-Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 547
Instituted on : 23.10.2019
Decided on : 15.01.2024.
Mahabir Singh Rathee age 65 years s/o Sh. Fateh Singh R/o H.No.1583,. Sector-2, Rohtak.
.......................Complainant.
Vs.
- Royal Sundaram General Insurance Corpn. Ltd. VishranthiMela Ram towers no.2/319, Rajiv Gandhi Salai(OMR), Kerapakkam, Chennai-600097.
- Royal Sundaram General Insurance Corpn. Ltd. Rider House Plot No.136, Sector-44, Gurugram-122002.
- Royal Sundaram General Insurance Corpn. Ltd. Opp. Service Club, Unit No.644-45/19, Civil Road, Rohtak-124001(Haryana).
……….Opposite parties
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER
Present: Sh.PulkitPreetSingh , Advocate for complainant.
Sh. PuneetChahal Advocate for the opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainantare that he obtained Health Insurance policy for Foreign Travel on 2nd May 2018 on Tourist Visa to travel Sweden on 08thJune 2018 to meet his relatives from the respondents vide policy no.TYPS025791000100 of plan name Travel insurance plan for the period 08thJune 2018 to 29th June 2018 for sum insured USD 100000 and paid Rs.1952/- as premium to the opposite parties. During the stay in Sweden on 9th June 2018 he felt urine retention and later fever and stomach infection developed then admitted to Emergency health Centre, Rosenlund, Sweden but after initial diagnosis he was referred to Stockholm South Hospital and treated for urine blockage. During setting up of Catheter Urethra ruptures he developed infection and need of hospitalization arisen and he got treatment there and was discharged on 13thJune 2018 with Catheter with prescribed medicines. On 26th June 2018 the complainant was again admitted to emergency room in Stockholm South hospital for Urine Blockage then during his treatment blockage cleared and got discharged on the same day. As per the hospital policy, overseas travel insured patients are expected to be paid upfront. Therefore, hospital staff filled Royal Sundram Cashless Hospitalization for medical insurance policy form and sent the same to opposite parties for treatment approval but the Stockholm South hospital did not receive any update/approval from the opposite party after a lot of follow ups and finally requested the complainant to be discharged from the hospital as he was unable to afford their daily charges. The claim was rejected by the opposite party’s company stating that patient “Insurer had past history of Benign Prostatic Hyperplasia(BPH) prior to the inception of the policy and hence pre-existing”. The complainant had paid all the medical expenses incurred during the stay in Stockholm South Hospital which include multiple emergency admit tests, medical and treatment. The complainant had never had any prior history of the medical conditions and hence there are no medical record for the same in India regarding BPH. On 29th June 2018 complainant had to return to India due to the illness and condition. After returning to India the complainant was advised by the doctor to undergo a surgery to remove the part of prostrate as was also advised by doctors of Sweden. Complainant requested the opposite parties to re-consider the claim and also filed claim before the Insurance Ombudsman but the same was rejected. During the treatment of complainant in Sweden total expenses of 44302 SEK amounting to Rs.320304/- were spent by the complainant. Due to non payment of cashless insurance the complainant decided to come back to his country earlier and cancelled his visit to Switzerland Due to on time cancellation of Air tickets and hotel booking which were booked in advance for his visit to Switzerland. The complainant had to bear additional expenses of SEK3130 equal to Rs.22700/- and hotel booking of 170 CHF equal to Rs.12000/-. Hence this complaint and it is prayed that opposite parties may kindly be directed to clear all the medical expenses and airline ticket fare of Rs.355004/- and to pay Rs.200000/- as compensation for mental agony and harassment and Rs.50000/- as litigation expense to the complainant.
2. After registration of complaint, noticeswere issued to the opposite parties. Opposite parties in their reply has submitted that the subject policy travel shield was issued to the complainant’s father vide policy certificateNo.TYPS025791000100 w.e.f. 08.06.2018 to 29.06.2018 for his Overseal Travel InsuranceCover(Sweden). The complainant had lodged a claim under reimbursement mode for a period of hospitalization from 09.06.2018 to 13.06.2018 with respect to the Hospitalizationfor :Retentionof urine with hematuria”. On scrutiny of claim, the respondent company had noted that complainant is a known case of Benign prostatic hyperplasia(BPH) and furthermore medical panel of the respondent company had opined that the present hospitalization is the complication of insured’s pre-existing condition. The pre-existing condition of Benign prostatic hyperplasia(BPH) has been clearly established from the hospital’s Journal Sheet. The said claim was repudiated on the grounds of pre-existing disease vide letter dated 29 June 2018. It may be noted that since the claims were related to the complication of pre-existing disease, the repudiation of the claim is in order and in line with policy terms and conditions of the travel shield policy. It is also submitted that in view of the clear exclusion under the policy for pre-existing ailment and also considering the declaration given by the hospital in their Journal Sheet stating the complainant is a known case of Benign prostatic hyperplasia(BPH), the claim repudiation by the respondent company is in order. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Learned counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.C28 and has closed his evidence on dated 08.04.2021. On the other hand, learned counsel for opposite parties in his evidence has tendered affidavit Ex. RW1/A and documents Ex. R1 to Ex. R7 and closed his evidence on dated 06.07.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. We have minutely perused the documents placed on record by both the parties.In the present case the claim of the complainant has been repudiated by the insurance company vide letter dated 29.06.2018 placed on record as Ex.R5 on the ground that the complainant have a pre existing disease at the time of inception of the policy. The insurance company further submitted in this letter that “On scrutiny of the claim documents we observe that the insured had past history of Benign Prostatic Hyperplasia which is prior to the inception of the policy and hence pre-existing. Our medical panel has opined that the present hospitalization is the complication of the pre-existing BPH. Expenses incurred for treatment of pre existing conditions are outside the scope of policy”. We have minutely perused the documents. Complainant has submitted two clarification to the insurance company which are Ex.C8 & Ex.C9”. As per Ex.C8, : “Patient Mahabir Singh Rathee was admitted to the emergency at the hospital on 9th June 2018 due to infraversial. Moreover the insurance company also placed on record a document Ex.R6 email dated 11.07.2018 in which the complainant has pleaded that: “No such pre-knowledge of the problem was known to the insuree and this was the first time such problem was faced by the patient. Complainant requested to check again and consider the claim.” On perusal of clarifications and documents we came into the conclusion that as per Ex.C9, Medical authorities of Sweedenwere unable to understand the disease and there was less communication between the patient and the doctor and this fact has been mentioned in the clarification Ex.C9 itself. In this document it has been specifically mentioned that: “The patient does not speak in Sweedish and only some English which made communication very difficult”. Moreover in Ex.C8 it has been specifically mentioned by the doctor that : “There is a suspicion that urine retention might have been caused by BPH(BenighProstataHyperiapsi), however no diagnosis or treatment was done for BPH at the hospital. Instead, patient was advised to consult the urologist in India upon return. Prior to 09th June, 2018, no previous medical/surgery records for the patient exist in Sweden”. Meaning thereby the patient was not suffering from BPH(BenighProstataHyperiapsi). As per our opinion there was no pre existing disease at the time of inception of the policy. Moreover it has been specifically mentioned in the clarification that the patient was admitted for urinary tract infection. We have also perused the letter Ex.C21, the hospital has written that In general healthy 64 years old man from India, visiting his children in Sweden. Admitted to emergency due to urine retention, bladder scan at emergency showed 800ml. In connection with Catheter setting in patient gets heavy hematuri. Suspected injury on urethral mucosa”. The alleged document shows that the complication occurred when the catheter setting in patient get heavy hematuri. So due to this infection and other complication, the complainant took treatment from the hospital in different times. But opposite parties has neither placed any proposal form nor any medical record of complainant to prove that he had a past history of benign prostatic hyperplasia prior to inception of policy. The date of inception of the policy is 08.06.2018 and the complainant got complications on 09.06.2018. Hence it is not proved that complainant had any history of pervious disease. As such the repudiation of claim by the opposite party is illegal and amounts to deficiency in service. Hence the complainant is entitled for the claim amount of the expenses incurred by him on his treatment. As per the receipt issued by Stockholm South General Hospital placed on record as Ex.C19, complainant had paid a total of Rs.44302 SEK i.e. Rs.320304/- to the hospital.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party No.1 to pay the amount of Rs. 320304/-(Rupee three lac twenty thousand three hundred and four only)alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 23,.10.2019 till its realization and shall also pay Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
15.01.2024
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Nagender Singh Kadian, President
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TriptiPannu, Member
……………………………….
Vijender Singh, Member
