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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Dr. S.M. Kantikar, Presiding Member
Royal Sundaram Alliance Insurance
Co. Ltd. and Anr. —Appellants
versus
Melanie Das —Respondent
First Appeal No.366 of 2014
(Against the Order dated 02/04/2014 in Complaint No. 17/2014 of the State Commission Haryana)
Decided on 22.1.2018
Counsel for the Parties:
For the Appellants:Mr. S.M. Tripathi, Advocate with Ms. K. Karuna Sree, Advocate
For the Respondent:Mr. Jayant Tripathi, Advocate with Mr. Dinesh Dahiya, Advocate
IMPORTANT POINT
OP was trying to repudiate the claim one or other ground.
Headnote:Consumer Protection Act, 1986 - Section 19- Insurance- complainant frequent visitor to the United States of America, and had opted for ‘Single Trip Secure Class Silver Policy’ from OP- In March 2011, she started having episodes of double vision, known as ‘Diplopia’- Doctor advised her to undergo an MRI scan and she informed the OP- Doctors recommended a Gama Knife Radio Surgery (GKRS) costing US$60000 to US$70000, and she had to spend US$39339- complainant sought reimbursement which was refused, so she seeks damages as well as refund- State Commission’s orders right- Appeal dismissed.
Held: It is pertinent to note that, at the time of undertaking the policy, the complainant had no knowledge of the fact that she was suffering from “Right Posterior Clinoid Meningioma” and as such there was no question or occasion for its declaration in the proposal form. Moreover, complainant’s symptoms of diplopia were noticed in March 2011. It was due to the meningioma pressing over the optic nerve. Therefore, I do not think, it was either misrepresentation or misdescription or non-disclosure by the complainant.
It is quite surprising to read the exclusion clause 1(c) that “Treatment that could reasonably be delayed until the Insured Person’s return to the Republic of India.” No doubt it was not an emergency, but it was also unpredictable that how the disease especially the tumors behave in future, no one can wait and watch under such circumstances and invite undue risk by the delay in the treatment. In the case of tumors it is most important that early detection and treatment at early stage will definitely useful to avoid future complications and even mortality also. In my view the OP was trying to repudiate the claim one or other ground. The complainant took treatment in US to avoid unforeseen complications. The decision of the complainant to opt treatment by GKRS was a prudent and correct decision.
Thus, it is not acceptable that the meningioma was pre-existing in the instant case. For example, logically the insurance company will not cover heart attack caused by arthrosclerosis/arteriosclerosis commonly because arteriosclerosis is pre-existing due to dietary and several reasons. The insurance companies are misleading the innocent consumers by introducing such unconscionable and misleading terminologies like pre-existing disease. The human body itself is a complex structure, having regular changes at molecular level, which are undetectable until the signs and symptoms are seen. For example, simple dysplasia is a pre-disposing for development of cancer, but cancer will manifest in the 5th or 6th decade of life.
On the basis of foregoing discussion, there is no need to interfere in the order of the State Commission. I do not find any merit in the instant appeal, hence, it is dismissed.
The parties to bear their own costs. (Paras 13 to 16)
Result: Appeal dismissed.
In this appeal under Section 19 of the Consumer Protection Act, 1986 (for short “the Act”), the appellant questions the correctness of order dated 02-04-2014 passed by the State Consumer Disputes Redressal Commission, Haryana at Panchkula (for short “the State Commission”), whereby the complaint was allowed and directed the appellant to pay Rs.17,70,255/- with interest @ 9% per annum from the date of filing of complaint along with Rs.1,00,000/- as compensation.
2. The complainant, Ms. Melanie Das, since the year 2005 is a frequent visitor to the United States of America (USA), as her son was studying there. During such visits, she had been taking ‘Single Trip Secure Class Silver Policy’ from M/s. Royal Sundaram Alliance Insurance Company Ltd. (for short “the Insurance Company”). In the year 2011, before leaving for the US, she took one such policy from the regional office of the Insurance Company at Gurgaon (Haryana). A premium of Rs.17,101/- for the policy was paid by cheque dated March 1, 2011, at Gurgaon.
3. The complainant left for the US on March 7, 2011, and in the last week of March 2011, she started having episodes of double vision, known as ‘Diplopia’ each was lasting for 15 to 20 seconds, about 3 to 4 times a day. The problem persisted, therefore, she consulted one doctor in Cleveland, who after evaluation, advised her to undergo an MRI scan. She informed the OP-Insurance Company about her health problem, who in-turn, asked her to contact the US helpline. The US helpline of the Insurance Company permitted her to proceed with the MRI as advised. Accordingly, MRI was done on May 6, 2011 at the Eastside Imaging Centre, Cleveland, it revealed ‘Right Posterior Clinoid Meningioma’. Therefore, she was referred for further management. The doctors in USA had recommended a Gama Knife Radio Surgery (GKRS) to be conducted within the next two months costing US$60000 to US$70000. Due to the location of meningioma and the severity of her problem, IMRT/IGRT procedure was carried out. She had incurred US$39339 towards medical expenses. The complainant requested the OP to reimburse the expenses incurred by her on diagnostic tests as well as on treatment. In spite of repeated requests, telephone calls & emails, there was no avail. Subsequently, OP repudiated the claim vide letter dated July 5, 2011 on the ground that, their panel doctor has opined that ‘Meningioma’ is usually a slow growing disease and takes several months to years to attain the size of about 3 cms., thus, it was pre-existing disease of the complainant. The expenses incurred for treatment of pre-existing condition was outside the scope of policy. Being aggrieved by the repudiation, complainant issued a legal notice to the Insurance Company on March 12, 2012, to the regional office at Gurgaon, calling upon them to reimburse the entire expenses incurred by her and also towards future expenses. Having failed to get any response thereto, on April 2, 2012, the complainant filed complaint against the Insurance Company before the State Commission, inter alia, praying for a direction to the Insurance Company to reimburse the medical expenses incurred by her for treatment along with punitive damages and cost of proceedings, totaling Rs.31,23,467/-.
4. The OP - Insurance Company filed written statement before State Commission. The OP submitted that the State Commission at Panchkula had no jurisdiction to entertain the complaint as the policy was issued from the Corporate Accidents and Health claims department based at Chennai. She took treatment at the United States. The complainant had submitted her claim with their Chennai office and same was repudiated.
5. The State Commission initially on 12-02-2013 dismissed the complaint holding that it had no territorial jurisdiction. Therefore, the appeal was preferred by the complainant before this Commission and on 13-01-2014 this Commission set aside the order passed by the State Commission and remanded the complaint back to State C
