CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/374/15

          Date of Institution:-   20.07.2015

          Order Reserved on:- 20.03.2024

                   Date of Decision:-     28.06.2024

IN THE MATTER OF:

ShriRakesh Kumar Jain

Sector C-6, Flat No.6221,

VasantKunj, New Delhi - 110070

.….. Complainant

VERSUS

1. Axis Bank
2.  

New Delhi (DL),

New Delhi – 110070

2. Tata AIG General Insurance Company Limited

A-501, 5^th Floor,

Building No.4, Infinity Park

Gen.A.K. VaidyaMarg,

Dingoshi, Malad (E)

Mumbai, India 400097

.…..Opposite Parties

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations thathe took an insurance plan from  TATA AIG Travel Guard Silver Plus with family policy no.JR223305 through OP-1 which also covered medical expenses of his wife. The policy was applicable worldwide including America. He along with his wife travelled to USA on 18.12.2014 to meet his daughter. He stayed with his daughter and son in law. During the night of 08.01.2015, he slipped badly and fallen on the ground after coming from the restaurant. He was in great pain. On 09.01.2015, he went to local pharmacy and brought pain reliving medicines and cotton braces for reliving the pain. He stayed till 20.01.2015 with his daughter. It was not possible to travel in economy class and therefore came back to India through first class. He along with his wife landed in India in the night of 22.01.2015. On 23.01.2015, they visited Max Care Health Hospital and consulted orthopaedic surgeon who advised x-ray and CT-Scan. A Fracture in knee was deducted upon which hard plaster was got fixed from Sukhmani Hospital,VasantKunj on 23.01.2015. The plaster was broken after some days and reinforced on 11.02.2015 at Sukhmani Hospital, VasanjKunj,CT-scan was done before removing the plaster. The plaster was removed. On 20.02.2015, he visited Max Hospital. It was advised that knee brace should be used for four to six weeks. He has incurred an expenses of Rs.610510/- and filed a claim with OP-2 on 25.03.2015 and forwarded the copy to OP-1 on 12.04.2015 through mail. OP-2 vide mail dated 11.06.2015 has rejected the claim. The medical accident has taken place out of India which is covered under medical insurance policy which expired on 07.02.2015. He has informed the insurance helpline number. He has entitled for his claim.

2. The OP-1 did not the appearance despite service and accordingly ex-parte on 15.01.2016.

3. The OP-2 has filed the reply with the averments that policy in question was valid from 18.12.2014-07.02.2015. The benefits under the policy were available till the expiry of the policy or returned to India whichever is earlier. The benefits expired on 22.01.2015 when the complainant has come back to India. Section 3 under Part D coverage of the terms and conditions of the Travel Guard Global Travel Protection says about the benefits of accident and sickness medical expenses. The policy does not cover the medical expenses incurred in India as complainant sustained injury on 08.01.2015 while in USA. The complainant has neither visited any hospital nor consulted doctor or contacted insurance assistance of OP-2 in USA. Complainant has not attached any proof of medical injury sustained during his stay at USA. The complainant has himself decided to travel by first class without any recommendation from the Assistance Company of OP-2. Section 8 of part D – coverage says that in case of medical evacuation, when in the opinion of Assistant Company medical panel, it is judged medically to move a person to another location for his better treatment or return to India, the Assistant Company will arrange the evacuation. All decisions as to the means of transportation and final destination will be made by Assistance Company. The complainant has not informed or contacted assistance company so there is no occasion to make payment of the cost of tickets of first class. The claim has been registered with OP only on 07.02.2015. The present claim pertains to the medical treatment expenses incurred by him in India so complainant is not entitled for the same in terms of the policy.  There is no deficiency of service on the part of OP-2.

4. The complainant has filed the rejoinder wherein he has denied the averments of written statement and reiterated the stand taken in the complaint.

5. The parties were directed to lead the evidence.
6. The complainant has filed his own affidavit in evidence and corroborated the version of complaint and placed reliance on the documents.

7. The OP-2 has filed the affidavit of Mohd. AzharWasi, in evidence and corroborated the version of written stastementand placed reliance on the documents i.e. Ex. RW1/1 (letter dated 01.04.2015 written by the complainant to OP) and Ex.RW1/2 (terms and conditions of the medical policy).

8. We have heard the Ld. Counsel for the OP and perused the entire material on record.

9. It is clear from the material on record that issuance of policy dated 18.02.2014 in question with validity till 07.02.2015is not in dispute. The policy was valid till theexpiry date or return to India whichever is earlier.

10. The complainant has gone to USA on 18.12.2014 where he has allegedly fallen and sustained injury on his knee. He took pain killers to relieve the pain.

11. The complainant has not consulted any doctor or visited hospital to know the reason of pain or to have an opinion whether he has suffered any fracture or not. The complainant should have consulted doctor once the pain was persisting which he did not do for the reasons best known to him. There is no medical prescription slip to show that complainant has sustained any injury in the knee while staying in USA.

12. The complainant has travelled by first class to India. The complainant did not inform Assistance Company of the OP-2 which could have arranged medical evacuation by assessing his medical condition in terms of Section 8 of Part D – coverage of the terms of policy Ex.RW1/2. The complainant of his own travelled by first class without informing about his condition to the Assistance Company of OP-2 which is a clear breach of the terms and conditions of the policy.

13. On the night of 22.01.2015 the complainant has landed in India from USA and thereafter on 23.01.2015 consulted the Max Healthcare Hospital where fracture was detected in the knee after doing CT-Scan and X-ray. The plaster was done from Sukhmani Hospital, VasantKunj, New Delhi. The complainant has taken the treatment and incurred an expenses of Rs.610510/- and thereafter lodged the claim with OP-2 on 25.03.2015.

14. The complainant did not inform the OP-2 after landing in India and consulting the doctor at Max Hospital. The Section 3 of Part D – Coverage of the Terms and conditions of the policy Ex.RW1/2 shows that policy is valid till the date of expiry or return to India whichever is earlier.

15. The complainant has returned to India on the night of 22/23.01.2015. The policy has expired on that day. The complainant should have informed the OP to before 23.01.2015 which he did not do. The complainant has not taken any medical treatment from any hospital in USA. There was no detection of fracture at USA. There is no medical prescription slip. There was no intimation to Assistance Company of OP-2. The complainant cannot take benefit of the policy once it has expired after his return to India. There is violation of the terms and conditions of the policy Ex.RW1/2. The claim has been rightly rejected by the OP-2.There is no deficiency of service on the part of OP-2.

16. In view of above discussion, the complainant has failed to substantiate the allegations as set out in the complaint and accordingly the complaint is dismissed.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 28.06.2024.