IN THE CONSUMER DISPUTES REDRESSAL FORUM, ALAPPUZHA
Wednesday the 30th day of November, 2016
Filed on 19.02.2015
Present
1. Smt. Elizabeth George (President)
2. Sri. Antony Xavier (Member)
3. Smt. Jasmine D (Member)
in
CC/No.52/2015
Between
Complainant:- Opposite party:-
Sri. Thomas Prasad Parackal The Manager, Travel Insurance Health
Parackal House Administrator, Bajaj Allianz General
Thathampally P.O. Insurance Company Ltd., A – Wing
Alappuzha 2nd Floor, Bajaj Fin-service Building
(By Adv. V. Mohandas) Behind IT Park, Nagar Road
Viman Nagar, Pune – 411 014
(By Adv. P.S. Ramu)
O R D E R
SMT. ELIZABETH GEORGE (PRESIDENT)
The case of the complainant is as follows:-
The complainant and his wife decided to visit their son who is working in U.K. So he insured with the opposite party under a Travel Insurance Policy for senior citizen aged between 61 to 71 years immediately before his travel to U.K. The premium for the policy was Rs.21,196/- and it was remitted by the complainant through the bank at Alappuzha. The sum assured amount for the policy is about one lakh US Dollars. The complainant and his wife reached at U.K. on 7.4.2014. While they were residing there, on 13.6.2014 the complainant developed intermittent chest pain and he was taken to Liver Pool Heart and Chest Hospital in U.K. and treated there for Acute Myocardial Infarction (STEMI anterior). On the same day, complainant informed the same to the opposite party and they were extended their help to the complainant and hospital authority. The complainant submitted his insurance policy details to the hospital and they provided all his insurance policy details to the hospital authority and they provided all medicines and treatments on the basis of the above insurance policy. Thereafter the complainant was discharged on 17.6.2014 without making any payment. As per the terms of the policy, the complainant submitted his claim statement before the opposite party with all relevant documents. But the opposite party repudiated the claim without any sufficient reason vide letter dated 5.8.2014. It is illegal and unsustainable and a clear violation of the settled principles of the terms of the contract and deficiency in services of the opposite party. The opposite party is legally bound to remit the bill amount to the hospital in respect of the claim statement filed by the complainant. Complainant returned to India on 29.11.2014 for better treatment and he was admitted at Lissy Hospital, Ernakulam. Now the Liver Pool Hospital authority in U.K. demanded him to pay the bill amount of 4,610 GBP. More over the hospital authority in U.K. issued a legal notice dated 25.12.2014 through debt collectors for the recovery of bill amount. As per the terms of the insurance policy the opposite party is legally bound to pay the bill amount issued by the Liver Pool Hospital in U.K., with respect to the treatment of complainant. The complainant has suffered much mental agony, loss and damage. Alleging deficiency in service on the part of the opposite party, the complaint is filed for the following reliefs:-
- The opposite party may be directed to pay the bill amount for 4,610.51 Great Britain Pound (nearly Rs.4,61,000/-) with interest to the Liver Pool Heart and Chest Hospital in U.K. which is incurred for the treatment of the complainant during the period from 14.06.2014 to 17.06.2014.
- To realize the damages for harassment and mental agony assessed Rs.1,25,000/-.
- Such other cost of the petition.
2. The version of the opposite party is as follows:-
Complainant has taken a Travel Companion Insurance Policy bearing No. OG-15-1602-99100000130 for the period from 7.4.2014 to 3.10.2014. At the time of taking the policy, the complainant has not disclosed any past history of disease/ailment. The opposite party requested the complainant to give details of medical history and also to give details, if the proposed person has suffered from any disease/illness irrespective of whether hospitalized or not. It was mandatory for issuance of policy which result in the alteration of the risks covered under the policy and the premium amount. Against the said question the complainant/insured has answered ‘No’. The complainant has not disclosed any medical history or the details of any disease/illness suffered by him. On the basis of the details furnished and believing the statements and placing credence on the complainant, this opposite party has in good faith issued the policy to the complainant. The coverage amount for medical expenses for one illness is $12,500/- US dollars. Complainant had submitted a claim form fated 17.6.2014 along with the attending Physician Dr. Flore Paulo’s statement. In the said statement the doctor had stated that – Nature of illness ‘Acute Myocardial Infarction’ (Stemi Anterior). While processing the claim, the opposite party obtained expert medical opinion which confirmed the hyper- tension since 10 years. Since the complainant had the history of hypertension for several years, the claim was rejected on the ground of suppression of material facts and making it clear that the non-disclosure of the past medical history of the complainant at the time of taking the policy would make the insurance policy void abinitio and the opposite party does not admit/incur any liability for the insured person under the policy. The complainant is not entitled to get any reliefs sought for in the complaint.
3. Complainant was examined as PW1. Documents produced were marked as Exts.A1 to A10. Opposite party was examined as RW1. Documents produced were marked Exts.B1 to B4. Ext.B3 marked subject to objection.
4. The points came up for considerations are:-
1) Whether there is any deficiency in service on the part of the opposite party?
2) If so the reliefs and costs?
5. It is an admitted fact that complainant had taken a Travel Insurance Policy from the opposite party. According to the complainant, when he reached at U.K. on 13.6.2014 complainant developed intermittent chest pain and taken to Liver Pool Heart and Chest Hospital in U.K. and treated there for Acute Myocardial Infarction and discharged on 17.6.2014. Complainant submitted insurance policy details to the hospital authority and they provided all medicines and treatment on the basis of the insurance policy. Thereafter complainant submitted his claim statement before the opposite party with all relevant documents, but his claim was repudiated by the opposite party. The contention of the opposite party is that the claim was not payable because the complainant was having a history of hypertension for several years and for the management of the same, the complainant is taking medicine regularly. According to the opposite party the complainant had suppressed material facts past medical history at the time of inception of the policy.
6. Ext.A1 is the policy issued by the opposite party. It shows that the maximum liability for illness is 12500 US dollars. Ext.A3 is the claim form dated 17.6.2014 submitted by the complainant. As per Ext.A3 document, the nature of the illness of the complainant is Acute Myocardial Infarction. In Ext.A3 under the title history of the following, it is noted that the duration of “Hypertension” is 10 years. According to the opposite party with (HTN) arterial walls become thickened, inelastic and resistant to blood flow, and as a result, the left ventricle becomes distended and hypertrophied, in its efforts to maintain normal circulation, in adequate blood supply to the coronary arteries cause angina or myocardial infarction. The opposite party further contended that since the complainant was hypertensive and was taking medicine for the same at the time of purchase of insurance policy, he had obtained the insurance policy by misrepresentation and concealment of material fact regarding previous ailment. By relying the judgment of Hon’ble National Commission in Revision Petition No. 2314 of 2012 the learned counsel of opposite party argued that complainant suppressed the material facts with regard to pre-existing disease if any at the time of taking of medi-claim policy and hence the complainant is not entitled to get the insurance claim. There is no evidence produced by the opposite party to show that complainant despite of having knowledge of his heart ailment concealed the fact in the proposal form by giving a wrong information. The relevant document in this regard is the proposal form submitted by the complainant at the time of taking the policy which should certainly be in the custody of the opposite party, but it has not been produced. Hence their contention that complainant had taken the policy, suppressing the material fact is not sustainable. Another contention of the opposite party is that as per the Ext.A8 medical report of the complainant, he was suffering from hypertension prior to the purchase of the insurance policy and since hypertension has direct nexus with heart ailment they have every right to repudiate the insurance claim. Hon’ble National Commission in Revision Petition No. 3619/13 Sathish Chandra Madan Vs. M/s. Bajaj Allianz General Insurance Co. it is laid down that, “Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack.” The said decision is squarely applicable in the instant case. In view of the above, we are of opinion that the repudiation of the claim form submitted by the complainant by the opposite party amounts to defect and deficiency in service.
In the result, the complaint is allowed. The opposite party is directed to pay the bill amount of 4,610.51 GBP amounts to ( Rs.4,61,000/-] - (Rupees four lakh and sixty one thousand only) with 8% interest per annum to the complainant from the date of complaint till realization. The opposite party is further directed to pay Rs.1,000/- towards costs of this proceedings to the complainant. Since primary relief is granted there is no order as to compensation. The order shall be complied within one month from the date of receipt of this order.
Dictated to the Confidential Assistant transcribed by her corrected and pronounced by me in open Forum on this the 30th day of November, 2016.
Sd/- Smt. Elizabeth George (President):
Sd/- Sri. Antony Xavier (Member) :
Sd/-Smt. Jasmine.D. (Member) :
Appendix:-
Evidence of the complainant:-
PW1 - Thomas Prasad (Witness)
Ext.A1 - Copy of the Travel Companion identification and schedule
Ext.A2 - Leaflet of the policy
Ext.A3 - Copy of the claim form dated 17.6.2014
Ext.A4 - Discharge Summary
Ext.A5 - Copy of the invoice
Ext.A6 - Repudiation letter dated 5.8.2014
Ext.A7 - Letter dated 25.11.2014
Ext.A8 - Medical report
Ext.A9 - True copy of the report of department of cardiology
Ext.A10 - Report of Department of clinical biochemistry
Evidence of the opposite party :-
RW1 - Alice John (Witness)
Ext.B1 - True copy of the Travel Companion identification and schedule
Ext.B2 - True copy of the claim form
Ext.B3 - Certificate dated 9.2.2015
Ext.B4series - Copy of the repudiation letters (3 Nos.)
// True Copy //
By Order
Senior Superintendent
To
Complainant/Opposite parties /S.F.
Typed by:- pr/-
Compared by:-
