Haryana

Yamunanagar

CC/235/2011

Anil Goel S/o Jai Parkash - Complainant(s)

Versus

The New India Assurance Company Ltd. - Opp.Party(s)

D.S.Khurana

22 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                          Complaint No… 235  of 2011.

                                                                                          Date of institution: 17.03.2011

                                                                                          Date of decision: 22.02.2017.

Anil Goel aged about 65 years son of Shri Jai Parkash Goel, resident of Akanksha, Bilaspur Road, Jagadhri, District Yamuna Nagar.

 

                                                                                                               …Complainant.

                                    Versus

The New India Assurance Company Limited, through its Branch Manager, Opposite Madhu Hotel, Yamuna Nagar, tehsil Jagadhri, District Yamuna Nagar.

                                                                                                               …Respondent 

 

BEFORE:         SH. ASHOK KUMAR GARG, PRESIDENT.

                         SH. S.C.SHARMA, MEMBER.

 

Present:  Sh. D.S.Khurana Advocate, counsel for complainant.  

                Sh. Rajiv Gupta Advocate, counsel for respondents.            

             

 

ORDER

 

1.                     Complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986.

2.                     Brief facts of the present case, as alleged by the complainant,  are that  complainant, who is a businessman and intended to go to US, had taken one insurance policy bearing No. 2010/353503/34/10/45/00000056 pertaining to overseas medi-claim B & H vide cover note policy schedule No. 258336 operative from 03.08.2010 to 01.10.2010 vide receipt dated 27.07.2010 and paid a premium of Rs. 5614/- to the respondent (hereinafter respondent will be referred as OP). The policy in question covered a personal liability to the tune of $ 2,00,000/- and the same was valid for a period of 60 days. Thereafter, complainant travelled to U.S. under his passport No. F-5635098 and stayed there for the requisite period but during that period of staying in U.S. the complainant sustained an injury to his left lower extremity below knee as a result of bump with the license plate of the car and was admitted in Sherman Hospital, 1425, N. Rendal Road, on 15.08.2010 and was discharged from the hospital on 18.08.2010. The bill of the hospital was covered under the insurance policy so the hospital was provided necessary information and accordingly the insurance company i.e. OP was informed regarding the admission of the complainant in hospital and ultimately an amount of Rs. U.S.$ 22,354.50 was the expenditure incurred on the treatment of the complainant. However complainant was allowed to leave the hospital on account of the fact that the OP through its agent in U.S. had undertaken to clear all the bills of the hospital on behalf of complainant and all the requisite documents were gathered and provided to the OP in that regard.

            Despite completing all the formalities, it came to the knowledge of the complainant that the OP Insurance Company are not clearing the bills of the hospital and after repeated requests and remainders and ultimately the OP Insurance Company has wrongly and illegally repudiated the claim of the complainant vide letter dated 13.01.2011 on the ground that the Hematoma in the leg of the complainant was due to meditation being taken by the complainant, which finding of the Op Insurance Company was totally illegal and without any basis. The complainant was suffered an injury to his left lower extremity below knee as a result of bump with the license plate of the car as is also depicted in the case summary of the complainant issued by the hospital. It has been further mentioned that at the time of taking medi-claim policy, the Op Insurance Company assured the complainant to indemnify him, however, by not indemnifying the complainant, the OP Insurance Company has rendered deficient and negligent service due to which the complainant has suffered a lot of mental agony and harassment. Hence, this complaint praying therein that the OP Insurance Company may kindly be directed to clear the hospital bills of Sherman Hospital where the complainant remained admitted and taken treatment and further to pay compensation as well as litigation expenses.

3.                     Upon notice, OP Insurance Company appeared and filed its written statement by taking some preliminary objections such as complaint is not maintainable; complainant has got no locus standi to file the present complaint; there is no cause of action in favour of complainant; complainant has not approached this Forum with clean hands and has concealed the true and material facts; complainant is estopped by his own act and conduct from filing the present complaint and on merit it has been admitted that complainant has taken an overseas medi-claim policy bearing No. 2010/353530/34/10/45/00000056 valid from 03.08.2010 to 01.10.2010 from the OP Insurance Company. It is also admitted that the policy covered a personal liability for a sum of $ 2,00,000/- subject to terms and conditions of the policy for a period of 03.08.2010 to 01.10.2010. Further, it is also admitted that complainant visited U.S. and he was treated for left lower extremity hematoma with cellulitis. It has been further admitted that complainant was submitted the bills and treatment record to the OP Insurance Company. The claim was processed by Heritage Health TPA Pvt. Ltd. who have correctly and validly repudiated the claim of the complainant vide letter dated 13.01.2011 on the ground that the pre-existing condition and related ailments are not covered by the policy and specifically excluded all the medical expenses incurred directly due to ailment arisen due to pre-existing condition. Rest contents of the complaint were denied being wrong and incorrect. Lastly, prayed for dismissal of complaint.

4.                     In support of his case, counsel for the complainant tendered into evidence short affidavit of complainant as Annexure CW/A and documents such as Insurance policy as Annexure C-1, Receipt of premium of Rs. 5614/-  as Annexure C-2, Photo copy of discharge summary of Sherman Hospital as Annexure C-3, Photo copy of claim repudiation letter dated 13.01.2011 as Annexure C-4 and closed the evidence on behalf of complainant.

5.                     On the other hand, counsel for the OP Insurance Company tendered into evidence affidavit of Sh. S.L.Gulati, Senior Divisional Manager as Annexure RW/A and affidavit of Dr. P.R. Purandare as Annexure RW/B and documents such as photo copy Insurance Policy as Annexure R-1, Photo copy of proposal form as Annexure R-2, Photo copy of discharge summary as Annexure R-3, Photo copy of letter dated 28.12.2010 as Annexure R-4, Photo copy of claim repudiation letter dated 13.01.2011 as Annexure R-5  and closed the evidence on behalf of OP Insurance Company.

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very carefully and minutely. The counsel for the complainant reiterated the averments mentioned in the complaint and prayed for its acceptance whereas the counsel for OP reiterated the averments made in the reply and prayed for dismissal of complaint.

7.                     It is not disputed that the complainant had taken one insurance policy bearing No. 2010/353503/34/10/45/00000056 pertaining to overseas medi-claim B & H vide cover note policy schedule No. 258336 valid w.e.f. 03.08.2010 to 01.10.2010.           It is also admitted that the policy covered a personal liability for a sum of $ 2,00,000/- subject to terms and conditions of the policy for a period of 03.08.2010 to 01.10.2010. Further, it is also admitted that complainant visited U.S. and he was treated for left lower extremity hematoma with cellulitis. It has been further admitted that complainant had submitted the bills and treatment record to the OP Insurance Company.       

8.                     The claim of the complainant has been repudiated by the OP Insurance Company mentioning in the repudiation letter (Annexure C-4) that “ the policy carries specific exclusion of all medical expenses incurred directly due to ailments excluded in policy and any consequences attributable to accelerated by or arising there from as per the medical history”. Our Medical Panel is of the opinion that you have been treated for left lower extremity hematoma with cellulitis. As per the medical report you had bumped your left calf against the car door after drinking. We also note that you have past medical history of hypertension and diabetes and on medication alongwith Coumadin. As per the medical opinion from our panel doctor the Hematoma is due to medications being taken by you for your past medical history. Please note that policy does not cover any pre-existing condition and its complications. Hence, we shall not consider your claim admissible for the reasons they are related to the direct complications of your past medical history.”  

9.                     From the perusal of above noted ground of repudiation taken by the OP   Insurance Company, it is clear that claim of the complainant has  been   repudiated  on the ground that the ailment were related to  the direct complications of the past

medical history of the complainant. We have perused the medical record of Sherman Hospital (Annexure C-3) which is in detail consisting 22 pages carefully and minutely at page No.3, it has been specifically mentioned under the head past medical history; Type 2 diabetes, history of left lower extremity DVT ( Deep Vein Thrombosis) and on the first page of discharge summary (Annexure C-3) it has also been mentioned that initial the patient had elevated INR of over 6 as he was taking acitrom which is equivalent to Coumadin in India. It was stopped. The patient was given vitamin K with improvement in his INR, after which Dr. Wu drained it; it was found to be an infected hematoma. Even at page No.2 under the head history of present illness it has been mentioned that the patient is a 59 years old male with the history of diabetes and previous Deep Vein Thrombosis (DVT) who is visiting the United State from India. Further at page No.7&8 of the discharge summary it has been further mentioned by the another doctor the patient had a DVT for which he was on Coumadin 6 to 7 months ago and further he has noted that patient/complainant diagnosed for diabetes mellitus 16 years ago in India and since then has been on insulin. Presently on a strange combination of insulin. He takes Novolog 8 units with break fast, 18 units at lunch and mixed 70/30 insulin 20 units at dinnertime with very erratic glycemic control. The patient is taking way too much bolus insulin and too little of basal insulin. He is in the habit of drinking a lot to the point of becoming a drunk and oblivious. And under the head social history it has been mentioned that the patient/complainant taking alcohol and smoking as mentioned; excess alcohol and a chronic smoker since age 16. And further at page No.11 under the head past surgical history it has been so recorded that; pancreatic duct surgery, open, and gallbladder removal, Hernia repair. The patient has no artificial joints and at page No.13 under the head assessment by the doctor Priya Behari, MD it has been mentioned that history of Deep Vein Thrombosis (DVT) in the left lower extremity 6 months ago, without evidence of thrombosis on recent Doppler and diabetes mellitus.

10.                   So going through the above noted facts mentioned in the medical treatment of the patient, we are of the considered view that claim of the complainant has been rightly repudiated by the OP Insurance Company. Although no medical record for taking previous medicine has been placed on file by the OP Insurance Company and further no affidavit on behalf of the Doctor of Sherman Hospital has been placed on file even then as in the present case the complainant/patient has taken treatment from the hospital in Foreign ( U.S.) and complainant himself has placed on file discharge summary alongwith treatment record Annexure C-3 in his evidence which is self explanatory cannot be disbelieved.

11.                   It is also pertinent to mention here that complainant has himself admitted in para No.5 of his complaint that the complainant was allowed to leave the hospital on account of fact that the OP Insurance Company through its agent in U.S. had undertaken to clear all the bills of the hospital on behalf of the complainant and all the requisite documents were gathered and provided on behalf of the complainant had been made to that hospital, it may be due to the reason as alleged by the complainant or otherwise but we are of the considered view that when the complainant has not made any payment then he is not entitled to get the same from the OP Insurance Company. Learned counsel for the OP Insurance Company referred the case law titled as LIC of India Versus Minu Kalita 2003(2) CLT page 201 in which it has been held that Insurance Claim- Repudiation- Ground that life assured intentionally suppressed material facts regarding the state of his health, his age and income- Information as to the insured having suffered from Cancer before the policy was taken and the hospitalization for the same came to the light afterwards and the insurance company is not to know this by an examination of their medical officer- It is for the respondent to give the correct information on his health which he did not disclose at that time- Ground of incorrect information and false statements regarding age of the insured and income made the insurance contract null and void- Claim rightly repudiated. And also referred the case law titled as Smt. Vidya Devi etc. Versus Life Insurance Corporation of India, 2002(1) CPC page 159.

12.                   We have also perused the certificate/opinion given by the Dr. P.R. Purandare, MS (Bom.)FIAGES, PGDHA dated 28.12.2010 (Annexure R-4) in which doctor has specifically mentioned that Hematoma is due to medicines being taken by the insured. Also DM is pre-existing. The policy schedule does not mention any exclusions. Kindly check whether the insured had disclosed the pre-existing conditions like HTN, DM and use of medications- blood thinners. The claim can’t be allowed due to pre-existing medical conditions.

13.                   Further, we have also perused the proposal form Annexure R-2 in which the complainant has given answer of the question under the head of medical history; Are you in good health and free from physical and medical disease or infirmity: Yes. And under the question No.2 to 6 has mentioned as “No” Hence, it is clear that complainant obtained the insurance policy in question from the OP Insurance Company by suppressing the material facts regarding his health.

14.                   In the circumstances noted above and going through the law cited by the counsel for the OP Insurance Company, we are of the considered view that the claim of the complainant has rightly been repudiated by the Op Insurance Company vide its letter dated 13.01.2011 (Annexure C4/R-5) and we have no option except to dismiss the present complaint of complainant.

15.                   Resultantly, we find no merit in the present complaint and the same is hereby dismissed with no order as to costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court: 22.02.2017.

 

                                                                                    (ASHOK KUMAR GARG)

                                                                                     PRESIDENT

                                                                                     D.C.D.R.F. YAMUNANAGAR

 

 

 

                                                                                     (S.C.SHARMA)

                                                                                      MEMBER