Order-21.
Date-22/07/2016.
This is an application u/s.12 of the C.P. Act, 1986.
The instant case emanates from repudiation of insurance claim.
The case of the complainant, in short, is that complainant has a continued/renewed mediclaim bill having policy no.150100/11119/6000061815 renewed up to 29-11-2015 Easy Health Policy with the OP Company and till date he paid the premium regularly. The policy was previously with National Insurance Company Ltd. for the period from 18-11-2010 to 27-11-2011 and subsequently it has been switched over with the OPs under policy No.150100/11051/ 1000132095. In the year 2013, complainant went to a holiday trip to Switzerland. On 10-06-2013, complainant while bicycling in Lucerne in Switzerland around 3.30 p.m. in the afternoon, the complainant fell down and got hurt on his knee very badly. He was promptly treated there by the local doctor and then for 5 days in bed rest and then came back to India.
In the year 2014, complainant was operated in the right knee and for such purpose he was admitted in Belle Vue Clinic and has spent Rs.4,73,450/- for the said operation and medication. On 30-03-2014 complainant submitted a claim before the OP for realization of the cost of the treatment along with documents. Complainant received no response and he submitted reminder on 05-05-2014 pursuing his claim. On 14-05-2014 OP issued a letter and expressed their inability to process the claim application as much as the injury sustained by the complainant on account of mountain bike riding. It is alleged that the insurance company in a biased manner repudiated the claim of the complainant. Complainant also moved before the Insurance Ombudsman but to no good. Hence, this case.
OPs have contested the case by filing written version contending, inter alia, that the instant complaint is not maintainable in its present form. It is submitted by Apollo Munic that the policy KIT contending all relevant documents were duly delivered to the proposer, thereby, giving him an opportunity to verify and examine all the benefits, terms and conditions of the policy taken by him. A claim for reimbursement was received from the complainant on 11-04-2014. The documents submitted by the complainant were reviewed in light of terms and conditions of the policy. It is mentioned in the discharge summary of Belle Vue Clinic “Recurrent Swelling RT Knees, History of Injury during Mountain Biking”. The prescription dated 10-01-2014 pertaining to Sports med, the history mentioned is that “fall during mountain biking, fell on RT knee, experienced immediate buckling, had significant swelling, took 6 weeks to recover”. The reimbursement claim as it is alleged by the OPs was reviewed on the basis of the documents submitted by the complainant and the OPs found that the claim is not payable because as per submitted documents insured was treated for ACL insufficiency right knee, sustained during mountain biking. Treatment for any injury sustained in adventure sports including mountain climbing are excluded as per Section 4 (e) iii of the terms and conditions of the policy. The claim was as such repudiated. The OPs have prayed for dismissal of the case.
Point for Decision
- Whether the OPs have rightly repudiated the claim of the complainant?
- Whether the complainant is entitled to get the relief as prayed for?
Decision with Reasons
We have travelled over the documents filed from the respective sides including medical prescriptions and medical papers. We find that the complainant had availed of a medical policy being Easy Health Policy of the OP1 which was ported from National Insurance Company Ltd. The said policy as renewed from time to time and was valid till 27-11-2015. It has also transpired from the documents that in 2013 the complainant had gone to Lucerne in Switzerland for a holiday trip and during mountain biking at Lucerne he fell down and got injury in his knee. Initially he was treated in Lucerne and thereafter, in 2014 he underwent a knee surgery at Belle Vue Clinic, Calcutta. Insurance Company repudiated the claim on the ground that the complainant sustained injury, as a result of fall during mountain biking and it is an adventure sports and no payment can be made against any claim arising out of injuries sustained during such adventure sports.
We find that it has been presumed by the insurance company that by riding of mountain bike, actually he participated in his sports. We find that the complainant went to Switzerland in a leisure trip and there is no document that he participated in a sport of mountain bike. It also appears from the certificate of Belle Vue Clinic that he did not sustain injury during adventure sports like mountain biking. It also appears that the complainant examined himself by the doctors of Sports med, Bombay Expert in sports medicine and clinic and they after examining him issued a certificate on 21-06-2014 and categorically certified that the injury sustained by him was not during adventure sports. Mountain bike racing as we know shorten (MTD or ATB racing) is a competitive cycle sports held on a off-road terrain. The said racing needs huge technicality and expertise. The OPs failed to produce any sort of evidence that complainant going on a leisure trip at Switzerland, took part at competitive Cycle sports. Perused the Section 4(3)iii of the terms and condition of the policy. It is envisaged that the insurance company will not make any payment for any claim in respect of an insured person for participation or involvement in Naval, Military or Air-force operation, Racing, Driving, Aviation, Squva Driving, Parachuting, hang gliding, rock or mountain climbing. “Mountain Climbing” and “Mountain Biking” are not identical. Mountain Climbing is climbing the mountain and mountain biking is a competitive cycle sports held on off-road terrain. It is a race. There is no evidence that the complainant took part in mountain biking race, we think that it has been imaginarily presumed by the insurance company that the complainant by riding the mountain bike actually participated in adventures sports as alleged. There is no evidence that the complainant participated in any such adventures sports. The doctors of Belle Vue Clinic also certified that he had not sustained the injury during adventures, sports, viz. mountain biking. The doctor of Sports med, Bombay also issued a certificate on 21-06-2014 certifying that the injury sustained by him was not during by adventure sports. We think the claim of the complainant does not come within the purview of Exclusion Clause 4(e)iii of the Insurance Policy. We hold that the OPs have not been justified in repudiating the claim of the complainant. we have perused the medical papers, bills etc., and we think that the claim for reimbursement for Rs.4,73,457/- holds good.
In result, the case succeeds.
Hence,
Ordered
That the instant case be and the same is allowed on contest against the OPs.
OPs are jointly and severally liable to settle the claim of the complainant at an amount of Rs.4,73,452/- along with interest thereon from the date of passing this judgment till compliance apart from litigation cost of Rs.10,000/- within 40 days from the date of this order.
The OPs are also directed to pay an amount of Rs.40,000/- as penalty to be paid to this Forum within the stipulated period.
Failure to comply this order will entitle the complainant to put the order into execution and in that event OPs will be liable to pay damage at the rate ofRs.2000/- per month to be paid to the complainant till full and final satisfaction of the decree.
