PRESIDENT 

1)        By this complaint the original Complainant Krishna Jadhav prayed that it be declared that the Opposite Parties are guilty of deficiency of service and unfair trade practice as per the provisions of the Consumer Protection Act, 1986 (hereinafter referred to as the Act). It is also prayed that the Opposite Parties be directed to pay Rs.5,16,600/- amount of medical expenses incurred by the Complainant for treatment of Eye illness with interest @ 21% p.a. from 11/06/08 till the realization of the same and Rs.1,00,000/- towards compensation for mental harassment and Rs.30,000/- towards cost of this proceeding. 

2)        According to the Complainant in the month of March, 2008 the Complainant obtained Air Travel Insurance Policy of the Opposite Parties as he has to visit USA to meet his son who resides in USA.  The copy of the said policy is Annexure ‘C-1’.  It is submitted that before issuing the policy the Complainant was called by Opposite Parties for conducting various medical test by the Doctor’s of the Opposite Parties and the same was complied by the Complainant after being satisfied with the Complainant’s health and by excluding “Diabetes” the Opposite Party issued the aforesaid policy in favour of the Complainant.

3)        It is submitted that while staying in USA on 20/05/08 the Complainant faced eye problem therefore, he obtained medical treatment at Baptist Memorial Hospital of Memphis.  The said treatment was provided as the Complainant was suffering from Conjunctivitis and he had to incur Rs.5,16,600/- for the treatment in the aforesaid hospital.  The copy of the medical bill and discharge card are at Annexure ‘C-2’ colly. It is alleged that as per the procedure of the said hospital the Complainant had handed over the policy paper to the hospital and the hospital directly filed the claim form to the Opposite Parties for settlement of the said amount.  It is submitted that however, the Complainant’s claim was erroneously repudiated by Opposite Party vide letter dtd.11/07/08 on the ground of suppression of material facts.  The copy of the letter of Opposite Party No.1 dtd.11/06/08 is Annexure ‘C-3’.  It is alleged that the Opposite Parties have unlawfully repudiated the claim without considering the fact that the Complainant approached the Doctors for treatment for eye illness and not for “dizziness”. It is alleged that the Opposite Parties wrongly repudiated the Complainant’s claim for treatment of eye illness.  According to the Complainant, he thereafter approached the Opposite Parties to reconsider the genuine claim of the Complainant by letter dtd.05/11/08 addressed to the Opposite Party No.1.  The copy of which is marked as Annexure ‘C-4’.  It is alleged that as the Opposite Parties Doctor had conducted various medical tests and investigation of the Complainant and after being satisfied with the medical reports of the Doctor of Opposite Parties they issued the medical policy to the Complainant hence, the question of suppression of material facts from the Opposite Party did not arise.  It is thus, submitted that the repudiation communicated by the Opposite Parties is improper.  The Complainant has therefore, prayed to grant the reliefs as mentioned in para 1 of this order.

4)        The Opposite Party No.1 filed written statement and contested the claim.  The material allegations in the complaint are denied.  According to the Opposite Party, the policy reimburses individual expenses incurred by the Insured arising out of hospitalization only with certain additions and deletions which are widely publish and form part of the policy.  It is contended that Annexure ‘A’ collectively are the prospectus and a copy of the Standard Policy drawn up by the General Insurance Corporation of India which highlights the silent features of the overseas Mediclaim Policy.  It is alleged that as per Annexure ‘C-1’ Medical cover is only to the extent of Rs.50,000/- and not over and above that. It is denied that the Opposite Parties erroneously repudiated the claim of the Complainant.  According to the Opposite Parties, the dizziness was not brought to the notice of the Insurer at the time of inception of the policy is supported by the report of Dr. Ashok Kumar Kunnure.  It is thus, contended that the Complainant is having a medical history of similar complaint of dizziness since many years was not disclosed at the time of taking the policy.  It is contended that it was the duty of the Complainant to furnish all the details of pre-existing diseases at the time of taking insurance policy.  The copy of the Doctor’s report dtd.10/06/08 is marked as Exh.‘A’ to the written statement.  It is contended that the Opposite Parties have rightly repudiated the claim of the Complainant on the basis of exclusion clause and suppression of material facts.  It is submitted that there is no deficiency on the part of the Opposite Parties.  The Opposite Parties have therefore prayed to dismiss the complaint with cost as provided u/s.26 of the Act. 

5)        The Complainant has filed his affidavit of evidence and Opposite Party No.1 has filed affidavit of Shri Sujit Datta, Divisional In-charge of Opposite Party No.1.  Both the parties filed their written arguments.  The Ld.Advocate for the Opposite Party No.1 in spite of notice remained absent for oral argument.  We heard the oral argument of Ld.Advocate Smt. Rashmi Manne for the Complainant.

6)        The Complainant had obtained insurance policy as per Annexure ‘C-1’ is not disputed by the Opposite Parties.  In the said document medical expenses, education and repatriation coverage is shown to 50,000 USD.  The Complainant has produced on record the medical treatment documents at Annexure ‘C-2’ and bill of 8037.25 USD issued by Baptist Hospital + four other bills of USD 702 + 236 + 697 and 660.  The Opposite Parties have come out with the case the Complainant was suffering from pre-existing diseases and therefore, as the policy carries specific exclusion of all medical expenses incurred directly due to past history ailments and any consequences attributable to accelerate by or arising there from as per medical history are not payable to the Complainant as informed in the letter dtd.11/06/08 at Annexure ‘C-3’.  In our view the said contention and reason for rejection of claim cannot be accepted as the Hon’ble State Commission in First Appeal No.A/10/921 decided on 06/07/2011 observed that “whenever case is made out in respect of pre-existing disease, it was/is obligatory for Insurance Company to produce on record proposal form so as to show suppression of pre-existing disease. However, in the present matter Insurance Company has not produced any proposal form in respect of Insurance Policy so as to infer that the deceased Malti had suppressed her pre-existing disease of diabetes from the Insurance Company.  Inference of pre-existing disease has been drawn by the Insurance Company on the basis of history given in the discharge card, when the deceased Malti was admitted in the hospital”.  In this case the Opposite Parties have not produced the proposal form so as to show pre-existing disease suffered by the Complainant. The Opposite Party has relied upon the report of Dr. Kunnure dtd.10/06/08.  The Opposite Parties have not placed on record on which basis Dr. Kunnure has submitted the opinion that the Complainant had dizziness symptoms for many years in the past.  The Opposite Party has also not submitted the available notes which was taken into consideration for diagnosis by Dr. Kunnure.  The Opposite Parties in their written argument have relied so many judgments of the Superior Courts but have not supplied the copies of the said judgments before this Forum.  The advocate of the Opposite Party No.1 remained absent at the time of oral argument and did not satisfy as to how the repudiation communicated by the Opposite Party No.1 & 2 to the Complainant is justifiable.  We therefore, hold that as the Opposite Parties failed to produce the proposal form and medical investigation papers regarding the Complainant at the time of issuance of the policy at Annexure ‘C-1’and thus, the denial of the claim lodged by the Complainant to the Opposite Parties is unjustifiable.  The contention raised by the Opposite Parties that as per Annexure ‘C-1’ the coverage for the medical treatment was available to Rs.50,000/- is also improper as in the said document such coverage is provided upto to 50,000 USD.  We therefore, hold that the claim made by the Complainant against the Opposite Parties of Rs.5,16,600/- needs to be allowed with interest @ 6% p.a. from 11/06/08 till its realization.  We also hold that the Complainant is entitled for Rs.25,000/- as compensation from the Opposite Parties towards the mental harassment and cost of Rs.8,000/-.  In the result the following order is passed –

O R D E R 

i.                    Complaint No.92/2009 is partly allowed against the Opposite Parties.

ii.                 The Opposite Parties are directed to pay an amount of Rs.5,16,600/-(Rs. Five Lacs Sixteen Thousand Six Hundred Only) to the Complainant alongwith interest @ 6% p.a. from 11/06/2008 till its actual payment and Rs.25,000/- (Rs. Twenty Five Thousand Only) as compensation for the mental harassment caused and cost of Rs.8,000/- (Rs. Eight Thousand only) to the Complainant. 

iii.                The Opposite Party No.1 & 2 are directed to comply the aforesaid order within one month from the date of receipt of this order.

iv.               Certified copies of this order be furnished to the parties.