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2009(1) CPR 169
KARNATAKA STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE
Chandrashekaraiah, President and M. Shama Bhat, Member
Valsa Jose —Complainant
versus
Bajaj Allianz General Insurance Co Ltd.
and Anr. —Opp. Parties
Complaint No. 15 of 2006
Decided on 13.8.2007
Counsel for the Parties:
For the Complainant:Mr. R.B. Deshpande, Advocate.
For the Opp. Parties:Mr. Y.P. Venkatapathi, Advocate.
IMPORTANT POINT
A stray incident of hypertension cannot be treated as a disorder. In order to establish that a person is suffering from hypertension, necessarily the said person has to be under regular medication to control the blood pressure.
Headnote:Consumer Protection Act, 1986—Sections 12 and 17—Insurance claim—Complainant obtained Overseas Travel Insurance Policy from 13.11.2003 to 11.3.2004 and visited USA—She developed shortness of breath, chest heavy-ness and was performed angiography and angioplasty of right Coronary Artery in US hospital on 29.1.2004—Claim for medical for 36,538 US Dollars i.e. Rs. 17,17,300 was repudiated on ground that complainant was suffering from hypertension for a long time and same was not disclosed in proposal for obtaining policy— No material produced by OP that complainant was hospitalized in respect of any illness—It relied upon a certificate issued by doctor when complainant had consulted for Gynae problem that patient was diagnosed as hypertensive earlier for which she was given medication by cardiologist—No affidavit of such cardiologist was filed—Stray incident of hypertension could not be treated as disorder—Repudiation of claim was purely based on report of investigation and even no affidavit of investigator was filed—Non-reimbursement of medical expenses was deficiency in service—Complainant held entitled to compensation of Rs. 17,17,300 with interest at 9% p.a. from date of complaint. (Para 10 to 17)
Result: Complaint allowed.
Chandrashekaraiah, President— Complainant has filed this complaint for a direction to the opposite parties (for short, “OPs”) to pay Rs. 32,17,308 with interest at the rate of 18% per annum from the date of complaint till realization.
2. The case of the complainant is as
follows:
The complainant had to go to the USA for her daughter’s delivery and, accordingly, she and her husband approached travel agent by name M/s. Alfa Air Travels, Infantry Road, Bangalore, and booked to and fro tickets for travel to USA for herself and her husband. They also obtained “Overseas Travel Insurance Policy” from the OPs for the period from 13.11.2003 to 11.3.2004. As per the schedule, the complainant and her husband left to Woodbury MN in USA on 14.11.2003. On 29.1.2004 at about 3.30 a.m. the complainant developed shortness of breath, chest heavyness and burning sensation and, therefore, she was taken to the
Emergency Room at Woodwinds Hospital, USA. Thereafter she was shifted to St. Joseph’s Hospital. The Doctors who examined the complainant in St. Joseph’s Hospital performed the angiogram and angioplasty of right Coronary Artery of the complainant. In respect of the abovesaid procedure the hospital issued a bill for payment of 36,538.47 US Dollars.
3. The complainant sent all the documents pertaining to the treatment through Electronic Mail to the OPs since she had a valid Insurance Policy issued by the OPs. However, the OPs on 8.3.2004 informed the complainant that their Claims Department was not able to take up a decision on the settlement and requested the complainant to pay the medical expenses and file her claim directly with the Claims Department. Accordingly, the complainant submitted her claim with all the documents to the OPs. Ultimately, the OPs have repudiated the claim by their letter dated 28.5.2004 stating that the complainant was suffering from hypertension for a long time and the same was not disclosed by her in the proposal form at the time of obtaining Insurance Policy. This repudiation of the claim has made the complainant to file the complaint before this Commission claiming reimbursement of Medical expenditure of
Rs. 17,17,300 and for compensation of
Rs. 15,00,000.
4. The case of the complainant is that there is no suppression of any material fact in the proposal form and, therefore, the repudiation of the claim by the OPs is illegal and, consequently, non-reimbursement of medical expenses amount to “Deficiency in service”.
5. On the complaint, this Commission ordered Notice to the OPs. The OPs on service of notice, have filed their version justifying their action.
6. The case of the OPs in the version is that as per the hospital records, the complainant as had the cardiac and hypertension problem even prior to 5 years and the same was not disclosed in the proposal form, which resulted rejecting the claim on the ground that the suppression of pre-existing cardiac and hypertension problem vitiates the very contract and, therefore, there is no liability on the part of the OPs to reimburse the medical expenditure said to have been incurred by the complainant his repudiation, according to the OPs is based on the investigation conducted by an investigator appointed by the OPs and also on the basis of expert opinion on the documents. According to the OPs, the repudiation of the aim is justified and, therefore, there is no deficiency in service on the part of the OPs as to reimburse the medical expenditure in favour of the complainant.
7. Both the parties have filed affidavits and also the documents in support of their cases. The documents so produced by the parties were all marked as exhibits.
8. On the rival contentions of the parties, the points that arise for consideration in this complaint are as follows:
(1) Whether the complainant proves that there is no suppression of material fact?
(2) Whether the OPs are justified in repudiating the claim of the complainant on the ground that the complainant has suppressed th
