Punjab

Moga

CC/17/2

Gurcharan Singh Brar - Complainant(s)

Versus

United India Insurance Co. Ltd. - Opp.Party(s)

Sh. Vishal Jain

17 May 2017

ORDER

THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

 

                                                                                      CC No. 2 of 2017

                                                                                      Instituted on: 04.01.2017

                                                                                      Decided on: 17.05.2017

 

Gurcharan Singh Brar aged about 66 years son of Sh.Ram Bakhash Singh Brar, resident of VPO Kotla Rai Ka, Tehsil Baghapurana, District Moga.

                                                                                ……… Complainant

 

Versus

1.       United India Insurance Company Ltd., registered office at 24 whites Road, Channai- 600014.

 

2.       United India Insurance Company Ltd., having Branch Office at 6-7, Shahid Bhagar Singh Market, G.T. Road, Moga.

 

3.       Heritage Health TPA Private Ltd., Elite Auto House 54-A, Ground Floor (Rear sight) Andheri- Kurla Road, Chakala, Mumbai- 400093.

 

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12 of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President

                   Smt. Bhupinder Kaur, Member

 

Present:       Sh. Vishal Jain, Advocate Cl. for complainant.

                   Sh. Arun Sood, Advocate Cl. for opposite parties.

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as the "Act") against United India Insurance Company Ltd., registered office at 24 whites Road, Channai and others (hereinafter referred to as the opposite parties) directing them to pay an amount of Rs.$ NZ 6982.98 (Approximately Rs.3,50,000/- in Indian Currency) regarding the medical treatment of insured Sh. Gurcharan Singh Brar incurred at Tairawhiti District Health Board, Private Bag 7001 Gisborne Hospital 4040 New Zealand alongwith interest throughout. Further opposite parties may be directed to pay Rs.1,00,000/- as compensation for causing mental tension, harassment and agony suffered by complainant and Rs.22,000/- as litigation expenses to the complainant or any other relief which this Forum may deem fit and proper be granted to the complainant.

2.                Briefly stated the facts of the case are that the complainant was the policy holder of Overseas Mediclaim B & H Policy bearing no.2012002815P114824127 valid from 07.03.2016 to 02.09.2016 issued by opposite party no.2, through opposite party no.1. The complainant was the regular policy holder of opposite party nos.1 & 2. Earlier the complainant also taken the same policy in the year 2011 bearing no.201200/46/11/44/70000017 valid from 29.06.2011 to 26.09.2011 and the latest policy had also been taken by the complainant valid from 07.03.2016 to 02.09.2016.The policy in question is a Overseas Medi-claim policy and as per this policy the complainant is covered in case of his illness during the visitor visa of the complainant for New Zealand during the insurance period for an amount upto $ 50,000. The complainant obtained a visitor visa for New- Zealand for the period 07.03.2016 to 01.09.2016 and during that visitor visa, the complainant got ill and admitted in Gisborne Hospital at New Zeanland on 2^nd and 3^rd August of 2016 and during that treatment the said hospital charged approx. $ NZ 6982.98 (i.e. Rs.3,50,000/- in Indian Currency) and the same was paid by the complainant. Thereafter, in the month of September, 2016 the complainant lodged the claim alongwith original bills and other formalities demanded by opposite parties from the complainant. The opposite party nos.1 & 2 sent the same to opposite party no.3 regarding the payment of the claim amount. Thereafter, the complainant received a letter dated 17.11.2016 from the opposite party no.3 that the claim of the complainant has been repudiated by mentioning false facts regarding the past medical history of hypertension. The complainant was not suffering from any type of hypertension and moreover, the hypertension is not a disease and the same is curable and also covered in this policy and the claim of the complainant has been repudiated on false and frivolous grounds. The complainant a number of times requested the opposite parties for the settlement of the claim, but the opposite parties kept mum and revealed nothing in this respect. Due the aforesaid act of opposite parties, the complainant has to face mental tension, harassment and financial loss. Hence this complaint.

3.                Upon notice, opposite parties appeared through their counsel and filed written reply taking certain preliminary objections that the complaint of the complainant is not maintainable as per law; that the complainant has got no locus standi to file the present complaint; that the complainant has concealed material facts from this Forum and have been telling lies to this Forum. In fact the complainant suffered following problem/complaints during his trip to abroad:-

Left sided weakness and slurred speech; Diagnosis: Partial Anterior Ischemic Infarct, Hypertension; Past Medical History: Hypertension; Policy exclusion: Pre-existing and related complications as under:

          However, the policy carries specific exclusion of all medical expenses incurred directly due to past medical history ailments and any consequences attributable to accelerated by or arising there from as per the medical history. The medical panel of the answering parties is of the opinion that the complainant has been treated for hypertension and partial anterior ischemic infarction and it has also been noted from the documents of the complainant that he had past medical history of hypertension and it is worth to state here that this policy does not cover pre-existing disease and related complications. As such, the claim of the complainant is not admissible for the reasons that they are complications of the past medical history of the complainant which are excluded from the scope of policy coverage and this was duly informed to the complainant vide letter dated 17.11.2016. Moreover, the patient concealed his previous illness from the company at the time of purchase of this policy, as he falsely stated facts in the proposal form; that no cause of action ever arose to the complainant against the answering opposite parties. On merits, all other allegations made in the complaint have been denied being wrong and a prayer for dismissal of the complaint with heavy costs has been made.

4.                In order to prove the case, complainant tendered in evidence his duly sworn affidavit Ex.C-1 alongwith copies of documents Ex.C-2 to Ex.C-18 and closed the evidence. 

5.                On the other hand, opposite parties tendered in evidence affidavit of Sh.Baldev Singh, Divisional Manager United India Insurance Company Ltd. Moga Ex.OP-1 to 3/1 and copy of proposal form Ex.OP-1 to 3/2 and closed the evidence.

6.                We have heard ld. counsel for the parties and have very carefully gone through record placed on file.

7.                The case of the complainant is that he had to visit New Zealand on visitor visa. So, he purchased Overseas Mediclaim B & H policy valid from 7.3.2016 to 2.9.2016 from opposite parties. As per this policy, the complainant was covered, in case of his illness during his visit for New Zealand for a sum upto $50,000. During his visit to New Zealand, he got ill and was admitted in hospital at New Zealand on 2^nd and 3^rd August of 2016. During that for treatment the hospital charged $ NZ 6982.98. The complainant paid the said bill to the hospital. The complainant lodged the claim for reimbursement of these medical bills with opposite parties alongwith original bills and other documents demanded by opposite parties from him, but opposite parties did not pay this amount to complainant, rather vide letter dated 17.11.2016, they repudiated the claim of the complainant on false grounds mentioning the false facts regarding the past medical history of hypertension, which is altogether wrong, as the complainant was not suffering from any type of Hypertension and the opposite parties repudiated the claim of the complainant on false and frivolous grounds.

8.                On the other hand, opposite parties admitted that the complainant purchased the policy in question from them covering himself in case of any illness during his visit to New Zealand. They further admitted that the complainant lodged the claim for the reimbursement of medical expenses borne by him for his treatment in the hospital of New Zealand. Ld. counsel for opposite parties argued that as per documents submitted by the complainant, he admitted in the hospital with the complaints of  Left Sided weakness and slurred speech, Diagnosis: Partial Anterior Ischemic Infarct, Hypertension with past medical history of hypertension. He argued that as per terms and conditions of the policy, there is specific exclusion of medical expenses incurred directly due to past medical history ailments and any consequences attributable to accelerated by or arising there from as per the medical history. As per opinion of panel of opposite parties, the complainant has been treated for hypertension and partial anterior ischemic infraction. As per documents, the complainant had past history of hypertension and the policy does not cover pre-existing disease and related complications. So, the claim of the complainant is not admissible for the reason stated above, as there is complication of the past medical history of hypertension. So, the claim of the complainant has rightly been repudiated and duly informed vide letter dated 17.11.2016. At the time of purchase of policy, the complainant did not disclose regarding his previous history of hypertension. On it, ld. counsel for complainant argued that it is wrong that the complainant had any past medical history of hypertension. He was not suffering from any type of hypertension. Moreover, if it is presumed that the complainant was suffering from hypertension, in that case also the opposite parties cannot repudiate the claim of the complainant, as hypertension is the not a disease and the same is curable with medicines and also covered under policy. The opposite parties repudiated the claim of the complainant on false and frivolous grounds. He put reliance on judgement passed by our Hon'ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition no.3619 of 2013 decided on 11.01.2016 titled as Satish Chander Madan Vs M/s Bajaj Allianz General Insurance Co. Ltd., whereas our Hon'ble National Commission held that the only fact established by the above reports is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified. Ld. counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hypertension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the heart problem suffered by the petitioner was caused by pre existing hypertension. There is not merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected.

                   He further put reliance on citation of Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose”, IV (2012) CPJ 839 (NC), wherein it was observed that diabetic and hypertension is a life style disease and easily controllable with conservative medicines. Further the Hon’ble Himachal Pradesh State Consumer Disputes Redressal Commission, Shimla in citation titled as “ICICI Lombard General Insurance Company Ltd. Versus Jasbir Singh”, 2014 (1) CLT 220 followed the above observations. In that case, claim was repudiated on the ground that the insured suppressed pre-existing disease of hypertension at the time of filling the proposal form. Insured medically examined by the empanelled medical officer of the insurance company before issuing the insurance policy. It was held that hypertension is a life style disease and easily controllable with conservative medicines.”

9.                From the above discussion and in light of the earlier decision of Hon'ble National Commission, New Delhi, we are of the considered opinion that the opposite parties have wrongly and illegally repudiated the claim of the complainant on false grounds. Hence the present complaint is hereby allowed with directions to opposite parties to pay New Zealand $ 6982.98 or equivalent to in Indian Currency with interest @ 9% per annum from 17.11.2016 when they repudiated the claim of the complainant till final realization. Further opposite parties are directed to pay Rs.5000/-(Five thousand only) as compensation for causing mental tension and agony to complainant and Rs.3000/-(Three thousand only) as litigation expenses to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of this order, failing which, the complainant shall be entitled to initiate proceedings against opposite parties under section 25 and 27 of the Consumer Protection Act. Copies of order be sent to parties free of cost as per rules. File be consigned to record room.

Announced in Open Forum

Dated : 17.05.2017

                                                  (Bhupinder Kaur)                               (Ajit Aggarwal)

                                                        Member                                            President