MUKUL SONAWALA Vs. ORIENTAL INSURANCE CO. LTD

JUDGEMENT

(1.) This complaint is filed under sec. 12 read with sec. 14 of the Consumer Protection Act, 1986 (in short, the 'Act') alleging deficiency in service and unfair trade practice on part of the opposite parties in respect of the Overseas Travel Insurance issued by the opposite parties no. 1, 2 and 3, The Oriental Insurance Company Ltd, Mumbai to the complainant who availed of a policy for his overseas travel in May - June 2010.

(2.) In brief, the facts are that the complainant obtained an Overseas Travel Insurance (No. 121800/48/2010/15534) on payment of a premium from opposite party no.1 through opposite party no. 2, Heritage Health TPA Service Pvt. Ltd, who is the agent of opposite party no.1 for the period 17/5/2010 to 13/6/2010 for a sum of USD 2,50,000. Shortly after arrival in the USA, on 27/5/2010, the complainant fell ill and was admitted to Poudre Valley Hospital, Fort Collins, Colorado, USA. He was diagnosed with fever with malaria and was required to remain admitted in hospital. The expenditure incurred was USD 2,59,000. His claim was repudiated by the opposite party no. 2 on 30/12/2010 on the ground that the cause of hospitalization was a pre-existing illness as per clause 10 (c) of the policy. The complainant contested this ground of repudiation, stating that he would not have travelled overseas if he was unwell and that the report of a medical doctor from the panel of opposite party no.2 prior to issue of the policy had certified him to be medically fit to travel.

(3.) The complainant has alleged that the act of repudiation is illegal and amounts to deficiency in service and unfair trade practice. It is his averment that he had been examined by an authorised doctor on behalf of opposite party no. 2 and not diagnosed with a pre-existing illness and that the terms and conditions of the policy were not disclosed to him even though he paid the premium. He avers that as per IRDA Regulations Act and various judgements of the Hon'ble Supreme Court and this Commission he is entitled to compensation of the sum assured along with interest and damages. He is before us with the following prayer: