IMPORTANT POINT
Travel Medical Policy – Repudiation of claim – When the insured was thoroughly examined by doctor of insurance company before approval of the insurance policy, repudiation on ground of non-disclosure of illness prior to obtaining of insurance was not justified.

ORDER

This Revision Petition No.277 of 2017 filed under Section 21(b) of the Consumer Protection Act, 1986 (for short, “the Act”), challenges the order dated 01.09.2016, of the Haryana State Consumer Dispute Redressal Commission, Panchkula (in short, “the State Commission”) in First Appeal No.274 of 2016 wherein the State Commission, allowed the appeal filed by the Respondents and set aside the order 03.03.2016 passed by the District Forum, Panchkula in Complaint Case No.196/2015.

2. We have heard the Learned counsels for both the parties and perused the records.

3. The relevant facts of the case, in brief, are that the Petitioner had been regularly taking travel insurance policies for his trips to the USA. In 2014, he obtained a “Travel Super Age Elite” policy on 21.06.2014 valid from 24.06.2014 to 21.09.2014 for a sum assured of USD 50,000 after paying a premium of Rs.13,693. Prior to the issue of the policy, the Petitioner underwent a medical examination by the Respondent’s recommended doctors on 06.06.2014, which did not reveal any ailment, although the Petitioner himself disclosed that he had an hypertension and asthma. During his stay in the USA, the Petitioner requested an extension of his policy for 30 more days, which was granted, extending the coverage until 27.10.2014. On 25.09.2014, he experienced blood in his urine and was diagnosed with Haematuria, but no serious treatment was required. The hospital sent a medical bill of USD 11,516 directly to the Respondents for clearance.

4. Despite the existence of a valid travel medical policy, the Respondents rejected the claim on 27.02.2015, stating that Haematuria was linked to a pre-existing condition, prostatic hypertrophy, which was not covered under the policy. The Petitioner issued a legal notice on 11.05.2015, disputing the claim denial, explaining that Haematuria is not a chronic condition and can occur due to various factors. When no response was received, the Petitioner filed Consumer Complaint No.196 of 2015 before the District Forum, Panchkula, claiming Rs.7.60 lacs, interest, and compensation. The District Forum allowed the complaint on contest on 03.03.2016, directing the Respondents to pay Rs.7.60 lacs with 9% interest and Rs.25,000 as compensation.

5. Aggrieved by this decision, the Respondents filed First Appeal No.274 of 2016 before the State Commission, Haryana. It is the contention of the petitioner that the State Commission, without providing him an opportunity to reply, erroneously allowed the Respondent’s appeal and dismissed the complaint, holding that the Petitioner was suffering from a pre-existing medical condition and therefore, not entitled to the claim under the policy.

6. The counsel for Petitioner argued that the Petitioner obtained a “Travel Super Age Elite” policy on 21.06.2014 for a sum assured of USD 50,000 on paying a premium of Rs.13,693/- for travel to USA. The policy was preceded by a medical examination by the Respondent’s doctor on 06.06.2014, when no ailments were detected, though the Petitioner disclosed having an hypertension and asthma, which was recorded. While in USA the Petitioner requested and was granted a 30 day extension of the Policy from 23.09.2014 to 27.10.2014. However, on 25.09.2014, the Petitioner was required to visit a hospital for blood in urine and was diagnosed with Haematuria. However, no treatment or hospitalization was needed. A medical bill of $11,516 (Rs.7.60 lacs) was sent directly to the Respondents for payment under the Policy which was repudiated despite the submission of all required documents on the grounds of pre-existing medical conditions. The Petitioner’s legal notice on 11.05.2015, clarifying that Haematuria was not a chronic condition but a one-time ailment, was not considered forcing him to approach the District Forum.

7. Counsel for Respondent argued that the Petitioner obtained a Medi Claim Travel Insurance Policy from the Respondent Company, initially valid from 17.08.2013 to 14.11.2013, a