Per Mr.Narendra Kawde – Hon’ble Member: (1) This consumer complaint pertains to alleged deficiency in service as the Complainant’s mediclaim has not been settled fully under the mediclaim policy titled as ‘Overseas Individual Travel Insurance’ issued by the Opponent – ICICI Lombard General Insurance Co. Ltd.(‘insurance Company’ in short). (2) Admitted facts on the record are that the Complainant Shri Shreepad Manohar Mondkar subscribed to overseas individual travel Insurance Policy for a period of 90 days effective from 16.11.2007 to 13.02.2008 bearing policy no.4030/2646168/00/000 with insurance cover to the tune of US$ 1,00,000/- for his travel plan to visit his daughter at Austin, U.S.A. The Complainant commenced his tour to Austin on 15.11.2007. While staying with his daughter in the U.S.A. he suffered heart attack and was required to be admitted to the hospital viz.North Austin Medical Centre, Austin in an emergency situation on 27.01.2008 in intensive care unit. He underwent treatment in the said hospital and was discharged on 02.02.2008. The Opponent Insurance Company was informed hospitalization of the Complainant and promptly established the contact with one Ms.Priyanka Dhavan of the Opponent Insurance Company. (3) The cashless Insurance policy though provided insurance cover to the tune of US$ 1,00,000/- and the expenditure charged by the said hospital was US$ 170394, the Opponent Insurance Company sanctioned amount of US$ 40,550/- leaving huge gap of amount to be settled. The Opponent Insurance Company informed the terms and conditions of the said Insurance policy stating that if the insured is 56 years and above then the sub-limit clause of the policy is applicable. As per the sub-limit clause the Opponent Insurance Company has considered their liability which worked out to the tune of US$ 40550. Aggrieved and dissatisfied with the part settlement of the hospital bills, the Complainant preferred this consumer complaint alleging deficiency in service and unfair trade practice against the Opponent to reimburse balance medical expenses to the tune of US$ 74866.75 (Indian `37,61,305.52) as on 22.04.2008 in terms of US$ exchange rate together with compensation of `2,00,000/- for mental harassment and `50,000/- as costs of litigation. (4) The Opponent Insurance Company denied the contention of the Complainant by filing written version and affidavit of evidence together with written notes of arguments. It is the averment of Opponent Insurance company that the subject policy was issued with certain terms and conditions as laid down in part-II of the schedule of the Policy which though denied by the Complainant of having received but acknowledged the said terms and conditions by the Complainant by his e-mail dated 30.04.2008 (page 66 of the complaint compilation) and further averred that out of US$ 170394 medical expenses reportedly charged by the hospital authorities the Opponent Insurance Company has settled the bills to the extent of US$ 40550/- directly with the hospital as per the permissible terms and conditions appended to policy (sub-condition-2, page no.92 of the complaint compilation) and the Complainant thereafter paid only US$ 5503.45 and not US$ 74866.75 claimed to have been paid. (5) Heard the Ld. Advocates of the parties and perused the record placed before us. The Complainant denied any knowledge of the policy conditions set out by the Opponent Insurance Company regarding sub-limit clause as applicable to him. However, as pointed out by the Ld.Advocate of the Opponent the Complainant admitted such sub-clause limit saying that it is reasonable and acceptable to all medical institutions (page 66 of the complaint compilation). Therefore, the Complainant was well aware to sub-limit clause for settlement of medical expenses as he was above 56 years at the time of subscribing the insurance policy and hence, the submission of Complainant that the condition of sub-clause limit was beyond his knowledge is not acceptable. (6) The Opponent Insurance Company placed reliance on judgement of Hon’ble Supreme Court, reported in (2005) Supreme Court Cases 174 in Civil Appeal No.4366 of 1999 (Polymer India (P) Ltd. & Anr. V/s.National Insurance Co.Ltd. & Anr., stating that since Insurance Policy is a contract and the parties to this contract are strictly covered by the terms and conditions of the contract, the stipulation as to terms and conditions accompanying the policy document is part of contract of insurance. The Opponent discharged its obligation by settling medical expenses to the permissible limit of US$ 40550/-, even settled directly with the hospital authorities as a cap provided under Sub-clause limit of the policy as narrated hereinabove. (7) In view of the policy provisions and discussion above, we find that the Complainant failed to establish alleged deficiency in service against the Opponent Insurance Company. The complaint is devoid of merit, we hold accordingly and pass the following order: O R D E R (i) Complainant stands dismissed. (ii) In the given circumstances, both parties to bear their own costs. Pronounced on 12th April, 2012. | 
