Indian Kanoon - Search engine for Indian Law

(Per: Mrs. Veena Sharma, Member):

The complainant has filed this consumer complaint before this Commission under Section 12 read with Section 18 of the Consumer Protection Act, 1986, against the opposite parties for compensation of Rs. 56,97,500/- on the basis of deficiency in service on the part of opposite parties in repudiating the insurance claim submitted by the complainant.  

2.       The facts of the case are that the complainant-Sh. Veerendra Nath Mittal S/o Late Sh. T.N. Mittal R/o 674 Indira Nagar, Dehradun had taken an Overseas Mediclaim Insurance Policy No. 2012/461000/48/12/0570000018 from the opposite party No. 1 for the period from 16.11.2012 to 31.2.2013. The policy was purchased for a coverage of treatment of illness upto the extent of USD 50,000/- (at the relevant time 1 USD meant Rs. 53.95).  The complainant had duly paid the premium as per the terms agreed for purchase of the said policy.  The said policy was required to be purchased since the complainant and his wife regularly visit their son, who is residing in Singapore and before every visit the complainant and his wife obtain such policy and duly pay the premium.  However, before the policy in question, the complainant never had to use the previous insurance covers.   The complainant and his wife had duly got their tests done and also the policy is issued only after the opposite parties are satisfied that there are no past history of illness.  For the policy in question also the complainant had undergone the tests and his ECG was normal and a mild hypertension was diagnosed, which by no means was any past illness.  At the age of complainant, a mild hypertension is a normal symptom particularly when the tests etc. are carried out.  The complainant regularly took medicine for the same.  Mild hypertension is not an illness, it is merely a condition which is easily controllable by medication. The complainant after purchasing the policy went to Singapore on 16.11.2012 itself and on 28.12.2012, he caught dengue and remained hospitalized for three days from 02.01.2013 to 05.01.2013.  The complainant was issued health bill on 14.01.2013 after fully recovered. On 14.01.2013 itself the complainant suffered heart attack and was admitted to Changi General Hospital and a balloon angioplasty on the right coronary artery was conducted on him. The complainant was further advised to undergo    by-pass surgery to avoid any future risk of heart attack. The complainant obeying the advice of the doctors underwent a by-pass surgery at the National Heart Centre, Singapore General Hospital on 05.02.2013.  The surgery left the complainant with an irregular heart rhythm on account of Atrio Ventricular Node which did not regain normalcy leading to life threat of the complainant as such the complainant had to get installed a permanent pace maker and thereafter he was discharged from the hospital on 06.03.2013. The complainant hence after lodged his claim since he had already incurred expenses of more than USD 50,000 alongwith all the medical bills and relevant documents with the opposite parties. That on 11.03.2013, the complainant was shocked to receive a communication that his claim has been rejected on account of false accusation that there was any past medical history of hypertension.  It is rather unfortunate that the opposite parties attributed the illness of the complainant to the "mild hypertension".  It is relevant to point out here that at the time when the policy was purchased, an endorsement of mild hypertension was there, but at no point of time any communication was made to the complainant that his mild hypertension would disallow illness cover in question.  The premium was duly received by the opposite parties.  It is relevant to mention here that the insurance policy particularly mediclaim policy by a senior citizen, as the case of complainant, is obtained keeping in mind the unforeseen health contingencies and it was the case of the complainant that unforeseen contingencies arose and he had to undergo his treatments spreading over a period of time.  At the time when the policy was purchased, the complainant was even assured that in case he invokes the policy he will not have to pay any amount because it being cashless and all the bills will be settled by the opposite parties. The complainant, however, not only suffered on account of the illness and financial gravity, but also on account of the callous attitude of the opposite parties that amounts to deficiency in service provided to the senior citizen.  The opposite parties have committed deficiency in service by denying the agreed claim to the complainant, who has duly paid the premiums after purchase of the policy from the opposite parties. The complainant who has already suffered a lot on account of his illness has further suffered financial loss on account of the deficiency in service by the opposite parties and also suffered mental pain and agony on account of rejection of claim, which has further aggravated the loss and legal injury to the complainant.  Due to deficiency in service on the part of the opposite parties, the complainant has filed the consumer complaint before this Commission for a sum of Rs. 56,97,500/-

7.       The complainant in his written arguments submitted that he and his wife being regular visitors to Singapore and and and as and when have visited their son, they have been obtaining mediclaim insurance policy and likewise when they visited their son in 2012-13 they obtained Overseas Mediclaim Insurance Policy No. 2012/461000/48/12/0570000018 from the opposite party No. 1 for the period from 16.11.2012 to 31.02.2013 after having duly paid the premium for the policy.  The policy was for coverage of treatment expenses upto the extent of USD 50,000.  As precondition the complainant and his wife got themselves medically tested by the doctors of opposite party No. 1 before filing their respective proposal forms for their medical policies.  A bare reading of proposal form shows that there is no past history of illness nor any such aspect was found by the doctor of the opposite party No. 1.  The complainant had declared that he gets little tensed at times and the words mentioned to describe the said situation are "mild hypertension", which prevalent and does not lead to the consequences of heart disease. After being fully satisfied by the good medical condition of the complainant and his wife, the respective policies were issued by the opposite party No. 1.  A perusal of proposal form clearly shows that no stress test was recommended.  In case there was any likelihood of the medical condition on account of the "mild hypertension" then the opposite party's doctor would have recommended the stress test.  On 4.01.2013 the complainant suffered heart attack and was admitted to Changi General Hospital as is evident from paper No. 31 and a balloon Angioplasto was conducted followed by the by-pass surgery at the National Heart Centre, Singapore General Hospital on 05.02.2013 and the complainant was installed with permanent pace maker, as adviced before getting discharged from the hospital on 06.03.2013.  Paper No. 28 shows that on 14.01.2013, the complainant was admitted to another hospital with chest pain and no past history of the complainant is mentioned and at paper No. 29, there is clear mention that the patient did not suffer any similar complaints in the past.   To further elaborate it is necessary to point out that at paper No. 43 principal diagnose is Ischaemic heart disease and the secondary diagnose is hypertension. Dictionary meaning of Ischaemic heart disease is the disease of heart on account of reduced blood supply and hypertension means high blood pressure.  High blood pressure is merely a condition and it may be a direct result of anxiousness. The complainant was not a heart patient either at the time of purchase of the mediclaim policy nor prior to it.  The opposite parties in order to deny the lawful mediclaim forgetting that the contract of insurance is of utmost good faith. After the mediclaim was rejected the complainant got issued a notice dated 21.03.2013 to respondent calling upon them to honour the mediclaim policy.  The opposite parties also filed its written arguments in which they accepted that the complainant had obtained an Overseas Mediclaim Insurance Policy No. 2012/461000/48/12/0570000018 from the National Insurance Company for medical coverage upto USD 50,000.  The complainant went to Singapore on 16.11.2012 and while he was there, he contacted Dengue for which he had to be hospitalized for three days.  He suffered a heart attack on 04.02.2013 and was admitted in Changi General Hospital and thereafter he he underwent by-ass surgery at National Heart Centre, Singapore General Hospital and a pace maker was also installed.  The insured presented his claim of indemnity with the opposite parties on the receipt of which the case was forwarded to the Heritage Health TPA Pvt. Ltd.  The claim of the insured was found to be not payable and was repudiated vide letter dated 11.03.2013. It was found by the TPA that the claim was not payable because the policy carried a specific exclusion clause of all medical expenses incurred directly due to past history ailments and any consequences attributable to accelerated by or arising therefrom as per the medical history.  In the proposal form for Overseas Mediclaim Policy, which was filled and submitted by the insured, the attesting doctor Dr. Ashutosh Mathur did not endorse in coloumn 4, whether the proposer was fit to travel anywhere abroad.... condition ?  Therefore, it is clear from the proposal form that there was no consent given to the insured for travelling abroad.  A letter of Dr. P.R. Purandara dated 06.03.2013 clearly mentions in his opinion:- "Present claim is for IHD (First of PCI and then for CABG) HTN is pre-existing.  Hence the claim cannot be allowed as it falls under exclusion of Heart and Circulatory disorders."