IMPORTANT POINT
Suppression of pre-existing ailment may vitiate insurance claim.

The instant complaint No.1240 of 2015 has been filed by the Complainant— Harjinder Kaur Dadiala against the Opposite Parties No. 1—National Insurance Company Ltd, Opposite Party No.2— Karvat Travel Services Pvt. Ltd. and Opposite Party No.3—Heritage Health TPA Pvt. Ltd. for alleging deficiency in services on their part.

2. Briefly, facts of the case as per the Complainant are, that son of the complainant namely Mr. Surjit Singh worked and lived in United States, for which the complainant used to travel to United States very often out of her love and affection towards her son. During these visits the complainant had been availing the services for consideration of “TrawellTag” offered by the opposite party no. 2, from time to time. The opposite party no.2 offered protection for luggage and valuables worldwide, while travelling. Apart from the other benefits, as a privileged TrawellTag member, complainant was also offered an overseas Mediclaim Policy underwritten initially by Oriental Insurance Company Ltd. during her travel in the year 2010. The complainant after obtaining the aforesaid overseas Mediclaim policy, travelled to United States of America in March, 2010 to visit her son and returned home safely thereafter and there had been no complaint of her health, whatsoever.

3. Opposite party No.2 had been able to develop and build trust and confidence with the complainant and as such, when the complainant planned to travel to United States in the year 2013, she did not think twice before availing the services of “TrawellTag” offered by the opposite party no. 2. Apart from the other benefits, as a privileged TrawellTag member, the complainant was also offered an overseas Mediclaim Policy underwritten this time by the Opposite Party No.1—National Insurance Company Ltd, for her travel period between 13.05.2013 to 19.10.2013. The complainant was hale and healthy at the time of taking the policy and made all disclosures as were required by the opposite parties no.1 & 2.

4. Further, the opposite party no.1 issued a confirmation of availability of Insurance Policy and as such Overseas Mediclaim Insurance Policy bearing No.251100/48/11/057000001/80198014 for the period valid from 13.05.2013 to 19.10.2013 was issued to the complainant. Unfortunately, during the complainant’s stay in United States, she experienced chest pain and as such was admitted to Providence St. Vincent Medicare Hospital at Portland, USA, wherein the Doctors advised for a heart operation. The complainant had been keeping reasonably good health and had never been diagnosed with any heart trouble before and this was the first instance when she felt such pain in her chest.

5. As per the policy norms, the complainant informed April USA Assistance Inc. and was operated by doctors at Providence St. Vincent Medicare Hospital, Portland, USA, wherein she incurred an expenditure of USD 2,36,938.00 on her treatment which was duly paid by the complainant. Thereafter all the medical records and various documents were also sent to the opposite party no.3 through the hospital concerned. On 29.11.2013, the opposite party no.3 informed the complainant that her claim was sought to be rejected on the ground of policy exclusion to the effect that the policy did not cover any pre-existing condition and related ailments. Further, the complainant contended that so called exclusion terms of the policy were never made available to her nor was she ever informed about the said clause, which makes the opposite parties guilty of Suppressio veri, suggestio falsi as they have deliberately and willfully suppressed material facts from the complainant. But the fact of the matter remained that the diagnosis and operation of the complainant being coronary artery disease had no relation with the alleged past medical history of Dyslipidemia, Diabetes Mellitus and in any case diabetes was not the immediate or proximate cause of coronary artery disease.

6. The main grievance of the complainant against the