DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Rajinder Kumar Sharma s/o Sh. Sukhdev Sahai, resident of House No. 326, Ward No.5, Shastri Marg, District Mansa (Punjab).

              ---Complainant

Vs

[1]  Future Generali India Insurance Co. Limited, through its authorized person, SCO No. 78-79, 2^nd & 3^rd Floor, Sector 17-C, U.T. Chandigarh.

[2]  Future Generali India Insurance Co. Limited, through its authorized person, Corporate and Registered Office 001, Delta Plaza, 414, Veer Savarkar Marg, Prabhadevi, Mumbai – 400025.

[3]  Future Generali India Insurance Co. Limited, through its authorized person, 3^rd Floor, Kailash Building, 26 K.G. Marg, New Delhi – 110001.

[4]  Piyush Kohli [Travel Agent], B.R. Forex Enterprises Pvt. Limited, SCO No.26-27, Sector 34-A, U.T. Chandigarh.

---- Opposite Parties

BEFORE:    SH.LAKSHMAN SHARMA              PRESIDENT

MRS.MADHU MUTNEJA               MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. Navdeep Monga, Counsel for Complainant.

Sh. Vishal Aggarwal, Counsel for Opposite Parties No.1 to 3.

None for Opposite Party No.4.

PER MADHU MUTNEJA, MEMBER

1.          The Complainant had taken a cashless Travel Suraksha Individual insurance policy from the OPs No.1 to 3, through OP No.4 for his trip to Switzerland effective from 17/6/2011 to 21/7/2011 (Annexure C-1). The Complainant was insured for a maximum of US$ 50,000/- for medical care including accidental medical expenses etc. The Complainant has stated that when he reach Switzerland on 23/06/2011, he suffered from bloody diarrhea on the same day, due to which an ambulance had to be called and he was taken to Spital Lachen for emergency medical treatment. The Complainant was discharged the same day after a few hours. He was called for check-up the next day again and was given medicines to be taken regularly for 03 months. He was also asked to get his Hemoglobin (HB) tested after a week. The Complainant has stated that after getting the treatment, the problem did not reoccur and the Complainant remained stable throughout. He was also advised by the doctors to get his Endoscopy and Protoscopy conducted on his return to India.      

          The Complainant has stated that according to his past history, he was a patient of Diabetes and Hypertension and had been taking treatment from Dr. Parshotam Jindal of Mansa. The Complainant has alleged that despite promise of cashless facility by the OPs if conducted within 24 hrs, the Complainant was not provided the same despite the OPs being contacted by his son through internet. The Complainant has stated that the medical ailment had never occurred before boarding the aircraft and was not connected with his known diseases of Diabetes and Hypertension. The Complainant has also stated that he incurred an expense of 1196.30 Swiss Francs on the treatment (Bills Annexure C-4). Payment was made to the Hospital authorities from the credit card of the son of the Complainant. Photocopies of treatment/ prescription from Dr. Parshotam Jindal are at Annexure C-5 and the one given in Switzerland is Annexure C-6. As the claim was not being paid, the Complainant issued a registered legal notice through his counsel to the OPs No.1 & 2 for making payment. However, when the OPs failed to make payment to the Complainant, he has filed the present complaint, claiming the payment of the amount of 1196.30 Swiss Francs spent on the treatment, along with interest and compensation of Rs.5.00 lacs. The Complainant has attached all mails exchanged by him with the OPs.

2.          Notice of the complaint was sent to Opposite Parties seeking their version of the case.

3.          The Opposite Parties No.1 to 3 in their joint reply have taken the preliminary objection that the claim of the Complainant is pre-mature, as the Complainant has not still submitted the claim along with complete documents to enable the OPs to consider the same. Also, it is an essential condition of the Policy that documents provided to the insurer shall be in English language to know about the disease and permission for cashless facility. In the present case, the notes received from the doctor in Switzerland were in Swiss language and therefore, it was not possible to give immediate sanction for cashless facility. The Complainant was discharged before the cashless facility could be sanctioned or rejected. Also, on translation of the documents sent by the Complainant it was found that the Complainant was suffering from variable diseases i.e. Hypertension, Diabetes Mellitus and Epilepsy which were never disclosed at the time of taking the Policy.

          On merits, OPs No.1 to 3 have admitted the issuance of insurance policy to the Complainant, but have stated that there was no deficiency in service on their part. The factum whether bloody diarrhea is directly or indirectly connected to the past or existing medical condition can be known only when the Complainant furnishes his complete medical record and an opinion given by the doctor for the same. The amount if any payable can be determined only after claim is submitted by the Complainant along with complete medical record. As per the existing facts it appears that the Complainant was suffering from a pre-existing disease. OPs have reiterated that the Complainant has never furnished his entire medical record and necessary details. Pleading that there was no deficiency in service on their part, Opposite Parties No.1 to 3 have prayed for dismissal of the complaint with costs.

     OP No.4 has stated that there is no agency relationship between OPs No.1 to 3 and OP No.4. OP No.4 is running a Travel Agency and has rendered his services to the full satisfaction of the Complainant. The Complainant has taken the insurance policy from OPs No.1 to 3 and OP No.4 has no role to play, except suggesting the name of different companies dealing in travel insurance. Pleading that there was no deficiency in service on its part, OP No.4 has prayed for dismissal of the complaint.

4.          Since none appeared for the Opposite Party No.4 on 24.01.2013, therefore, we proceed to dispose of this complaint on merits under Rule 4(8) of the Chandigarh Consumer Protection Rules, 1987 read with Section 13(2) of the Consumer Protection Act, 1986 (as amended upto date) even in the absence of the Opposite Party No.4.

5.          During the course of proceedings, the Complainant was directed to submit translated copies of the documents which were in Swiss language. The said documents were placed on record by the Complainant on 13.08.2012 (Annexure C-13 and C-14).

6.          Parties were permitted to place their respective evidence on record in support of their contentions.

7.          We have heard the learned counsel for the Complainant and OPs No.1 to 3 and have perused the record.

8.          The grievance of the Complainant is that despite taking a cashless facility from the OPs No.1           to 3 the said facility was not provided to him when needed in Switzerland, also payment has not been made by the OPs despite submission of claim. OPs No.1 to 3 in reply have expressly taken the stand that as information about the medical treatment availed of by the Complainant in Switzerland on his arrival was received in Swiss language, instant permission for cashless facility could not be given without getting a translation to see whether the claim was permissible or not. It is important to state that as the details of treatment taken from the Switzerland was in Swiss language, translated copies of the documents were needed by the OPs before any commitment could be made. We agree with this contention of the OPs No.1 to 3 and hence, to our mind, immediate denial of cashless facility cannot be attributed as deficiency in service by them.

9.          After return from Switzerland the Complainant has submitted his claim papers but the OPs No.1 to 3 have not yet made payment. A perusal of the documents on record shows that the OPs No.1 to 3 had been asking the Complainant for complete translations of his medical treatment as well as complete record of his earlier treatment with Dr. Parshotam Jindal, so as to be able to correctly co-relate whether the earlier diseases of the Complainant had any nexus or connection with the cause of the medical ailment in Switzerland.

10.        E-mail dated 27.06.2011 from the OPs No.1 to 3 is very clear with regard to this. The relevant excerpt of which reads as under:-

“………Unless and until we do not get the medical report, we cannot commit you anything in regards to coverage.

In regards to the family doctor, kindly advise if you have any relatives in India who can send the medical report for the consultation with Dr. Purschotam.”

          In reply, the Complainant has informed the OPs No.1 to 3 vide return e-mail on the same day that:-

“….The medical report or treatment slip is not with me here. All these reports are back home in India.”

          OPs No.1 to 3 have meanwhile contacted Dr. Parshotam Jindal and have informed the Complainant the same day as under: -

“We have contacted your family doctor in India, but he further informed us that he cannot recollect the patient.

So kindly advise if you have any medical report or else any treatment slip from him, so that we can forward him the same and get the past medical history from him.”

          All these e-mails besides others have been placed on record by the Complainant himself. It is also given in one of the e-mails written by the Complainant’s son that it was concluded by the doctor that bloody diarrhea was an emergent situation and could not be planned in advance. In reply to this e-mail the OPs No.1 to 3 have written to the Complainant vide mail dated 04.06.2011 requesting him to give complete documents about his treatment on his return to India, so as to ascertain whether the claim was payable. On his return the Complainant provided copies of the documents of his treatment, but the claim remained unpaid as the documents were not in the English language. As per the averments of the OPs No.1 to 3, the Complainant has later given the translations of the documents but the entire medical record has not yet been submitted due to which the claim has not yet been processed.

11.        Considering the allegations of the Complainant and counter demands of the OPs No.1 to 3, it is evident that there is a miscommunication between the parties. The claim filed by the Complainant has not yet been processed even though now the OPs No. 1 to 3 are now in possession of the complete records of Dr. Jindal as well as the translation of the treatment taken by the Complainant in Switzerland.

12.        In view of the foregoing discussion, we allow this complaint with a direction to the OPs No.1 to 3 to favourably consider the claim of the Complainant which to our mind does not seem attributable to a pre-existing ailment as no literature/ document is on record to prove so. Bloody diarrhea to our mind would be due to something wrong eaten by the Complainant and not caused by hypertension or diabetes. The claim be processed and payment due as per the policy be made to the Complainant within 45 days of the receipt of this order, failing which the OPs No.1 to 3 shall be liable to pay the Complainant the equivalent of the claimed amount of 1196.30 Swiss Francs in Indian currency, along with interest @9% p.a. from the date of this order, till the date of payment. No costs. 

13.        Since the role of the OP No. 4 being a Travel Agent is only limited to the extent that the Complainant had availed the visa and ticket services from it and there is no alleged deficiency in service on the part of OP No.4, therefore, the present complaint qua OP No.4 is dismissed

14.        Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

28^th January, 2013.                                                 

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

“Dutt”