BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 290 of 2015

Date of Institution: 07.05.2015

Date of Decision: 26.11.2015  

Mrs.Gargi Bhatia wife of Dr.Anil Bhatia, resident of 41, Anand Avenue, Maqbool Road, Amritsar. (aged 67 years)

Complainant

Versus

Universal Sampo General Insurance Company Limited, through its Chairman/ Managing Director/ Principle Officer Service through its Branch Office at SCO 113, 1^st  Floor, District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager.      

Opposite Party

Complaint under section 12 and 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Deepinder Singh, Advocate

              For the Opposite Party: Sh. P.N.Khanna, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Mrs.Gargi Bhatia under the provisions of the Consumer Protection Act alleging therein that she purchased overseas Health Insurance vide policy No.2984/54070954/00/000 from Opposite Party covering risk period from 12.5.2014 to 07.11.2014. Complainant alleges that unfortunately she fell ill and got some eye trouble while in USA and was to be under medical treatment at USA and the claim for his hospitalization and medical treatment was referred to Opposite Party and the claim bill of US $ 411 was filed with Opposite Party which was repudiated by the Opposite Party through its TPA vide repudiation letter dated 15.4.2015 on the frivolous ground that the complainant concealed the  material fact and was having mild hypertension. No policy condition was communicated to the complainant and now repudiating the claim on such ground which never remained a part of an agreement between the parties and moreover the treatment taken thereof has nothing to do with the mild hypertension and the complainant at the time of taking of said policy was never having any such disease at the relevant time. The Opposite Party had issued the policy in question on cashless basis for the medical treatment, but the complainant had to pay the amount from out of her pocket overseas.       Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the claim of US $ 411 or equivalent to the said amount in Indian Currency alongwith interest @ 12% per annum thereon from the date of payment till realization.  Compensation and litigation expenses were also demanded.
2. On notice, Opposite Party appeared and filed written version in which it was submitted that in the  present case the claim preferred by the complainant has already been repudiated by the Heritage Health TPA Private Limited, who is duly authorized to deal with the claim by the IRDA, vide repudiation letter dated 15.4.2015 giving detailed reasons of the repudiation of the claim clearly stating that the claim preferred by the complainant is not payable because as per opinion of medical penal of the said TPA, it has been confirmed that the complainant was treated for vitreous Detachment. It has also been noted from the medical documents that she had past medical history of mild hypertension for the last 4 to 5 years, but these facts were not disclosed by the complainant at the time of obtaining the policy in question, therefore, the same is violation of condition No.3 which relates to mis-description on the part of the insured. So, the repudiation made by TPA is perfectly legal valid and in accordance with terms and conditions and exclusion clauses of the policy in question. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C6 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Piyush Shanker Ex.OP1 alongwith documents Ex.OP2 to Ex.OP7 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant purchased overseas Health Insurance vide policy No.2984/54070954/00/000 (Ex.C2) from Opposite Party covering risk period from 12.5.2014 to 07.11.2014. The complainant went to USA and unfortunately she fell ill in USA and had undergone medical treatment there and spent US $ 411, claim of which was submitted with Opposite Party, but the Opposite Party repudiated the said claim  vide letter dated 15.4.2015 Ex.C3 on the ground that  the complainant had past history of mild hypertension from 4-5 years and the complainant did not disclose this material fact at the time of obtaining of aforesaid insurance policy by concealment of facts. Ld.counsel for the complainant submitted that the complainant was not suffering from any mild hypertension while taking the insurance policy. Opposite Party has wrongly repudiated the claim of the complainant and all this amounts to deficiency of service on the part of the Opposite Party.
7. Whereas the case of the Opposite Party is that the claim of the complainant has rightly been repudiated by Heritage Health TPA Private Limited who was duly authorized by the Opposite Party to deal with the claim of the complainant, vide repudiation letter dated 15.4.2015 Ex.C3 on the ground that the complainant had past history of mild hypertension for the last 4-5 years and these facts were not disclosed by the complainant at the time of obtaining the policy in question which amounts to violation of condition No.3 of the policy. Ld.counsel for the Opposite Party submitted that the Opposite Party has rightly repudiated the claim of the complainant. As such, there is no deficiency of  service on the part of the Opposite Party.
8. From the entire above discussion, we have come to the conclusion that the complainant purchased overseas Health Insurance vide policy No.2984/54070954/00/000 (Ex.C2) from Opposite Party covering risk period from 12.5.2014 to 07.11.2014. The complainant went to USA where she fell ill and was hospitalized and medically treated  and she spent US $ 411. The claim was lodged with the Opposite Party and the Opposite Party referred the matter to Heritage Health TPA Private Limited who was duly authorized by the Opposite Party to deal with the claim of the complainant and said TPA vide  letter dated 15.4.2015 Ex.C3 has repudiated the claim of the complainant on the ground that the complainant had past history of mild hypertension for the last 4-5 years and these facts were not disclosed by the complainant at the time of obtaining the policy in question which amounts to violation of condition No.3 of the policy. In this regard, the Opposite Party has also produced on record certificate from Dr.Sumeet Arora Ex.OP4 who has stated that he treated the complainant for mild hypertension, but she had not any significant medical illness. It has been held by Hon’ble National Commission, New Delhi in case Bajaj Allianz General Insurance Company Vs. Valsa Jose in 2013(1) CLT page 418 that where the complainant had taken Overseas Travel Insurance Policy including medical coverage and was medically treated in USA, fact that the patient was taking medicine for hypertension for some time does not amount to suppression of material fact because as is well known that hypertension is usually a life style disease and easily controlled with conservative medication, as in the instant case. There is no evidence that it was so acute or high that it was responsible for respondent’s subsequent angioplasty or any other past major illness. The certificate of Dr.Sumeet Arora Ex.OP4 on the basis of which the Opposite Party has repudiated the claim of the complainant, clearly shows that patient has not had any significant medical illness. She was some time treated by this doctor for mild hypertension. So, the Opposite Party was not justified in repudiating the claim of the complainant on the ground that the patient was suffering from mild hypertension   and she did not disclose this fact at the time of taking the policy because mild hypertension does not amount to suppression of material fact. Further,  hypertension is usually a life style disease and easily controlled with conservative medication. There is no evidence that mild hypertension of the complainant was so acute or high that it was responsible for complainant’s subsequent disease. Consequently, we hold that the Opposite Party has wrongly repudiated the claim of the complainant.
9. Resultantly, the complaint is allowed with costs and the Opposite Party is directed to pay the claim amount of the complainant i.e. US $ 411 or equivalent to the said amount in Indian currency, within one month from the date of receipt of copy of this order, failing which the Opposite Party shall be liable to pay interest @ 9% per annum on the said amount from the date of filing of the complaint till the payment is made. Opposite Party is also directed to pay litigation expenses to the complainant to the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. 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.

Dated: 26.11.2015.                                                              (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member