Per Shri S.R. Khanzode, Hon’ble Presiding Judicial Member
The consumer complaint refers to alleged deficiency in service on the part of the Oriental Insurance Company Ltd. (hereinafter referred to as ‘Insurance Company’) to repudiate the claim under the Overseas Mediclaim Policy (Business & Holiday) taken by insured/complainant- (hereinafter referred to as ‘complainant’) when she had gone to visit United Kingdom.
2. Undisputed facts are that complainant before proceeding to U.K. had taken Overseas Mediclaim Policy (B&H). The purpose of visit was holiday and countries to be visited mentioned in the Proposal Form were U.K., U.S.A. & Italy. While filling the Proposal Form, she had declared herself in good health, and further declared that she was suffering from Hypertension, Thalassemia and Dyslipidemia. She had also declared that she was not travelled against advice of Physician, she was not on the waiting list for any medical treatment and she was not travelling for obtaining medical treatment and had not received a terminal prognosis for a medical condition before filling the Proposal Form. Accordingly an Overseas Mediclaim Policy (B&H) was issued and wherein following diseases i.e. the one mentioned by her as existing diseases were excluded :-
“H.T. THALASSEMIA, MINOR DYSLIPIDEMIA & RELATED AILMENTS”
3. The complainant was to return back to India from U.K. by end of December 2005. A few days prior to it, she felt restlessness and breathing difficulties and therefore, consulted Dr.Deven Patel at London on 06/12/2005. He advised to the complainant, considering her critical condition to undergo for a “cardiac catheterization and urgent aortic valve replacement surgery”. After such advice the complainant had tried to contact one agency by name, Mercury, named by the Insurance Company to inform them about medical advice and necessary treatment. However, there was no response and therefore, on enquiry, ultimately contacted Coris International in Paris, a company representing the Insurance Company and forwarded to them her report and relevant papers including investigation/reports and estimated expenses and invoices on email on 20/12/2005 and informed them about her Cardiologist’s recommendation. However, there was no response from Coris International till 27/12/2005 and therefore, complainant’s daughter, namely, Dr.N.R. Bajekal called said Company on that day and enquired about progress of the claim. As per their demand additional information was also supplied which was collected from Dr.Khare from India who was treating the complainant. However, looking to serious heart condition of the complainant and seeing that operation could not be postponed, the surgery was arranged privately under Dr.Rakesh Uppal, a Consultant Cardio Thoracic Surgeon at WellingtonHospital in London and it followed with an urgent angiography (Cardiac Catheterization) on 03/01/2006 and operation was performed on 04/01/2006. As per the medical advice, complainant stayed in the Hospital till 21/01/2006. Total expenses incurred by the complainant were of £28478. Copies of medical expenditure incurred was sent to Insurance Company’s foreign agent-Coris International in Paris. On 28/02/2006 complainant was informed through Coris International that they have refused to cover the expenses incurred since heart disease was considered as pre-existence by their Medical Advisor. Consequently, Insurance Company was contacted returning after India on 11/05/2006 by the complainant, but they endorsed the refusal and therefore, ultimately, this consumer complaint was filed on 11/10/2007.
4. Insurance Company by their written version reaffirmed their repudiation. It was submitted on behalf of the Insurance Company that the complainant had disclosed about her past history suffering from Hypertension etc. but suppressed the material information that she was suffering from pulmonary oedema and had already developed symptoms with her aortic stenosis and that she was suffering from anginal symptoms. She was already under treatment for her heart ailment from Dr.Sanjay P. Khare, M.D. (Internal Medicine) in India during the period 2001 to 2005 and had taken treatment for various ailments including ischemic heart disease. The complainant used to frequently undergo ECG test and Lipid Blood test to monitor her heart ailment. For this purpose, as per advice of Dr.Khare, when the complainant underwent X-ray Chest on 22/03/2004 at Dr.Mude’s Diagnostic Imaging, it categorically referred to “Cardiomegaly with aorotic ectasis is noted. Kindly evaluate further for hypertensive heart disease. No active lung parencymal lesion is seen. The C.P. recesses are clear. No hilar or paratracheal adenitis is noted.” ECG report also suggested that prior to proposing for insurance cover in question there was STT changes indicating ischemic heart disease suffered by the complainant and even she was taken medicine prescribed for the same.
5. We heard both the parties and perused the material placed on record.
6. The complainant relied upon Certificate of Dr.Deven J. Patel dated 17/01/2006. Of course, there is no affidavit of Dr.Patel placed on record. However, this report of Dr.Deven J. Patel coupled with other medical papers inter alia including Dr.Shyam S. Mude’s X-ray Chest of the complainant report dated 22/03/2004, supra, ECG taken by Dr.Sanjay P. Khare dated 24/06/2005 i.e. just prior to leaving India before proposing for Overseas Mediclaim Policy were taken into consideration by Dr.P.R. Purandare, who offered his expert opinion in the form of report dated 30/10/2012 on affidavit. Dr.P.R. Purandare recorded his opinion as under :-
“Insured has been operated upon for Aortic valve replacement and CABG. HTN & Dyslipidemia are pre-existing. Hence all cardiovascular conditions fall under exclusion. Hence the claim can’t be allowed.”
7. It is pertinent to note that though the Insurance Company come with a specific case about suppression of material fact regarding her heart ailment and particularly, even mentioning the specific report of her treatment with Dr.Khare and also undergoing X-ray examination on 22/03/2004 as per advice of Dr.Khare at Dr.Mude’s Diagnostic and Imaging; the complainant preferred to maintain silence on it and therefore, in effect, she preferred not to dispute those statements. Her only case is that as referred by Dr.Deven J. Patel in his report dated 17/01/2006 commenting on the word used “threshold” referring to the statement in the said report, “Having questioned her a little further, it is clear that she did not have much in the way of symptoms prior to leaving India, and I therefore presume that she had reached her threshold for developing symptoms with her aortic stenosis, resulting in her presentation to me”; and submitted that word “threshold” means a level or point on which something would start and cease to happen or come into effect. We are unable to accept her such submission and explanation, particularly, in view of treatment papers on record including her X-ray examination by Dr.Mude dated 22/03/2004, supra, and the treatment of her from Dr.Sanjay P. Khare prior to departure from India for several years. This clearly establishes credibility of the opinion expressed by Dr.P.R. Purandare, supra. Thus, there is a just corroboration to the case pleaded in justification of their repudiation by the Insurance Company and also to the opinion expressed by their overseas agent-Coris International which was also given only after consulting their Medical Advisor. Thus, it is not a case of arbitrary repudiation of mediclaim on the part of the Insurance Company and as such no deficiency in service within meaning of Consumer Protection Act, 1986 could be inferred as against it. We hold accordingly and pass the following order :-
-: ORDER :-
1. Consumer complaint stands dismissed.
2. In the given circumstances, parties to bear their own costs.
3. Copies of the order be furnished to the parties.
Pronounced
Dated 20th August 2013.
