DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.203/2015
1. Mr. Karnik Rajat
S/o Sh. Sulakshan Kumar
2. Ms. Kavita Kumar
W/o Sh. Rajat Kumar
Both R/o:
A-164, Shivalik,
Malviya Nagar,
New Delhi-110017 ….Complainants
Versus
ICICI Lombard General Insurance
Registered office at:
C/o Europ Assistance India
301, C-Wing, Business Square,
Andheri (E), Mumbai-400093
Branch Office at:
Plot No.18, Block-K,
Lajpat Nagar-II,
New Delhi-110024 ….Opposite Party
Date of Institution : 31.07.2015
Date of Order : 08.09.2020
Coram:
Ms. Rekha Rani, President
Ms. Kiran Kaushal, Member
ORDER
Ms. Kiran Kaushal, Member
- The case as pleaded by the complainants is that the complainants purchased two Overseas Travel Policies by paying premium of Rs.5,934/- from ICICI Lombard General Insurance hereinafter referred to as OP. The policies were effective for the period from 18.05.15 to 04.06.15.
- It is averred that the complainants were to travel abroad from 18.05.15 till 03.06.15 to Canada and USA. However the travel was interrupted due to two reasons. First Complainant No.1’s mother developed certain health issues and she was advised hospitalization by a Doctor. Second on the same day wife of complainant No.1/complainant No.2 developed some kind of infection over her left knee. She was in tremendous pain and she had problem in walking. It is averred that due to this unforeseen illness of Complainant No.1’s mother and Complainant No.2, Complainants were forced to cut short their trip and they decided to come back to India. Complainants had to reschedule their return flight tickets to India and flew back on 21.05.15 instead of 03.06.15. Complainants had to incur costs for rescheduling the flight tickets, they were forced to cancel the hotel bookings alongwith other airlines tickets purchased for travel within Canada and USA which were non-refundable
- Complainants on returning to India immediately informed OP regarding the unforeseen illness and submitted their claim. However, OP repudiated the claim made by the complainants falsely showing that the benefits under trip cancellation/interruption is payable only in case of earthquake, storm, flood, inundation, cyclone, tempest and terrorism vide letter dated 14.07.15.
- Complainants have alleged that OP voluntarily reneged from policy benefits despite promise to complainants and has thereby caused deficiency in service. Complainants prayed for directions to OP to pay a sum of $.2,000/- alongwith pendantelite and future interest @ 18% per annum. Complainants seek compensation of Rs.2 lakhs for deficiency in service rendered by OP and for agony and shock.
- OP resisted the complaint and filed its written statement stating inter-alia that the Complainants have tried to mislead the Forum by annexing the false policy wording alongwith the complaint. Complainants have annexed Group Overseas Travel Insurance Policies at page No.13 & 14 of the complaint; however, the terms and conditions annexed are of the Individual Overseas Travel Insurance Policy.
2.1 It is further submitted that merely purchasing a policy or paying premium does not mean that the insurer is liable to pay. It is further stated that the insurance is a contract and obliged by certain terms & conditions of governing law. Any breach of the condition, amounts to repudiation of contract.
- OP has denied any deficiency of service stating that the claim has been rejected as per BENEFIT-10 of Group Overseas Travel Insurance Policy. For ready reference BENEFIT-10 is reproduced as under:-
The company shall indemnify the insured for the financial loss incurred by the insured arising out of cancellation of the Trip (whether wholly or in part) solely attributable to and/ or arising out of:
-Earthquake
-Storm, flood, inundation, cyclone, tempest
-Terrorism; provided that, the named perils hereinabove shall take place at or in the vicinity of the city of Residence or Place of Origin or Place of Destination or any intermediate place which is involved in or related to the Insured’s Trip; and Personal contingencies like death or imminent death, or emergency Hospitalization treatment necessitated to the insured or Insured’s Immediate Family due to an unforeseen illness or injury. Subject to the maximum liability of the Company as stated in Part I of Schedule, the company shall pay to the insured
1. Official cancellation charges;
2. Actual additional transportation expenses incurred to return to the City of Residence or Place of Origin, provided that, the additional expenses are for alternative travel arrangement of the same class and/ or type and by the most direct rout;
3.1 It is averred by OP that complainants claim was rejected as no Emergency Hospitalization or admission happened and the illness of the mother of Complainant No.1 was not unforeseen. On the above stated grounds OP seeks dismissal of the complaint.
- Complainant no. 1 and No. 2 have filed their evidence by way of affidavit. Evidence by way of affidavit of Mr. Vikas Goyal, Legal Manager ICICI Lombard is filed on behalf of the OP.
- After completion of pleadings and filing of written arguments, OP stopped appearing and was proceeded against exparte.
- Written arguments are filed on behalf of the parties.
- Arguments of the complainants are heard and material placed on record is perused carefully.
- Complainants in support of their case have appended Group Overseas Travel Insurance Policies at page No.13 & 14 of the complaint, copy of repudiation letter. Copy of prescription dated 20.05.15 of complainant No.1’s mother & copy of prescription dated 25.05.15 of complainant No.2. Before we proceed further the relevant portion of the repudiation letter is reproduced below wherein OP has rejected the claim stating:-
“For both the above mentioned incidents, there was no emergency hospitalization or admission. Your wife’s treatment was done on OPD basis and for your mother; the treatment was going on from 28/4/2015. Though Dr. Lokesh Gupta’s consultation paper dated 20/05/2015 states “the patient wants to consult family before admission”, there was no immediate hospitalization at that time.
As per the policy terms and conditions, under the benefit of trip Cancellation and interruption, there should be emergency hospitalization treatment necessitated to the insured’s immediate family due to an unforeseen illness or injury.”
- We have gone through the prescription dated 20.05.15 of Mrs. Alka Kumar, mother of the complainant No.1 which clearly shows that after receiving an IV injection in the clinic she was feeling better. Though she was advised Hospitalization and Needful, the patient wanted to consult the family for Admission to the hospital. The said facts clearly reveal that no emergency hospitalization was required for the patient. Further no documents have been attached to show that whether she was actually hospitalized ever on account of the complications developed during the period of validity of Insurance Policy. The next prescription dated 25.05.15 is also an OPD slip of complainant No.2 which mentions that she had an Abscess over her left knee and certain medicines were prescribed to her without any advice for Hospitalization. Study of both the prescriptions dated 20.05.15 & 25.05.15 has failed to convince the Forum that there was any emergency for hospitalization treatment which was necessary. Therefore this Forum is of the opinion that the claims of the complainants were rightly repudiated as per the terms and conditions of the Insurance Policy.
- In view of the discussion above, complaint is dismissed with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 08.09.2020
