Punjab

Nawanshahr

CC/24/2016

Jaspal Singh Deol - Complainant(s)

Versus

The Reliance General Insurance - Opp.Party(s)

SS Kundra, HS Kundra

07 Oct 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SHAHEED BHAGAT SINGH NAGAR

 

                             Consumer Complaint No.      :   24/2016        

Date of Decision                      :  07.10.2016

Jaspal Singh Deol aged 63 years resident of Village Seikhwan Mazara, PS-Rahon, District Shaheed Bhagat Singh Nagar                                                                                                             ….Complainant

Versus

1.       The Reliance General Insurance Company Limited through its Manager, 19, Reliance Centre, Walchand Hira Chand Marg, Ballard Estate, Mumbai – 400038.

2.       Reliance General Insurance Company Limited, Railway Road, Near Cinema, Banga City, District SBS Nagar, through its authorized agent, Aman Jain.

                                                                    ….Opposite Parties

                   Complaint under Section 12 of the Consumer Protection Act, 1986

 

ARGUED BY:

For complainant           :        Sh.S.S. Kundra, Advocate

For OP No. 1                 :        Sh.P.K. Dhir,  Advocate

For OP-2                       :        Ex parte.

 

 

 

 QUORUM:

S.BHUPINDER SINGH, PRESIDENT

S.KANWALJEET SINGH, MEMBER

 ORDER

S.BHUPINDER SINGH, PRESIDENT

1.       This complaint has filed under Section 12 of Consumer Protection Act against the opposite parties.  On the averments that complainant has purchased travel ticket to visit America in August 2014.  At the time of purchasing air travel ticket, OP No.2 approached the complainant and proposed for purchasing travelling insurance of OP No.1.  Under sweet talking, he purchased insurance from OP No.1 by OP No.2 namely Reliance Travel Care Insurance Policy. At the time of purchase the policy, he disclosed all the material facts about his health status, etc, thereafter OP No.2 being satisfied with the health status and information provided, issued policy after receiving the premium from complainant.  Unfortunately, while in USA, complainant got sick and was admitted in hospital for two days on 24.08.2014.  Complainant and hospital informed OP No.1, accordingly the treatment was provided and complainant was discharged.  As per the trade practice in USA, after the submission of the insurance policy details with the hospital, at the time of discharge, son of complainant stood as guarantor for the payment of the hospital bills, etc.  OPs repudiated the claim of the complainant on flimsy ground, without giving any opportunity to the complainant or taking any medical expert advice on the matter.  With no option, complainant paid hospital bills amounting to US$320, under protest.  After return to India, complainant approached to OPs to make the payment spend by complainant in USA but OPs illegally repudiated the claim of the complainant.  Unfortunately, complainant was again admitted in Santa Clara Hospital, USA on 09.09.204 and was discharged on the same day after giving medication as per the requirement of the patient.  The allegation on the basis of which the claim of the complainant was repudiated is that complainant had been suffering from hypertension, whereas, complainant never patient of hypertension.  He prayed that Ops be directed to pay to him Rs.1,00,000/- on account of non-payment of hospital charges alongwith interest @12%. 

2.       On notice, OP No.1 has filed written statement.  It is submitted that complainant has not approached this Forum with clean hands and concealed the material facts.  The complainant has suppressed the pre-existing disease of hypertension and having suffered from traumatic kidney injury in past (status post left Nephrectomy).  The claim is not maintainable on the ground of suppression of true facts from Insurance Company.  The complainant was suffering from Hypertension and having suffered from traumatic kidney injury  and he did not disclosed the same in proposal form at the time of inception and the claimed amount form public fund canoe b released to complainant.  The complainant was again asked to reconfirm the detail of particulars in the proposal form within 7 days or commencement of policy period whichever is earlier but he did not give any intimation about discrepancies of proposal form because of his malafide intention to take the money from public fund.  Complainant has no locus standi to file the complaint.  This Forum has got no jurisdiction to try and decide the complaint.  On merits, it is submitted that it is duty of complainant to disclose all her medical problem to the insurance company.  As the medical record provided by complainant, it proves that complainant palpitation of 20 days, sleeping difficulty of last several nights and had slept only for 2 hours in past 2 nights with the back ground medical history of ongoing treatment for hypertension and having suffered from traumatic kidney injury in past.  As per opinion of doctor the patient was suffered from Insomina disease.  Thus, current presentation was the result of somatic manifestation of Neuropshychiatric aliment.  The overseas medical records of the complainant reveals that the complainant had past pertinent medical history of hypertension and on continuing treatment for the same alongwith having suffered Traumatic Kidney Injury in past. Insurance policy shows that the complainant has not disclose past medical history hypertension and on continuing treatment for the same.  The claim of the complainant has been denied/repudiated vide the scope of coverage-benefit 1 medical expenses what it does not cover-point 9, General Exclusions Point 7 and standard terms and conditions -1 duty of disclosure.  It is prayed that complaint be dismissed with cost.

3.       Op No.2 has served with notice on 23.04.2015, but none has appeared on behalf of OP No.2, hence Op No.2 was proceeded against ex parte vide order dated 16.05.2016.

4.       In support his complaint, counsel for complainant has tendered affidavits of complainant Ex.CW1/A & Ex.CW1/B alongwith documents Ex.C-1 to Ex.C1-14 and closed the evidence.

5.       Learned Counsel for OP No.1 has tendered affidavit of Amit Chawla, Legal Manager Ex.OP1/A alongwith documents Ex.OP-1 to Ex.OP-3 and closed the evidence.

6.       We have heard the learned counsel for the contesting parties, minutely gone through the record and have appreciated the evidence, with the valuable assistance of learned counsels for the contesting parties.

7.       From the entire record i.e. pleadings of the parties and the  evidence produced on record by the parties, it is clear that complainant visited USA in August 2014 and obtained Traveling Insurance Policy from the OPs for a period from 13.08.2014 to 12.10.2014 Ex.C-2/Ex.OP-1.  Unfortunately, in USA, the complainant because sick and was admitted in hospital on 24.08.2014 and he remained admitted in that hospital for two days.  Complainant as well as hospital authorities informed the insurance company i.e. OP-1.  At the time of discharge from the hospital, son of complainant stood as guarantor for the payment of hospital bills i.e. of US$320.  The claim was lodged with OP but the OP repudiated the claim of the complainant on the ground that the complainant has concealed/suppressed the material facts while taking the insurance policy as he did not disclose the disease of hypertension and having suffered from traumatic kidney injury in the past.  The learned counsel for the complainant submitted that the complainant has disclosed all the material to the OPs regarding his health.  He was never suppressed the disease of hypertension nor he has having traumatic kidney injury.  The OP has wrongly repudiated the claim.  All this amounts to deficiency in services on the part of OP qua the complainant.

          Whereas, the case of the OP is that the complainant has not approached this Forum with clean hands as he has suppressed his pre-existing disease of hypertension and having traumatic kidney injury in past.  So he is not entitled for any compensation from OPs.  The copy of emergency department report proves that patient medical history of suffering from hypertension and having suffered from traumatic kidney injury in past prior to insurance coverage.  The report is Ex.OP-3, status history of present illness as the complainant has a past medical history of hypertension who presents to the Flagstaff Medical Center department via private vehicle complaining of heart palpitations for the past 2 days.  He denied having chest pain but noted tightness in his shoulders and legs.  He denied shortness of breath.  He denied having a cough.  However, he reported that he had difficulty in sleeping for the past several nights.  The OP submitted that the claim is not maintainable on the suppression of true facts from the insurance  company.  The learned counsel for the OP No.1 submitted that the OP has repudiated the claim of the complainant as per terms and conditions of the policy.  So there is no deficiency on the part of the OP qua the complainant.

8.       From the entire record and discussion we have come to the  conclusion that the complainant visited USA in August 2014 and he obtained travel care insurance policy from the OP for the period from 13.08.2014 to 12.10.2014 Ex.C-2 with sum assured of 50000 US$.  While in USA, the complainant got sick and was admitted in hospital on 24.08.2014.  He remained admitted there for two days as per document Ex.C-1 and paid US$320 to the hospital authorities.  Thereafter, the complainant again admitted in Santa Clara Valley Medical Center on 09.09.2014 and discharged on the same date after giving medication.  The complainant lodged claim with OP but the OP repudiated the claim of the complainant on the ground that as per history of the complainant regarding the present illness recorded by hospital, the patient has past medical history of hypertension who presents to the Flagstaff Medical Center emergency department via private vehicle complaining of heart palpitations for the past two days.  The OP submitted that the complainant has not disclosed this fact that he had pre-existed disease of hypertension and having suffered from traumatic kidney injury.  But the OP could not produce any documentary record/medical record or medical prescription slip of the complainant which could prove that he was suffering from hypertension or he has suffered from traumatic kidney injury in past or that he has acknowledge about hypertension prior to the inception of the policy in question nor the OP could produce any affidavit of any medical specialist or doctor to prove that the complainant was taking medicine/treatment for hypertension prior to the taking of the policy in question nor the OP has filed affidavit of any medical expert/doctor who could depose that he treated the complainant for hypertension prior to commencement of  the policy in question.  The OP has also failed to produce any medical record that complainant had ever suffered from traumatic kidney injury as alleged by the O.P. in the written version.  So the OP has failed to prove on record that complainant was suffering or has acknowledge that he was suffering from disease of hypertension prior to the taking  of the  policy in question or that he suffered from any kidney injury. Resultantly, we hold that the OP has wrongly repudiated the claim of the complainant on the ground of concealment/suppression of any fact from the OP while taking the policy in question from the O.P.

9.       Resultantly, we partly allow the present complaint with costs and the OPs are directed to pay the amount spent by the complainant on his treatment i.e. US$320 to the complainant within one month from the date of receipt of copy of this order.  OP is also directed to pay to the complainant compensation to the tune of Rs.5,000/- and Rs.2000/- as litigation.

 10.       Certified copies of this order be supplied to the parties, as per rules. File be indexed and consigned to the Record Room.

Dated:  07.10.2016

                                                          (BHUPINDER SINGH)

                                                          President

         

                                                          (KANWALJEET SINGH)

                                                          Member