Order dictated by:
Sh.Anoop Sharma,Presiding Member
- Sh. Paramjit Singh complainant has filed the present complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant has two sons namely Tejpal Singh and Amandeep Singh and both are currently settled in Brisbane, Australia. The complainant travelled to Brisbane to meet his sons and as per rules of immigration, he applied for medical health Insurance policy. After medical check up the opposite party provided the complainant the medical policy with policy No. 02160046143990695240 with commencement date 9.9.2015 and ended on 22.11.2015 for 75 days. The complainant departed from India on 9.9.2015 and reached Brisbane on 10.9.2015. At Brisbane on 24.10.2015 complainant suffered from chest pain. As per the advice of the doctors, the complainant admitted to Redland Hospital Brisbane in the emergency department on 24.10.2015. As per instructions of the doctors, medical check up was done the results of which were found to be normal and he was discharged on the same day. The two bills were generated for medical tests and medical fee i.e. 996.15 and 1705.50 in Australian dollars respectively. The total payable amount in Indian currency was Rs. 1,37,784/-. The complainant requested his son S. Tejpal Singh, to pay the amount and he will return the same after receiving the claim from the Insurance company. Son of the complainant Tejpal Singh paid the amount from his wife’s bank account. The complainant stayed there till 22.11.2015 and then returned back to India. Thereafter the complainant approached the opposite party for the claim and handed over all the original bills, treatment files and all other relevant documents to opposite party No.1. Opposite party assured the complainant that the claim will be settled . However, the complainant received a letter dated 18.12.2015 stating that the claim is not admissible. The reason stated in the letter was type 2 diabetes mellitus, hypertension, hyperlipidemia, whereas the complainant was fit and healthy and policy was issued after full medical check up . It was also stated that the complainant suffered because of the change in weather i.e. extreme cold climate. The non settlement of claim amounts to deficiency in service on the part of the opposite party. Vide instant complaint, complainant has sought for the following reliefs:-
- Opposite parties be directed to make payment of the claim amount of cost of the medical bills alongwith interest @ 18% p.a. as per invoice to the complainant ;
- Damages to the tune of Rs. 10000/- on account of mental agony, tension be also awarded to the complainant ;
- Complainant be also awarded cost of litigation to the tune of Rs. 5000/-.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was submitted that the present complaint is not maintainable in the light of terms and conditions of the mediclaim policy, it was found that the claim is not payable as per exclusion clause 12( c) which reads as under:-
“12( c) Pre existing conditions: The pre existing condition means any sickness/illness, which existed prior to the effective date of this insurance including whether or not the insured person had knowledge that symptoms were related to the sickness/illness. Complication arising from a pre-existing condition will also be considered part of the pre-existing condition.”
As per the opinion of the medical panel of the opposite party, the complainant presented to Emergency department on 24.10.2015 with left sided chest pain since 5 a.m. with background medical history of Type 2 Diabetes Mellitus, Hypertension and Hyperlipidemia. In view of the presenting symptoms of the complainant and past pertinent medical history, primary evaluation and treatment was directed towards acute coronary syndrome. Hence, the disease in question being a pre-existing one and the significant past history of the complainant also being undisclosed, the claim of the complainant was considered as inadmissible due to “Non disclosure of material facts”. Resultantly the opposite party intimated the complainant vide letter dated 18.12.2015 clearly stating that the present claim was not payable and the same was repudiated accordingly. It was submitted that as per discharge letter dated 24.10.2015 of Redland Hospital, Emergency Department, Cleveland, it was confirmed that the complainant had past medical history of Type 2 Diabetes Mellitus, Hypertension and Hypercholestrol. In the admission form also, the said fact had been mentioned by the complainant and the same was duly signed by the complainant which clearly implies that the disease in question is a pre-existing . As such the claim of the complainant was considered as inadmissible due to “Non disclosure of material facts” and the complainant was duly intimated vide letter dated 18.12.2015 clearly stating that the present claim was not payable and the same was repudiated accordingly. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case complainant tendered into evidence his duly sworn affidavit Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-15 and closed his evidence.
4. To rebut the aforesaid evidence Sh. Sandeep Khanna,Adv.counsel for the opposite parties tendered into evidence affidavit of Sh.Ashok Sharma,Deputy Manager Ex.OP1 alongwith documents Ex.OP2 to Ex.OP15 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file as well as written synopsis of arguments submitted on behalf of the complainant.
6. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant obtained medical policy vide policy No. 02160046143990695240 commencing from 9.9.2015 till 22.11.2015 for 75 days. It has been alleged by the complainant that he travelled to Brisbane to meet his sons on 9.9.2015 and reached there on 10.9.2015. On 24.10.2015 complainant suffered from chest pain and he was got admitted to Redland Hospital Brisbane , where medical check up was done and the results were found normal and he was discharged on the same day. The said hospital charged 996.15 and 1705.50 in Australian dollars for medical tests and medical fee from the complainant , which was duly paid by the complainant . The complainant stayed at Brisbane till 22.11.2015 and then returned back to India. Thereafter the complainant lodged claim with the opposite party after submitting relevant documents to opposite party No.1. However, the opposite party vide letter dated 18.12.2015 refused the claim stating that the claim is not admissible as the complainant was suffering from type 2 diabetes mellitus, hypertension , hyperlipidemia whereas the complainant was fit and healthy. The aforesaid act of the opposite party in not paying the genuine claim of the complainant is an act of deficiency in service, unfair trade practice
, malpractice and is not sustainable in the eyes of law. Ld.counsel for the complainant submitted that all this amounts to deficiency of service on the part of the opposite party.
7. Whereas the case of the opposite party is that as per the opinion of the medical panel of the opposite party, the complainant presented to Emergency Department on 24.10.2015 with left sided chest pain since 5 am with background medical history of Type 2 Diabetes Mellitus, Hypertension and Hyperlipidemia. In view of presenting symptoms of the complainant and past pertinent medical history, primary evaluation and treatment was directed towards acute coronary syndrome. Hence, the disease in question being a pre-existing and the claim of the complainant was considered as inadmissible due to “Non disclosure of material facts” and the complainant was duly intimated vide letter dated 18.12.2015 clearly stating that the present claim was not payable and the same was repudiated . The complainant has suppressed the material information regarding his medical condition, therefore, the claim is not tenable. Ld.counsel for the opposite party submitted that there is no deficiency in service on the part of the opposite party.
8. From the entire above discussion, we have come to the conclusion that the complainant obtained mediclaim policy bearing No. 02160046143990695240 and travelled to Brisbane to meet his sons where he suffered from chest pain. The complainant was got admitted to Redland Hospital Brisbane in the emergency department on 24.10.2015, where some tests were got conducted and the results were found to be normal. The complainant was discharged from the hospital on the same day. The complainant incurred expenditure on medical tests and medical fee in Australian dollars i.e. 996.15 and 1705.50 i.e. in Indian currency to the tune of Rs. 1,37,784/-. On reaching India, complainant lodged claim with the opposite party . But the opposite party repudiated the claim of the complainant vide letter dated 18.12.2015 on the ground that complainant had past medical history of Type 2 Diabetes Mellitus, Hypertension and Hyperlipidemia. But, however, the complainant never suffered from hypertension nevertheless no medical record showing such hypertension has ever been produced by the opposite party on the record. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from Diabetes Mellitus, hypertension and Hyperlipidemia. But, however, opposite party In such a situation, it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy on the same amount to concealment. During these days, hypertension is not a material disease, therefore, non disclosure thereof does not amount to concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
9. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
10. It is pertinent to mention here that complainant obtained the policy bearing No. 0216002615990695240 in which medical expenses are covered to the sum insured USD 50000. However, the complainant incurred expenditure on medical tests and medical fee i.e. 996.14 Australian dolloars as per tax invoice Ex.C-9 as well as Australian dollor 1705.50 as per receipt Ex.C-10. In all complainant incurred expenditure in Australian dollars 2701.64, which the opposite party is liable to reimburse the same to the complainant equivalent to Indian currency.
11. From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the claim of the complainant . As such, opposite party is directed to reimburse the Australian dollars 2701.64 equivalent to Indian currency i.e. Rs. 1,37,784/- . The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 7.4.2017
