DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 236

 Instituted on:   10.08.2020

                                                                         Decided on:     15.04.2024

Pritpal Singh son of Sh. Ram Singh, resident of Village Kalaudi, Tehsil and District Sangrur.

                                                         …. Complainant.     

                                                 Versus

United India Insurance Company Limited, Branch office: Railway Station Road, Sangrur, through its Divisional Manager.

                                                        ..Opposite party

For the complainant  :       Shri Sumir Fatta, Adv.

For Opp.party          :       Shri Ashish Garg, Adv.

Quorum                                          

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                             Kanwaljeet Singh, Member

ORDER

SARITA GARG, MEMBER

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that the complainant obtained the services of the OP by getting insured himself under Overseas Mediclaim B&H policy bearing number 1117002819P101364632 valid for the period from 02.05.2019 to 28.10.2019 by paying an amount of Rs.13,807/- and under the policy the complainant was insured for 1 lakh Canadian dollars.  It is further averred that the policy covers all kind of diseases, operations and other medical issues if arose during the stay outside India. Further case of complainant is that the complainant went to Canada and where during the subsistence of the insurance policy, he suffered heart problem and the complainant took treatment from Delta Hospital, Surrey B.C. (Canada) and remained admitted in the hospital for the period from 19.10.2019 to 22.10.2019 and from where he was referred for stunting to Vancouver Costal Health Hospital on 22.10.2019. Further case of complainant is that he complainant spent a total amount of 35822 Canadian dollars on his treatment during his admission in both the above said hospitals i.e. 17620 Canadian dollar were spent at Delta Hospital and 15926 Canadian dollars were spent at Vancouver Costal Health Hosptial and 3000 Canadian dollars were spent in cash and 2336 Canadian dollars were to be paid to David Wood Cardiologist.  Further case of complainant is that thereafter the complainant immediately lodged the claim with the OPs for release of the said claim amount, but the partner of OPs at Canada i.e. World Travel Assist declined the claim of the complainant on frivolous grounds of complication of past history.  Further case of complainant is that the complainant got served a legal notice upon the OP on 4.6.2020 and requested to release the claim amount of 35822.15 Canadian dollars, but nothing was done. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to release the claim amount of 32822.15 (Canadian Dollars) directly to the hospitals where the complainant had undergone treatment in the hospital till realisation and 3000 Canadian Dollars to the complainant which he had paid in cash at the time of treatment and  further claimed compensation and litigation expenses.

2.             In reply filed by OPs, legal objections are taken up on the grounds that the insured violated the principle of ‘utmost good faith’ at the time of taking the insurance policy and also concealed material facts from suffering hypertension in the proposal form, that the insured had committed fraud by not disclosing the fact of hypertension, that the complainant has no cause of action to file the present complaint and complicated questions of law and facts are involved in the present case. On merits, issuance of the insurance policy to the complainant is admitted. It is stated that as per clause 10-A of the said policy, it is not a General Health Insurance policy, rather the coverage under this policy is intended for use by the insured person in the event of a sudden and unexpected sickness or accident arising when the insured person  is outside the Republic of India. As per section 10-B of the said policy, the policy is not designed to provide an indemnity in respect of medical services, the need for which arises out of a pre-existing condition. As per Condition number 10-C of the said policy, any sickness for which the insured person has taken medical treatment at any time prior to the commencement of travel. It is admitted that the complainant lodged the claim for 35822 Canadian dollar with the OPs for getting the treatment as he was got admitted in Delta Hospital with Myocardial Infarcation and stunt was implanted in the heart of the complainant. Myocardial Infarction (MI) (commonly known as heart attach) occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle.  As per final report dated 19.10.2019 of Fraser Health Authority Delta Hospital, the complainant was past medical history of hypertension.  Lastly, the OPs have mentioned that the claim of the complainant has rightly been repudiated on the ground of past history of hypertension, which the complainant did not disclose at the time of taking the insurance policy.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-12 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/8 and closed evidence.

4.             We have gone through the pleadings put in by the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that complainant was insured with the OPs under the medical insurance policy in question. The contention of the complainant is that during the subsistence of the insurance policy the complainant suddenly suffered with heart problem and the complainant took treatment from Delta Hospital, Surrey B.C. (Canada) and remained admitted in the hospital from 19.10.2019 to 22.10.2019 and also referred for Vancouver Costal Health Hospital on 22.10.2019 and the complainant spent a total amount of 35822 Canadian Dollars and thereafter submitted the claim papers for release of the claim amount, but the OPs refused to pay the claim amount on the ground that the complainant was a case of hypertension meaning thereby the complainant suppressed this material information from the OPs at the time of taking the insurance policy. Though the complainant spent total amount of 35822 Canadian Dollars  on the treatment, but the claim was not paid by the OPs, as such has prayed for acceptance of the complaint.  Ex.C-3 is the copy of insurance policy which shows that complainant Pritpal Singh was insured for the Overseas mediclaim policy for US$ 1,00,000/-. Ex.C-4 to Ex.C-6 are the laboratory report and medical bills issued by the treating hospitals. Ex.C-9 is the copy of legal notice dated 4.6.2020, Ex.C-12 is the copy of invoice issued by Delta Hospital and all this evidence is duly supported by the affidavit of complainant Ex.C-1.  On the other hand, the learned counsel for the OPs has produced Ex.OP/1 copy of the internal letter of the OPs whereby waiving of pre-acceptance of health check up is waived upto the age of 70 years for all slabs of sums insured Max US$ 5,00,000/-. Ex.OP/2 is the copy of proposal form, Ex.OP/3 is copy of the bill for Canadian Dollar 25539 of Delta Hospital. Ex.OP/4 is the copy of discharge summary of the complainant dated 19.10.2019 issued by Delta Hospital. Ex.OP/6 is the copy of final report of Delta Hospital. Ex.OP/7 is the copy of letter dated 19.12.2019 of Heritage Health TPA Pvt. Ltd., whereby the claim of the complainant was denied on the ground of past medical history of hypertension. All this evidence is duly supported by the affidavit of Shri Ashu Sood, Deputy Manager of the OPs. Further in the present case the main reason for denial of the claim by the OPs is that the complainant was suffering from hypertension, however, this fact was not disclosed at the time of making the proposal for the policy, hence the claim was repudiated as per policy terms and conditions.  But we are unable to go with the contention of the learned counsel for the OPs that the claim can be rejected on the ground of hypertension as the Hon’ble National Commission in Bajaj Allianz General Insurance Company Limited versus Valsa Jose 2012(4) CPJ 839 (NC), wherein it has been held that patient was taking medicine for hypertension for some time does not amount to suppression of material fact because as is well known hypertension is usually a lifestyle disease and easily controlled with conservation medication. There is no evidence that it was so acute or high that it was responsible for respondents subsequent angioplasty or any other past major illness. Repudiation of claim was held to be unjustified on this ground.   The same view has also been taken by the Hon’ble National Commission in Satish Chander Madan versus M/s. Bajaj Allianz General Insurance Co. Ltd. 2016 (1) CPJ 613 (NC).   Further in Life Insurance Corporation of India versus Sushma Sharma 2008(2) CPJ 213 (Punjab State Commission),  wherein the case was that insured was suffering from hypertension and diabetes for last 10 years before death and it was not disclosed. Repudiation of claim under section 45 of Insurance Act. It is not concealed fact of every fact that gives right of repudiation of claim. Hypertension and diabetes are not material diseases. If these diseases had been material insured would not have survived for 10 years. Complaint allowed by Forum. Payment of insurance claim with interest was directed and the appeal of the opposite parties/insurance company was dismissed. In the circumstances of the case, we find that the OPs have wrongly and illegally repudiated the rightful claim of the complainant.

6.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of 1,00,000/- US$.  The complainant has though claimed an amount of 35822 Canadian Dollars, but the complainant has produced the treatment bills Ex.C-5, Ex.C-6 and Ex.C-8, a total of which comes to 32882 Canadian Dollars minus 100 USD (as per policy terms and conditions).  Ex.C-5 shows that  an amount of 3000/- Canadian Dollars was also paid by the complainant in cash and through VISA to  the concerned hospital.

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay directly to the concerned hospitals the amount of Canadian dollars 32882/- minus 100 USD as per policy. Further,  Ops are directed to pay  to the complainant 3000/- Canadian Dollers ( as per the INR ( Indian Rupees) exchange rate which was prevailed at the time of payment of the medical bill) alongwith interest @7% per annum to the complainant from the date of filing of the present complaint till realization. Further OPs are directed to pay to the complainant an amount of Rs.10,000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

9.             The complaint could not be decided within the statutory time period due to heavy pendency of cases.

10.           Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.      

                        Pronounced.

                April 15, 2024.

           (Kanwaljeet Singh)  (Sarita Garg) (Jot Naranjan Singh Gill)

                  Member                       Member                  President