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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Ajit Bharihoke, Presiding Member, Mrs. Rekha Gupta, Member
Satish Chander Madan —Petitioner
versus
M/s. Bajaj Allianz General Insurance Co. Ltd. —Respondent
Revision Petition No.3619 of 2013
(Against the Order dated 16/07/2013 in Appeal No. 305/2013 of the State Commission Haryana)
Decided on 11.1.2016
Counsel for the Parties:
For the Petitioner: M/s. Kawaljit Singh & Associates
For the Respondent: M/s. Suman Bagga & Associates
IMPORTANT POINT
History of hypertension does not lead to conclusion that petitioner was also having previous history of heart problem.
Headnote:Consumer Protection Act, 1986—Sections 15, 17, 19 and 21—Insurance—Overseas Travel Insurance Policy—Coronary Bypass Graft Surgery in foreign hospital—Repudiation of claim on ground of suppression of pre-existing disease—Complaint dismissed by State Commission in appeal—State Commission has failed to consider that concealment of material fact was not even a ground taken by opposite party in repudiation letter—There is no evidence which would suggest that petitioner despite of having knowledge of his heart ailment concealed this fact in proposal form by giving a wrong information—Only fact established by reports is that petitioner prior to obtaining insurance policy was having history of hypertension—This does not lead to conclusion that petitioner was also having previous history of heart problem—Insurance claim submitted by complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre-existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified—State Commission committed grave error in deviating from real facts in allowing appeal of respondent resulting in dismissal of complaint on conjectures and surmises—Impugned order set aside and order of District Forum restored. (Paras 7 to 11)
Result: Revision Petition allowed.
Key Points: - The State Commission erred in treating concealment of material fact as grounds for repudiation without the repudiation letter indicating such ground. (!) - Medical reports showed hypertension prior to policy but did not establish a pre-existing heart disease; thus the claim for heart problem treatment could not be categorized as pre-existing disease under the policy. (!) (!) - The District Forum’s order awarding expenses was restored in part after recognizing misapplication of facts by the State Commission; the revision petition was allowed, reversing the State Commission. (!) (!) - The insurer’s exclusion relied on pre-existing disease terms, which the court found not supported by the evidence of the patient’s condition prior to policy purchase. (!) - The Commission emphasized that there was no evidence showing suppression of material facts by the complainant in the proposal form. (!) - The factual background involves coronary bypass surgery in London and subsequent hospitalization; repudiation was challenged in a consumer dispute. (!) (!) (!) - The revision petition culminated in setting aside the State Commission’s order and restoring the District Forum’s order. (!)
What is the rightful basis for denying or allowing an overseas travel insurance claim where pre-existing conditions are involved?
What is the correct evidentiary standard for determining concealment of material facts in proposal forms for travel insurance?
What are the rights and remedies of the insured when an insurer repudiates a claim on grounds not stated in the repudiation notice or policy exclusion?
Ajit Bharihoke, Presiding Member—This revision is directed against the order of the State Commission Haryana in FA No. 305 of 2013 dated 16.072013, whereby the State Commission reversed the order of the State Commission and dismissed the complaint.
2. Briefly stated facts relevant for the disposal of the revision petition are that complainant purchased an Overseas Travel Insurance Policy from the respondent opposite party for sum insured US$ 2,00,000. As per the policy, against one ailment, the maximum insurance cover was 15000 US$ equivalent to Rs.7,50,000/-. The complainant reached London on 28.05.2010. Few days later, during the subsistence of the insurance policy, the complainant developed complaint of chest pain. He thus consulted the doctor and was admitted in Hospital at London on 03.06.2010 with problem of unstable angina. On the advice of doctor, the complainant underwent Coronary Bypass Graft Surgery at Wellington Hospital, London. He was discharged from the hospital on 14.06.2010. According to the complainant, he paid 12,005 pounds as expenses for surgery as also the consultation fee etc. The insurance claim for reimbursement of said amount was repudiated by the opposite party vide letter dated 06.07.2010 on the ground that claim was not payable because as per the medical record obtaining from the treating doctor / hospital, the complainant was having past medical history of hypercholestremia, Ischaemic Heart Disease as well as hypertension, which were excluded as per the insurance contract.
3. Being aggrieved of the repudiation of the insurance claim, the petitioner complainant raised a consumer dispute which was contested by the opposite party. The District Forum on consideration of the pleadings and evidence allowed the consumer complaint and directed the opposite party as under:
“The respondent insurance company is directed to pay an amount of Rs.7,19,500/- to the complainant towards expenses of his treatment with interest @ 9% p.a. from the date of complaint i.e. 22.3.2012 till the date of payment and also to pay Rs.2200/- as litigation expenses.”
4. Being aggrieved by the order of the District Forum, the respondent insurance company preferred an appeal. The State Commission on consideration of record and the submissions made on behalf of the parties came to the conclusion that respondent was justified in repudiating insurance claim because the complainant had obtained insurance policy by concealing the factum of his previous ailment, namely, hypertension, which has a nexus with the heart problem. Being aggrieved of the order of the State Commission, the petitioner complainant has filed the revision petition.
5. Learned counsel for the petitioner has contended that the impugned order of the State Commission has been passed on incorrect appreciation of fact. It is argued that State Commission failed to appreciate that insurance claim of the complainant was repudiated by the opposite party on the ground that claim in respect of the expenses incurred on the treatment of pre existing disease. It is contended that State Commission failed to appreciate that the opposite party had failed to lead evidence to show that the claim of the complainant was in respect of treatment taken for a pre existing disease. Instead, the State Commission on its own developed an argument that it is a case of concealment of material fact without making any reference to the information given by the complainant about his physical condition in the proposal form.
6. Learned counsel for the respondent on the contrary has argued in support of the impugned order. She has drawn our attention to the copies of treatment record of the complainant particularly medical report of Doctor David P Lipkin dated 04.06.2010 and letter dated 07.06.2010 wherein it is recorded that complainant is a known case to be hypertensive and is on medication. Learned counsel has argued that from said report it is clear that petitioner was hypertensive and was taking med
