The complainant Kulwinder Singh Rajput (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, (here-in after referred to as 'Act') before this Commission against The Religare Health Insurance Company Limited and Another (here-in-after referred to as opposite parties).
Briefly, the facts of the complaint as pleaded by the complainant are that he is holder of tourist health insurance policy bearing No.12332389 valid from 12.4.2018 to midnight of 8.10.2018 with spouse Harpreet Kaur Rajput. This policy was issued by the agent of opposite parties. All the formalities were completed at Bathinda and policy was given at Bathinda. This policy is for full health insurance covering foreign tour including Canada and it is covering medical health insurance upto USD 100000 each and covering 180, tour to Canada.
It is alleged that on 12.4.2018, the complainant had gone to Toronto (Canada) and during his stay, he suffered from ill health due to suffocation and his various tests were conducted. He spent 4560 Canadian Dollars. At that time, the value of the Canadian Dollar was Rs.54/-. After testing, he was provided treatment only for B.P and thereafter he was declared O.K. During his lifetime, he never faced any such botheration or ailment and it was for the first time that he faced the problem in Canada. He submitted the claim, claiming the amount of expenses incurred by him in Canada, but opposite parties instead of paying his claim, are insisting him to submit the previous document, but while in India, he has not suffered from any such ailment and was not under treatment of any doctor, so there are no past record of his any ailment. He has already sent e-mails to opposite parties, but inspite of that they are insisting him to submit the record regarding previous illness and treatment and are lingering on the matter on one way or the other.
It is further alleged that the complainant is entitled to recover the claim of 4560 Canadian Dollars and value of one Canadian Dollar at the relevant time was Rs.54/- and in the Indian currency comes to Rs.2,46,240/-, but opposite parties have failed to make the payment. As such, there is deficiency in service on their part.
On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay the claim amount of Rs.2,46,240/- and to pay Rs.2,00,000/- as damages in addition to Rs.15,000/- as costs of litigation.
Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and have raised the preliminary objections that the complaint is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this Forum. The complaint is liable to be dismissed as it is premature. The complainant without submitting all the requisite documents to opposite parties, has approached before this Forum with this complaint. As such, the complaint is liable to be rejected in limine. The complainant is required to file all the necessary documents sought duly as per the procedure provided in the policy terms for the respondent company to properly assess his claim of the complainant. This complaint is not maintainable in its present form as it involves disputed question of facts that cannot be determined in summary jurisdiction of Consumer Forum. This complaint is with malafide intention and complainant has not come before this Forum with clean hands, being litigation for sake of litigations is liable to dismissed with exemplary costs. The prima-facie, no cause has arisen in favour of the complainant to file this complaint as the complainant till date has not filed any reimbursement for claim. The intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and other party should have to cross-examine the witnesses and matter involved in this case cannot be decided in summary manner and complainant, if so advised, may approach the civil court. The complaint is false, frivolous and vexatious in nature. As such, the complainant is liable to pay penalty under 'Act' to opposite parties. He is estopped from filing this complaint by his own acts, conduct, omissions and acquiescence.
It is further pleaded that the complainant purchased the policy and submitted the proposal form for issuing the policy. After going through the contents of the proposal form, opposite parties issued the policy. The respondent company issued a health Insurance policy to the complainant bearing No.12332389 (Travel Insurance Policy) with effect from 12.4.2018 to 8.10.2018 covering the complainant and his spouse only for a sum insured of 100000 USD subject to policy terms and conditions. The copy of schedule bearing relevant details of the policy alongwith policy bond having terms and conditions were duly sent to the proposer. No assurance was given to the complainant beyond the terms and conditions of the policy.
It is further pleaded that the claim under the policy received by opposite parties with reimbursement claim on 22.9.2019 with respect to the treatment of the complainant for shortness of breath at Surrey Memorial Hospital taken on 29.6.2018 during the period of insurance for a claimed amount of Rs.1,22,819/-. As per Emergency/Ambulatory Care Clinical record of Surrey Memorial Hospital dated 29.6.2018, the complainant is specified to have a Past Medical History of Hypertension and Diabetes. In this regard, various query letters dated 15.10.2018, 5.11.2018 and 20.11.2018 were sent to the complainant wherein the below mentioned documents were sought:
Past Medical Reports/Consultation Notes Related to Hypertension and Diabetes Mellitus with complete ongoing medical list before and after travel overseas,
The complainant did not sent the requisite documents. As such respondent company sent a final reminder and closure letter dated 7.12.2018 and company has still not received any reply. The complainant without submitting all the requisite documents to the respondent company, approached this Forum with this complaint in a pre-mature manner. Opposite parties have also referred Clause 4.2(a) of the policy terms and conditions in support of their pleadings, detail of which is not necessary at this stage.
On merits, opposite parties have reiterated their stand as detailed above and prayed for dismissal of complaint with costs.
In support of his complaint, the complainant has tendered into evidence documents (Ex.C-1 to Ex.C-11).
In order to rebut the evidence of complainant, opposite parties tendered into evidence affidavit of Kashif Nazki dated 19.3.2019 (Ex.OP-1/1) and other documents (Ex.OP-1/2 to Ex.OP-1/7)
Counsel for the complainant has argued that the complainant is holder of tourist health insurance policy bearing No.12332389 valid from 12 Apr. 2018 to midnight of 08 Oct. 2018 with spouse Harpreet Kaur Rajput.
It is further argued that this policy is for full health insurance covering foreign tour including tour to Canada and it covers medical health insurance upto USD 100000 each and this policy is covering tour to Canada.
Counsel for the complainant has further argued that on 12.4.2018, the complainant had gone to Toronto (Canada) and during his stay at Toronto, he suffered from ill health due to suffocation and various tests were conducted. He has spent 4560 Canadian Dollars on his treatment and value of the Canadian Dollar was Rs.54/- at that time.
It is further argued that the complainant had never suffered from any ailment during his lifetime.
It is further argued that when the complainant submitted his claim with opposite parties, they instead of paying the claim, insisting him to submit the documents regarding previous ailment, but since he had not suffered from any problem while in India, as such, he was not in possession of any such record. Opposite parties failed to pay the claim on flimsy grounds, which amounts to deficiency in services.
Counsel for complainant has also relied upon the following judgments:-
i) Hon'ble Supreme Court of India– case titled Gurmel Singh Vs. Branch Manager, National Insurance Co. Ltd. - Civil Appeal No.4071 of 2022– Date of Decision 20-5-2022;
ii) Hon'ble National Commission – case titled Satish Chander Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., - Revision Petition No. 3619 of 2013 (Against Order dated 16-7-2013 in Appeal No. 305 of 2013 of the State Commission, Haryana) – Date of Decision 11-1-2016;
iii) Hon'ble State Commission – case titled Religare Health Insurance Company Ltd. Vs. Subhash Chander Aggarwal, 2017(3) CLT 140
On the other hand, counsel for opposite parties has argued that the alleged claim under policy was received by opposite parties on 22.9.2019 with respect to treatment of the complainant for shortness of breath at Surrey Memorial Hospital taken on 29.6.2018 and claim amount is Rs.1,22,819/-. However, as per Emergency/Ambulatory Care Clinical record of Surrey Memorial Hospital dated 29.6.2018, the complainant is specified to have a Past Medical History of Hypertension and Diabetes. Accordingly, he was time and again requested to submit the required documents, but he failed to submit the documents. Accordingly, finding no alternative, claim was closed as 'No Claim' for want of documents. As such, there is no deficiency in services on the part of opposite parties.
We have given careful consideration to these submissions.
It is admitted fact that the complainant and his wife had purchased the policy of insurance with health insurance cover up to USD 100000 and tour to Canada was covered under this policy.
It is further admitted that the complainant has suffered health problem at Toronto on 12.4.2018 and remained admitted under treatment and spent 4560 Canadian Dollars on his treatment.
A perusal of evidence, record and documents show that opposite parties have repudiated the claim of the complainant by relying upon document, (Ex.OP1/4) and as per which, the past medical history of Hypertention and Diabetes had been mentioned, but the said document produced on record by opposite parties is not eligible.
Moreover this Commission is of the view that there is no evidence on record in the shape of medical treatment obtained by the complainant in past in respect of alleged medical history of Hypertention and Diabetes. As such, this Commission is of the view that the claim cannot be refused by opposite parties by merely taking excuse for reference having been made in Ex.OP1/4.
Moreover this Commission is of the view that it was duty of opposite parties to have medically examined the complainant and his wife before issuance of policy of insurance and since they have failed to get the complainant and his wife medical examined. As such, they have waived their rights and they cannot deny the payment of claim to the complainant by taking excuse of past medical history of Hypertension and Diabetes without any evidence of medical treatment.
Accordingly, the present complaint is partly allowed and opposite parties are directed to settle and pay the claim of the complainant by calculating the value of Canadian Dollars at the time of making of payment to the complainant. The said amount shall also carry interest @9% per annum from the date of filing of complaint i.e. 25.1.2019 till realization. The complainant is further held entitled to receive Rs.5000/- as compensation.
The compliance of this order be made within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced :
08-06-2023
(Lalit Mohan Dogra)
President
(Shivdev Singh)
Member
