CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM. Present Sri. Santhosh Kesavanath P. President Smt. Bindhu M. Thomas, Member Sri. K.N. Radhakrishnan, Member CC No.252/08 Saturday the 30th day of October, 2010 Petitioner : Annamma Thomas, Thoompanayil House, Pazhuthuruthu, Thiruvampady PO, Vakom, Kottayam. (Adv. K.Z. Kuncheria) Vs. Opposite party : 1) The Area Manager, Tata American International Group, General insurance Company, Chicago Plaza, 2nd Floor, Rajaji Road, Cochin Rep. by Senior Manager, Tata AIG Office, Nagapadom, Kottayam. (Adv. Agi Joseph) ORDER Sri. K.N. Radhakrishnan, Member The case of the complainant filed on 7/10/08 is as follows:- She had taken a “Travel Guard” insurance policy from the opposite party’s on 25-9-07 Kottayam office for the period from 25-9-07 to 22-3-2008. On 26-9-07 the complainant along with her husband went to Chicago from Nedumbassery air port. When the complainant was at USA she had suffered from body pain, allergy and abscess on the axis. On 17/10/07 she was admitted in the causality ward of Lutheran General Hospital, USA. After keeping at observation for 8 hours she was discharged and treatment continued for 15 days. She had visited the hospital at several times for periodic check up. On the 2nd week of November, the same complaint was repeated and she became unconscious and was taken to hospital by Ambulance, admitted and treated in the above said hospital for 3 days. Altogether she had spend 5301.56 American dollars, personally and the concerned hospital had directly send certain bills to the opposite party for effecting payment. The opposite party was bound to pay both those amounts ie 5301.56 dollars to the complainant and an amount of 2619 American dollars and 953 American dollars towards the hospital bills and towards service charges respectively. The complainant and her husband on 24th March 2008 returned to India due to her illness. She herself and the hospital authorities submitted all the relevant records as stipulated in the policy conditions along with claim form for an amount of Rs.2,12,080/-. But the opposite party altogether paid only Rs.16455/- to her as against the claim of the complainant and the claim made by the hospital authorities was rejected by the opposite party without showing any sufficient and admissible reasons. The balance amount due to the complainant and as well as the claim made by the hospital authorities which are legally due is kept pending for payment by the opposite party. The reason stated for the non payment of balance amount, due by the opposite party is that the complainant had to submit past medical records towards treatment taken for diabeties in India prior going abroad and the original Ambulance bill and receipt. She was not at all a diabetes or cholesterol patient and she was never treated for any such illness in India. The diabetes and cholesterol was formed as a side effect of the ailment and allergy caused at U.S.A. She was in a very good health condition prior to going abroad and even now. There was deficiency in service on the part of the opposite party. Hence this complaint. The notice was served with the opposite party. They appeared and filed their version contending as follows: The complaint is not maintainable either in law or on facts. The complainant has not spent the alleged amount as stated in the complaint. The claim amount of the complainant was not the actual expenses incurred to her. The claim amount was excessive and not the amount actually spend. The opposite party settled the claim of the complainant as per the terms and conditions of the policy paying rs.16,455/- equivalent of US $ 418.07 after deducting the policy deductible of 100 US dollars. From the treatment records, it was found that the complainant had taken treatment for infection and diabetes. It was noted from the consultation Report of Advocate Medical Group USA that the complainant had a history of diabetes milletus and elevated cholesterol. To decide on admissibility of the claim, the opposite party demanded relevant documents for past medical history for supporting the claim with cogent evidence. But the complainant refused to give documents in supporting the claim. She had not clarified the reasonable doubts and points for processing the claim. The complainant has not produced the records of her pre-existing disease which revealed from her case history of the hospital records. The complainant has made claims for Ambulance charges which are not supported with bills and taxi charges are not payable under the policy. Air Fare claimed by her was also not payable under the policy. Another major claim of the complainant was regarding Emergency Cash Transfers and advance of 1000 US dollars. This was available to the people who require cash urgency and was intended to supplement the facility of the credit cards. This is an assistance facility available to policy holders and is not a benefit payable under the policy. The policy holder can avail this facility when they require cash urgently while abroad. Credit facility was provided under their credit card which needs to be paid to the card issuer once the policy holder is back in India. The benefit is only in the nature of credit. The opposite party is awaiting further medical records from the complainant to decide on the claims made by the complainant for certain expenses. As per the medical records of the complainant “she had a similar reaction two years ago and took Methyl Prednisolone 4mg that evening. She had an episode of urticaria about 2 to 3 years ago. At that time it was attributed to eating prawns, but she has eaten prawn since then without any adverse reaction. She ate some fish but that was the day before this reaction occurred. She had a history of diabetes mellitus and elevated cholesterol”. She was taking certain drugs for her diseases. On going through the medical records it was found that she was an allergic patient and has diabetic cholesterol. For substantiating a claim bill is highly essential. The complainant has not produced bill of ambulance, treatment expenses with prescriptions and previous records of her treatment. The non payment of the entire claim amount is legally valid and correct. There was no deficiency in service or unfair trade practice on the part of the opposite party. Hence the complaint may be dismissed with costs. The complainant filed proof affidavit and documents which are marked as exhibits A1 to A9. The opposite party filed proof affidavit and documents which are marked as exhibits B1 to B3. Heard both sides. We have gone through the complaint, version, documents and evidences of both sides. Case of the complainant is that the opposite party has not settled the entire claim of the complainant. According to her she was entitled for the entire claim amount submitted by her. The opposite party has taken a contention that the complainant has not submitted the entire treatment records. According to them the bills and treatment records is highly essential to settle the claim. Even after the demands made by the opposite party the complainant has not submit the relevant records. From the available records and documents it can be seen that there was nothing to produce by the complainant even after demanded by the opposite party. Moreover the opposite party has to pay some amount to the complainant. At this stage we can not say any deficiency in service on the part of the opposite party. The complainant is liable to co-operate with the opposite party for producing the records for her treatment. Hence we are of the opinion that the claim of the complainant is to be re-considered on the basis of all the treatment records along with bills. Therefore we direct the opposite party to re-consider the claim of the complainant within two months as a fresh claim complainant also co-operate with the opposite party. In the result the complaint is disposed accordingly. Both parties will suffer their respective costs. The order shall be complied with within a period of two months from the date of receipt of a copy of this order. Sri. K.N. Radhakrishnan, Member Sd/- Sri. Santhosh Kesavanath P. President Sd/- Smt. Bindhu M. Thomas, Member Sd/- Appendix Documents produced by complainant 1) Ext.A1 is copy of policy schedule 2) Ext.A2 is the copy of ICS collection service 3) Ext.A3 is letter from TATA AIG 4) Ext.A4 is the copy of part payment 5) Ext.A5 is the copy of bill statement 6) Ext.A6 is the copy of lawyer notice 7) Ext.A7 is the postal receipt 8) Ext.A8 is the post A/D card 9) Ext.A9 is the copy of letter from TATA AIG not readable Documents by opposite party 1) Ext.B1is the Policy 2) Ext.B2 is the copy of treatment history 3) Ext.B3 copy of letter dtd 24-6-08 By Order, Senior Superintendent. S/3cs
| | [HONORABLE Bindhu M Thomas] Member[HONORABLE Santhosh Kesava Nath P] PRESIDENT[HONORABLE K.N Radhakrishnan] Member | | 
