Complainant Kewal Krishan vide the present complaint filed U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short The Act) for issuance of the necessary directions to the titled opposite party to pay the full claim of $29710 (Rs.18,31,150/-) alongwith Rs.1,50,000/- for causing physical and mental harassment to him on account of deficiency in service alongwith Rs.10,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that his deceased wife namely Santosh Kumari had purchased the Traveller cum Overseas Medi-claim Insurance Cover from opposite party no.3 and he being the nominee is competent to invoke the jurisdiction of Hon’ble Forum for redressal of his grievance. Opposite party had issued the policy bearing No.233804/48/2014/942 which was valid from 02/02/2014 to 02/05/2014. His wife had paid premium of Rs.15,452/- towards the policy, the policy covered the risk to the extent of $1,00,000/-. Before taking the policy it was assured by the opposite parties that the insured would get trouble free cashless treatment under the said policy coverage. He has further pleaded that his wife left for Brampton (Ontario), Canada, Brampton 7732/Clevis Road, Brampton, Ontario L6Y5Lc on 02/02/2014 and on 15/03/2014, all of a sudden she fell uncomforted in the chest region and shortness of breath and chest pain and immediately taken to William Osler Health System, Brampton Hospital where she was treated and many clinical tests/examinations were carried out to ascertain the cause of illness but inspite of the best efforts made by the treating doctors, Mrs.Santosh Kumari showed no improvement and ultimately died on 28/03/2014. Opposite parties were informed immediately regarding her death and requested many times to settle the genuine claim but requests fell on deaf ears and finally  opposite parties rejected the bonafide claim vide letter dated 25/06/2014 and came out with alibi that deceased was suffering from Myeloid Leukaemia and it fell in exclusion clause. His wife was fit and fine. He had issued the legal notice dated 3.1.2015 and posted on 8.1.2015 besides visiting number of times to the office of opposite party for the settlement of his genuine claim but to no avail. He earlier approached the Hon’ble State Consumer Disputes Redressal Commission, Punjab vide consumer complaint no.220 of 2015 but after hearing the arguments they came to the conclusion that although the case made by him is not covered under that risk but still he is entitled to claim reimbursement for the expenses incurred regarding the treatment of illness of insured and they further directed the complainant to approach the District Consumer Disputes Redressal Forum for the settlement of their genuine claim because the instant complaint comes within the pecuniary jurisdiction of this Hon’ble Forum. Hence this complaint.

3.       Upon notice, the opposite parties appeared through their counsel and filed their written version taking the preliminary objections that the present complaint of the complainant is not maintainable. As soon as the claim of the complainant received by the opposite party, the same was referred to M/s.Heritage Health TPAS Pvt.Ltd. Mumbai for settling the claim as per the terms and conditions of the policy and as per the required record/documents M/s.Heritage Health TPA Pvt.Ltd. Mumbai is the claim settling authority, who settle the Claims under the Overseas Mediclaim-Business and Holiday Policy, as per the terms and conditions of policy. On scrutinizing all the documents including medical treatment record, M/s.Heritage Health TPAS Pvt.Ltd. Mumbai observed that the insured Smt.Santosh Kumari was suffering ‘CHRONIC MYLEOID LEUKEMIA’ disease, since in India, which was the pre-existing disease of the insured. Hence, the claim of the complainant is not covered under the terms and conditions of the policy ‘Overseas Mediclaim-Business and Holiday’ and the opposite party has rightly repudiated the claim of the complainant under the terms and conditions of policy. On merits, it was submitted that the insured Smt.Santosh Kumari had purchased the policy bearing No.233804/48/2014/942, for the period from 02/02/2014 to 02/05/2014 under the premium of Rs.15,452/- for a sum assured $ 1,00,000/-.  It was further submitted that the deceased insured purchased the policy in question by concealing her pre-existing disease i.e. Chronic Myelogenous Leukemia, by which she was suffering in India. It was next submitted that as soon as the claim of the complainant received by the opposite party, the same was referred to M/s.Heritage Health TPA Pvt.Ltd. Mumbai for settling the claim as per the terms and conditions of the policy and as per the required record/documents M/s.Heritage Health TPAS Pvt.Ltd. Mumbai is the claim settling authority, who settle the Claims under the Overseas Mediclaim-Business and Holiday Policy, as per the terms and conditions of policy. On scrutinizing all the documents including medical treatment record, M/s.Heritage Health TPAS Pvt.Ltd. Mumbai observed that the insured Smt.Santosh Kumari was suffering ‘CHRONIC MYLEOID LEUKEMIA’ disease, since in India, which was the pre-existing disease of the insured. Hence, the claim of the complainant is not covered under the terms and conditions of the policy ‘Overseas Mediclaim-Business and Holiday’ and the opposite party has rightly repudiated the claim of the complainant under the terms and conditions of policy of the complainant. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Complainant tendered into evidence his own affidavit Ex.CW1/A along with the other documents exhibited as Ex.C1 to Ex.C11 and closed the evidence.

5.        Counsel for the opposite parties tendered into evidence affidavit of Sh.Karam Singh D.M, OIC Pathankot Ex.OP-1, alongwith the other documents Ex.OP2 to Ex.OP5 and closed the evidence.

6.    We analytically observe with the judicial precision (that the majesty of constitutional justice bestows upon the Indian Courts) & find that the OP insurers have validly (Ex.OP2) repudiated the complainant’s insurance claim for reimbursement of the medical expenses incurred on the medication and hospitalization at Canada of his ailing wife (75 years in age) covered for medical treatment/accident under the ‘overseas mediclaim-business & holiday’ insurance policy duly purchased from the OP insurers before travelling abroad. The OP insurers have clearly stated in the repudiation letter that they shall not consider the complainant’s ‘insurance claim’ admissible for the reasons they are related to the direct complications of ‘past medical history’, excluded from the scope of policy coverage; since the patient has been admittedly treated over there in CANADA for ‘myeloid leukemia’ pre-existing in India.

7.       We find that the terms of the related policy provide for such ‘exclusions’ as exercised here by the OP insurers. The clause ‘10’ of General Conditions Ex.OP4 under the head ‘Dispute resolution clause and procedure’ define the nature of coverage, Pre-existing Exclusions and Pre-existing condition and that clearly establishes the case of the OP insurers. Further, under Section A – Medical Expenses & Repatriation: Nature of coverage: it is clearly stated that the policy is not a general insurance policy. It simply covers the sudden and unexpected sickness or accident arising when the insured person is outside the Republic of India. We also find that the complainant produced documents exhibited here as: Ex.C1 & Ex.C2 (copy of the orders dated 15.09.2015 of the honorable State Commission in cc # 220/ 2015), Ex.C5 to Ex.C9 do prove that whatsoever medical investigations and medical treatment etc were received by the complainant’s wife at Canada Hospitals were not related to some sudden and accidental cause but pertained to the pre-existing ailment ‘chronic myeloid leukemia’ suffered by the complainant’s wife as a pre-existing disease, not covered under the applicable policy. Moreover, the complainant has failed to produce on records any cogent evidence that her ailing wife had received medical treatment at Canada Hospitals for some other disease caught by her suddenly/accidentally during her visit over there and was not caused by the pre-existing disease namely: myeloid leukemia.          

8.       In the light of the all above, we are of the considered opinion that the OP insurers have validly repudiated the impugned insurance claim and finding ‘no merit’ in the present complaint, we order for its dismissal with however no orders as to its costs,

9.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

          (Naveen Puri)

                                                                             President   

Announced:                                                     (Jagdeep Kaur)

July 21, 2016                                                          Member

*MK*