……………… PRESIDENT
SMT. SUKHDEEP KAUR…………………….MEMBER
SH. OM PARKASH TUTEJA………….MEMBER
Present : Sh. Manik Nehta, Advocate for complainant.
Sh. H.S. Raghav, Advocate for opposite parties.
ORDER:-
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to OPs).
2. In brief, the case of complainant is that son of complainant Naveen Mehta is residing in U.K. and accordingly complainant had gone alone to meet his son on Visitor Visa. He had gone from Delhi to U.K and reached there in the month of July, 2019 in hale and hearty condition. That before going to U.K, he has taken a religare health insurance policy from op no.2 on the recommendation of op no.1 i.e. Travel Health Insurance Policy bearing No. 14186944 for a period for 136 days i.e. from 25.6.2019 to 7.11.2019 for the sum insured of USD One Lac after paying the premium of Rs. 16116/-. It is further averred that op no.2 insurance company prior to issuance of mediclaim insurance policy inquired all relevant issues from complainant and complainant disclosed all information to them and later on insurer accepted the proposal form and issued letter dated 25.05.2019 to the complainant specifying that “this is in reference to above mentioned proposal number Gold Ex US- Canada Single, in this regard we would like to confirm that we have accepted the risk and the policy is issued in accordance with the details shared by you”.
3. It is further averred that complainant boarded a flight to U.K in month of July, 2019 from Delhi Airport and landed at U.K. London and during his stay at U.K, the eye glasses of the complainant were broken and complainant went to Lens Shop to bring new glasses but complainant got information from them that they required fresh prescription for new glasses with latest exact eye vision sight given by authorized Opthalmologist and for the same the complainant visited Private Opthalomogist on 27.7.2019 and found some problem in his eyes and again on 29.7.2019 complainant visited for further check up/ treatment advise. In check up, following observations were found by Mr. Mahi Muqit PHD FRCOphth Consultant Ophthalmologist and Vitreoretinal Surgeon and his opinion is given below:-
“ Mr Mehta attends my Moorfields Private clinic today. He reports recent onset difficulty with vision with central blur and distortion in the left eye. The pressures are normal at 14mmHg and the retina is secure. In addition, he has cataracts in both eyes. There are multiple drusen deposits at both macula consistent with intermediate AMD.
The OCT scans taken by the optician two days ago show a dry macula in the right eye with no signs of choroidal neovascularisation. In the left central macula there is a subretinal fluid with a large PED. The left eye has developed acute wet AMD with a new CNVM present in the macula. Regarding his AMD in the right eye he can take vitamin supplements (AREDS2 formulation) known as “Preservision.” and suggested EYLEA treatment and for the same he suggested some injections to the complainant.
4. It is further averred that complainant informed all these things on the helpline number of opposite party no.2 dated 27.7.2019 and again as per advise dated 29.7.2019 in order to avail the benefit under the mediclaim policy, complainant’s son Naveen Mehta contacted the opposite party no.2 through emails and submitted his request alongwith the details of treatment prescribed given by the Medical Centre and as well as the details of mediclaim policy for the purpose of considering the same for indemnifying the complainant. As per the advise of the doctor, complainant remained on further treatment and on 1.8.2019 took first injection as per the medical advise and accordingly second and third injections were taken on 9.9.2019 and 2.10.2019 under the observations of medical expert. That after coming back from U.K to India rest of the treatment was taken by complainant at Indian Hospital under his retirement facility as complainant has been retired as Senior Officer from Income Tax Department Govt. of India. That on 12.11.2019 complainant submitted his claim alongwith the bills to the op no.2 but however, on 18.12.2019 op no.2 in illegal and arbitrarily manner has rejected the claim of complainant with the alleged finding that as per the policy, any claim in respect of any insured person for arising out of or directly or indirectly due degenerative old age diseases is not covered under policy which is wrong and illegal. It is further averred that complainant then filed appeal to the Claims Manager regarding his claim but the same was also dismissed on 24.12.2019 and again complainant filed appeal to the Head of Customer Services which was also rejected on 27.01.2020. That ops were well within the knowledge regarding the age of complainant that has already been described in the letter dated 17.05.2019 issued by op no.2 and as such repudiation of the claim on the ground of old age disease by op no.2 was solely illegal. The complainant disclosed all relevant facts to his health to op no.2 and this eye problem was diagnosed for the first time when complainant visited to U.K. That complainant and his son sent emails to op no.2 in the very beginning before starting the treatment and it was duly received by ops but it was never replied. It is further averred that due to the act and conduct of the ops, the complainant has suffered much tension, harassment and also suffered much financial loss inspite of getting the above said policy and inspite of depositing the premium amount with the company. Hence, besides the amount of the medical bills of GBP 7279/- (Great British Currency Pond and now a days per pond Indian currency values around Rs.104/- per pond which amounts to Rs.7,57,016/- as in Indian Currency) submitted by complainant as claim amount of expenses on the treatment, the complainant is also entitled to compensation of Rs.10,00,000/- for causing harassment, mental tension etc. and is also entitled to an amount of Rs.55,000/- as litigation expenses as ops’ company without explaining any specific reason has repudiated the claim of complainant. Hence, this complaint.
5. On notice, ops appeared and filed written statement raising certain preliminary objections that complaint is time barred as same was filed after a long period of about two years and four months delay without giving any valid reason; that complaint is neither maintainable nor sustainable in the present form and is liable to be dismissed as the complainant has attempted to misguide and mislead this Commission and in fact the complainant has suppressed the true and material facts and that no cause of action ever arose in favour of complainant against the ops to file the present complaint.
6. On merits, it is submitted that ops’ company issued International Travel Insurance Policy namely Explore under the Plan “Gold Ex US Canada (Single)” bearing Policy No. 14186944 in favour of complainant as per his desire providing insurance coverage to himself. The said policy was issued w.e.f. 25.06.2019 till 07.11.2019 for sum insured of USD 1,00,000/- subject to policy terms and conditions. That an out patient care claim request no. 91164336-00 was received from the insured and as per the other consultation paper he was diagnosed with left choroidal neovasculzrization memberance (CNVM) “wet AMD” age related macular degeneration (AMD) macular drusen, bilateral cataracts. No hospitalization had taken place and the treatment was taken on OPB basis only. The ops’ company upon receipt of such claim request raised a query vide letter dated 27.11.2019 to the insured and asked for some specific documents in order to process the claim and reminder letter dated 06.12.2019 seeking information related to details of past medical history like previous medication details, ongoing illness details and treated medical conditions before travel. Further it was asked whether the insured has been treated for the present medical condition in India before travel and was asked to share supportive documents for the same. It is further submitted that ops’ company in view of the above finding rejected the claim request as per clauses mentioned in policy terms and conditions which are as under:-
*Outpatient claim : Rejection reason and clause.
*Clause 2.1.3 (IV) Any claim in respect of any insured person for,
arising out of or directly or indirectly due degenerative diseases shall not be admissible under the policy.
* Explore Policy Exclusion
7. It is further submitted that any claim in respect of any insured person for arising out of directly or indirectly due to any of the following shall not be admissible under this Benefit unless expressly stated to the contrary elsewhere in the policy terms and conditions and intimated the same to the insured vide repudiation letter dated 18.12.2019.
It is further submitted that relevant clauses are reproduced hereunder through which the ops’ company process the claim:
2.1 Benefit 1 : Hospitalization expenses
2.1.1. In-patient Care
2.1.2. Out-Patient Treatment
2.1.3. Exclusions applicable to benefit 1
Any Claim in respect of any Insured Person for, arising out of or directly or indirectly due to any of the following shall not be admissible under this Benefit unless expressly stated to the contrary elsewhere in the Policy terms and conditions:
(iv) Degenerative or oncological (Cancer) diseases.
8. It is further submitted that since, the cataract of the complainant was age related, hence the same is excluded from the coverage of the travel policy and claim of complainant was rightly rejected by the answering ops. That as per the judgment of the Hon’ble Supreme Court in the Export Credit Guarantee Corp of India Ltd. versus M/s Garg Sons International the insured cannot claim anything more than what is covered by the insurance policy and the terms of the contract have to be construed strictly without altering the nature of the contract as the same may affect the interests of the parties adversely and the clauses of an insurance policy have to be read as they are and consequently the terms of the insurance policy that fix the responsibility of the insurance company must also be read strictly. All other contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
9. The complainant in evidence has tendered affidavit of Sanjay Mehta son of Shri Radha Krishan Mehta, Special Power of attorney of complainant as Ex. CW1/A, special power of attorney of complainant in favour of Sh. Sanjay Mehta as Ex.C1 and documents Ex.C2 to Ex.C20.
10. On the other hand, ops have tendered affidavit of Sh. Ravi Boolchandani Manager Legal as Ex. RW1/A and documents Ex.R1 to Ex.R20.
11. We have heard learned counsel for the parties and have gone through the case file.
12. Learned counsel for the complainant while reiterating the contents of complaint has contended that ops have wrongly and illegally repudiated the genuine claim of complainant. The complainant while in UK visited the Lens Shop to bring new eye glasses as his eye glasses were broken and the Lens Shop required latest and fresh prescription slip of the authorized Ophthalmologist so that proper eye glasses for the eye of the complainant may be prepared and as such on 27.07.2019 complainant visited Ophthalmologist who found some problem in his eyes and again on 29.07.2019 complainant visited him for further check up/ treatment advise. The Ophthalmologist told the complainant that he has cataracts in his both eyes and regarding his AMD in the right eye he can take vitamin supplements known as Preservision and suggested EYLEA treatment for which he suggested some injections to the complainant. He has further contended that as per the advise of the doctor, complainant remained with further treatment and on 01.08.2019 complainant took first injection and second and third injections were taken on 09.09.2019 and 02.10.2019 respectively under the observations of medical expert. He has further contended that after coming back from U.K. to India, the rest of the treatment was taken by complainant at Indian Hospital under his retirement facility as complainant has been retired as Senior Officer in Income Tax Deparment in Central Government. He has further contended that complainant submitted his claim for the treatment taken in U.K alongwith the bills but on 18.12.2019 op no.2 in illegal and arbitrarily manner has rejected the claim of complainant with the finding that as per policy any claim in respect of any insured person for arising out of or directly or indirectly due to degenerative old age disease is not covered under the policy. The appeals filed by the complainant before higher authorities of ops have also been wrongly rejected because the ops were well within the knowledge regarding the age of complainant and knowing well about the age of complainant they had issued the Travel Policy to the complainant and prayed for acceptance of the complaint.
13. On the other hand, learned counsel for ops while reiterating the contents of written version has contended that ops in a legal and lawful manner have rejected the claim of complainant as per clause of the policy because the disease of the eyes of complainant was degenerative disease and treatment of the same could have been post-poned and could have been taken in India on return from U.K by the complainant under his retirement facility and prayed for dismissal of the complaint.
14. We have considered the rival contentions of the parties. Admittedly in the month of July, 2019 the complainant had gone to London (U.K) as his son Naveen Mehta is residing in U.K. and he had gone there to meet his son on Visitor Visa. It is also an admitted fact that prior to visiting U.K. the complainant had purchased a travel health insurance policy bearing No. 14186944 from op no.2 for a period of 136 days i.e. from 25.06.2019 to 07.11.2019 for the sum insured amount of USD one lac after paying premium amount of Rs.16,116/- and the date of birth of the complainant as 03.03.1950 was also mentioned in the policy documents by the ops as Ex.C4 meaning thereby that ops were duly informed about the age of the complainant by the complainant at the time of purchasing the policy in question. According to the complainant while his stay with his son at London (U.K) his eye glasses were broken and as such he visited Lens Shop/ Optician for purchasing new eye glasses but they required fresh prescription slip about exact eye sight of the complainant from an Ophthalmologist. The complainant in this regard has also placed on file referral request of Optician to Eye Department/ Private Ophthalmologist dated 27.07.2019 and accordingly on 29.07.2019 complainant visited eye hospital. In the prescription dated 29.07.2019 Ex.C3, Mr Mahi Muqit Consultant and Vitreoretinal Surgeon of London Clinic Eye Centre, London observed that the OCT scans taken by the optician two days ago show a dry macula in the right eye with no signs of choroidal neovascularisation. In the left central macula there is a subretinal fluid with a large PED. The left eye has developed acute wet AMD (aged related macular degeneration) with a new CNVM (choroidal neovascularisation membrane) present in the macula. The Ophthalmologist for the right eye of the complainant advised vitamin supplements known as Preservision and for his left eye Eylea treatment was prescribed to the complainant and as such complainant on the advise of the Ophthalmologist took Eylea treatment for his left eye and took three injections on 01.08.2019, 09.09.2019 and on 02.10.2019 and also remained on follow up treatment. According to the complainant on the said treatment of his left eye, he spent an amount of 7279/- GBP i.e. Great British Currency Pond and the value of one Pond is equal to Rs. 104/- as per Indian Currency and has claimed amount of Rs.7,57,016/-. In this regard complainant has also placed on file invoice and receipts of above said hospital of London. The complainant on coming to India also lodged his claim with the ops for reimbursement of 7279 GBP as is evident from claim form Ex.C2 but his claim as well as his appeals have been rejected by the ops and their higher authorities on the above said ground that any claim arising out of any Degenerative disease is not admissible as per terms and conditions of the policy. But however we are of the considered opinion that ops have illegally and wrongly repudiated the genuine claim of the complainant. The factum of old age of the complainant was very much known to the ops at the time of issuing the policy in question. The complainant while his stay in London (U.K) only visited the Optician for bringing new eye glasses as his old glasses were broken and thereafter Ophthalmologist diagnosed that left eye of complainant has developed acute wet AMD with a new CNVM present in the macula and he opined that condition of his left eye is critical and treatment of the same was urgent and necessary at that time and on the advise of the doctor the complainant took the treatment of his left eye at London. So, it cannot be said at all that complainant voluntarily took treatment of his left eye at London and same was not necessitated there. The complainant for the first time came to know about the above said disease while he was in U.K and as the complainant was at the risk of losing vision in his left eye due to the acute wet AMD and fluid buildup therein which needed urgent medical attention, as such the complainant under compelling circumstances and urgent medical situation took treatment of his left eye at London and remaining treatment was taken by him in India under his retirement facility. As such complainant is entitled to refund of the amount of Rs.7,57,016/- (in Indian Currency) spent by him on his above said treatment and ops are legally liable to reimburse this amount to the complainant. The ops have also caused unnecessary harassment and deficiency in service towards the complainant and as such complainant is also entitled to compensation and litigation expenses from the ops.
15. In view of our above discussion, we allow the present complaint and direct the opposite parties to reimburse the claim amount of Rs.7,57,016/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 24.03.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.25,000/- as compensation for harassment and Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President
Dt: 20.02.2024. District Consumer Disputes Redressal Commission, Sirsa.
