DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No. 47 of 04.02.2016

                                      Decided on:                      19.01.2017

Sushil Kumar aged 62 years son of  Late Sh. Bihari Lal R/o H.No.1026,   Rajpura Town, Gandhi Colony,  Rajpura,  District Patiala,  through  its  Manager.

                                                                   …………...Complainant

                                      Versus

1. The Oriental Insurance Company Limited Regd. & Head Office: A-25/27, Asaf Ali Road, New Delhi-110 002, through its M.D.
2. The Oriental Insurance Company Limited Branch Office: SCO No.126, IST Floor, Chhoti Baradari, Patiala (Pb.) through  its Manager.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Smt. Neena Sandhu, President

                                      Smt. Neelam Gupta, Member                              

ARGUED BY:

                                       Sh.Amar Singh, Adv. counsel for the complainant.

                                      Sh.D.P.S.Anand, Adv. counsel for O.Ps. No.1 & 2

 ORDER

                                    SMT.NEENA SANDHU, PRESIDENT

Sh.  Sushil Kumar   has filed this complaint under Section 12 of the  Consumer Protection Act, 1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-

1. To release the payment of Rs.9lac spent on medical treatment
2. To pay reasonable compensation and cost of litigation
3. To pay any other relief, which this Forum may deed fit.

2.                       In brief, the case of the complainant is that he and his wife purchased   Medi Overseas claim policies separately on 15.9.2014 from the O.Ps. after payment of premium.Both of them were medically checked up by qualified doctors before issuing Medi policies.These  policies remained in force for six months  i.e. w.e.f. 15.9.2014 to 13.3.2015. They went to London for the purpose of taking care of their 1 ½ year grand-daughter. On 15.10.2014, he felt acute chest pain and was immediately got admitted in Darren Valley Hospital, Dartford (London) for getting medical treatment. He remained admitted there for 6 days and was asked to deposit Rs.4,10,000/- as treatment charges. The overseas claim settlement agency of the company refused to make the payment against cost of treatment. The claim was declined on the ground that  he had a pre-existing disease. The treatment being very costly,he could not afford the same.  compared with the treatment in U.K. Therefore, he preferred to come to India on 2^nd November,2014 and got himself admitted in Medanta Hospital, Gurgaon (Haryana) for further treatment. Surgical operation was conducted on 5.11.2014. He  had to pay Rs.3,45,000/- for surgical treatment.The O.Ps. rejected the claim for the reasons that “An Overseas Medi Claim (OMP) policy covers expenditure incurred out of Republic of India only”. Thus his both claims i.e. Rs.4,10,000/- in U.K. and Rs.3,45,000/- in India, respectively were rejected. The rejection of claim by the O.Ps amounts to deficiency in service and unfair trade practice on their part, which caused mental agony and financial hardship to him.

3.                        On being put to notice, the OPs appeared and filed their written version taking preliminary objections that the complaint is not maintainable on the ground that the complainant was suffering  from diabetes and hypertension before the purchase of the policy; that the complaint  is liable to be dismissed for not joining of necessary parties and that complicated questions of law and facts are involved in the complaint which can only be decided before the civil court.On merits, the issuance of Overseas Mediclaim Business & Holiday Policy in favor of the complainant for the period from 15.9.2014 to 13.3.2015 is admitted.It is stated that on receipt of intimation of loss, they sent all the record including discharge summaries, bills and  other documents to Heritage Health TPA Pvt. Ltd,Mumbai, who is the 3^rdparty administrator of the policy,which consists team of experts and highly qualified professional doctors ,who after examining the record of the complainant found that the claim was not maintainable under the terms and conditions of the policy because at the time of purchase of the said policy,  complainant did not disclose that he was suffering from pre existing diseases i.e. diabetes and hypertension. The second claim for the treatment taken from Medanta Hospital, Gurgaon was not tenable as the Overseas policy covered the treatment expenses outside India. There is no deficiency in service and unfair trade practice on their part in rejecting the claim of the complainant. The OPs denied all other averments made  in the complaint and have prayed for dismissal of the complaint.

3.                         In support of the complaint, the ld. Counsel for the complainant  has tendered affidavit of complainant Ex.C1, photocopies of documents Ex.C2 to C14 and closed the evidence.  On the other hand, the learned counsel for the O.Ps. has tendered affidavit of Sh.Amarjit Singh Dhingra, Ex.OPA, affidavit of Dr.P.R.Purandare, Ex.OP1 and photocopies of documents Ex.OP2 to Ex.OP5 and closed the evidence.

5.                       We have heard the ld.counsel for the parties, gone through the record of the case, and have also gone through the written arguments filed by the complainant,carefully.

6.                       The ld. Counsel for the complainant submitted that the          complainant was duly checked up by the qualified  doctor   and     the     OPs. issued the policy in question on the basis of medical report   of   the complainant furnished by their empanelled doctor.        In support of  his version, he drew our attention to the page no.2             of the  policy document  Ex.C1 ,wherein  it has been written :

                   No. of Days outside India                                    180

                   Original copy of physician’s report attached:               Yes

                   Adverse Medical History                                               NIL

                   Medical report attached                                       Attached

                   From the said document, it is apparent that before issuance of          the said policy, the complainant was duly  examined by the doctor . However, neither of the party has produced the medical report of the complainant on record. Had the medical report of the complainant been placed on record then, this Forum would have easily come to know, as to whether the complainant was suffering from diabetes or not, at the time of obtaining the policy in question. If for the sake of arguments, it is believed that as per the medical report the complainant was actually suffering from diabetes and the complainant has willfully given wrong   information regarding his health status, in the proposal form,  then  the Ops should not have issued the insurance policy  in question to the complainant. At this stage, ops have no ground to repudiate the claim of the complainant on the ground of non-disclosure of pre-existing disease. It may be stated that in medical history, Ex.C4, recorded by Darren Valley Hospital, Dartford, NHS,(London),  it is mentioned that  the complainant was having type 2 diabetes, which was controllable by diet but it is no where mentioned, for how long the complainant was suffering from diabetes or whether he was taking some treatment from any doctor.  Even in the discharge summary, Ex.C7, issued by Medanta Hospital, Gurgaon , there is no mention  for how long the complainant was suffering from diabetes . Taking all these facts into consideration, we are of the view that the Ops are not justified by not paying the claim amount to the complainant for the treatment, which he had taken from Darren Valley Hospital, Dartford, NHS, London. From the invoice dated 31.10.2014 Ex.C.2 issued by Dartford and Gravesham, NHS, London, it is evident that the complainant paid 4166.72 pounds to the said hospital for his treatment. The O.ps. are thus, liable to indemnify the complainant for the expenses, incurred by him on his treatment at Darren Valley Hospital, Dartford, NHS, (London) and as such, they are liable to pay an amount equivalent to 4166.72 pounds in Indian currency. However, the prayer made for indemnification of sum of Rs.3,45,000/- which the complainant incurred for the treatment taken from Medanta Hospital, Gurgaon is not acceptable because it was a overseas medical policy and as per clause 5(d) of  policy terms and conditions Ex.OP5 no claim will be paid in respect of medical treatment and related services obtained within Indian.

7.                 In view of the aforesaid discussion, we partly allow the complaint and direct the Ops in the following manner:

1. To pay an amount equivalent to 4166.22 pounds in Indian currency alongwith interest @7%  p.a. from the date of repudiation till actual payment.
2. To pay Rs.5000/-as compensation on account of mental agony and physical harassment suffered by the complainant.
3. To pay Rs.5000/-as litigation expenses

            The Ops are further directed to comply with the order within a period of 30 days from date of  receipt of the certified copy of this order. The file be indexed and consigned  to the Record Room.

ANNOUNCED

DATED:19.01.2017              

                                                                   NEENA SANDHU

                                                                       PRESIDENT

                                                                   NEELAM GUPTA

                                                                         MEMBER