Date of Filing:16.01.2009<br /> Date of Order:30.05.2009<br /> <br /> <br /> <br /> BEFORE THE II ADDITIONAL DISTRICT CONSUMER DISPUTES REDRESSAL FORUM SESHADRIPURAM BANGALORE-20<br /> <br /> <br /> <br /> Dated: 30TH DAY OF MAY 2009<br /> PRESENT<br /> <br /> <br /> <br /> Sri S.S. NAGARALE, B.A, LL.B. (SPL.), President.<br /> Smt. D. LEELAVATHI, M.A.LL.B, Member.<br /> Sri BALAKRISHNA. V. MASALI, B.A, LL.B. (SPL.), Member.<br /> <br /> <br /> <br /> COMPLAINT NO: 160 OF 2009<br /> <br /> R. Sundaralingam<br /> No. 848, 10th Cross<br /> 26th Mian, 1st Sector<br /> HSR Layout & Post<br /> Bangalore 560102 Complainant<br /> <br /> V/S<br /> <br /> 1. M/s. ICICI Lombard Travel Insurance<br /> ICICI Lombard General Insurance Co. Ltd.<br /> Zenith House<br /> Keshavarao Khadye Marg<br /> Opp. Race Course, Mahalaxmi<br /> Mumbai 400034<br /> Represented by his Regional Manager<br /> <br /> 2. M/s. Orchid Voyage Pvt. Ltd.<br /> No. 4, First Floor<br /> ‘O’ Shaughnessy Road<br /> Langford Town<br /> Bangalore 560025<br /> Represented by his Proprietor Opposite Parties<br /> <br /> <br /> ORDER<br /> By the President Sri. S.S. Nagarale<br /> <br /> This is a complaint filed under section 12 of the Consumer Protection Act.<br /> The facts of the case are that opposite party No. 1 is subsidiary of the ICICI Banking Sector. Opposite party No. 2 is a private travel agent and authorized insurance agent. Complainant is a retired major in Indian Army. The second opposite party booked Air ticket of the complainant to travel USA by Lufthansa Airlines vide Ticket No. ETKT 220 591684035253 and also travel insurance from ICICI Lombard Travel Insurance Policy under Gold W 100 plan vide No. 4030/ 2385743/ 00/000 here after referred as Insurance company. The insurance policy covers the risk of complainant in the event of an accident or sudden illness or any other claim caused by a contingency from mid night 28th July 2006 to 23rd Jan 2007 midnight (for single Trip) or actual date of arrival which ever is earlier. The insurance covers medical treatments (included medical evacuation cost) up to USD 1,00,000/- and paid premium of amount of Rs. 28,487/-. The complainant during his stay at Boston, USA, on 19/11/2006 had suffered sever abdominal pain and discomforts, immediately he was taken to Massachusetts General Hospital No. 55 Fruit Street, Boston M.A. 02114 USA an authorized hospital of the Insurance company where he was admitted and treated for Epigastric discomfort, vide patient No. 4445876 and was discharged on the same day, with medical instructions to follow up service and consult Dr. Inglessis next day. Since complainant’s abdominal pain and discomforts persisted he was forced to under go further medical treatment as per the advice of the Medical Doctors and consultant Dr. Inglessis on 21/11/2006. As per his advice he underwent various investigations, tests and procedures. For the above treatment the service provider Massachusetts General Hospital submitted three Medical Invoices bill amounting to USD 10,735/- the same has been forwarded to insurance company for settlement. The complainant submits that he has received notice dated 11.03.2008 from OVAG International AG authorised collection agent of Massachusetts General Hospital asking to settle the outstanding amount of USD 7168.19 pending on the complainant’s account. As per the terms and conditions of the policy the opposite party should settle the entire claimed amount. The opposite party had settled only part of the claimed amount as under:<br /> Service Date Invoice date Invoice amount in USD Insurance allowed in USD Difference to be settle in USD<br /> 19/11/2006 24/01/2007 2695.00 989.00 1706.00<br /> 21/11/2006 24/01/2006 6911.00 1500.00 5411.00<br /> 21/11/2006 26/01/2006 1129.00 1129.00 0.00<br /> Grand Total 10735.00 3618.00 7117.00<br /> <br /> Complainant made several requests to opposite party and made representation to Insurance Ombudsman and Insurance Regulatory and Development Authority. In spite of all the efforts opposite party had failed to settle the amount due to the hospital. The Massachusetts General Hospital, USA through their collecting agent threatened complainant that they will initiate legal proceedings against complainant for not settling the medical bill. The opposite parties are negligent in settling the bills. This amounts to deficiency in service. Therefore, the complainant requested that opposite party be directed to pay USD 7117 to Massachusetts General Hospital, USA and complainant has prayed that opposite party be directed to pay liquidate damage of Rs. 2,00,000/-.<br /> 2. Notice issued to opposite party. The Opposite party No. 1 had appeared through advocate and opposite party No. 2 though served with notice has not appeared before this fora. Therefore, opposite party No. 2 is placed as exparte. Opposite party No. 1 has filed defence version admitting that travel insurance policy was issued in favour of the complainant. It is submitted by the opposite party No. 1 on verification of bills produced by the complainant the first opposite party has allowed the bill to the extent of USD 3618 as per the policy terms and condition. As per the applicable terms and conditions the opposite party has allowed the claim. Hence, the complaint is not maintainable. The liability of opposite party is limited. Opposite party has settled the claim as per the terms and conditions. Hence, there is no deficiency of service on the part of the opposite party. Therefore, the opposite party prayed to dismiss the complaint.<br /> 3. Affidavit evidences are filed.<br /> 4. Arguments are heard.<br /> 5. The points for consideration are:<br /> 1. Whether the opposite party can be directed to settle the claim and pay the hospital bills as per the bills of Massachusetts General Hospital, USA?<br /> 2. Whether the complainant is entitled for damages of Rs. 2,00,000/-?<br /> 6. I have gone through the documents, evidences produced by both the parties.<br /> 7. Complainant is a retired major of Indian Army. It is admitted fact that he had taken travel insurance policy of opposite party No. 1. The period of insurance is from 28.07.2006 to 23.01.2007. The complainant during his stay at Boston, USA was admitted to the hospital Massachusetts General Hospital vide patient No. 4445876. It is admitted case of the opposite party that he settled the claim and paid USD 3618 as against USD 10735. The complainant claimed balance amount of USD 7117. The learned advocate for the opposite party referred to us the terms and conditions applicable to benefit 1 medical expenses covered under the special conditions of ICICI Lombard Individual Travel Policy. The liability of the company is restricted to USD 100,000 per sickness, disease or accident sustained or contracted within the period of insurance whilst on the trip abroad that may lead to one or more medical expenses and / or hospitalization expenses. For persons aged 56 years and above, the limits are further restricted to maximum sum insured specified in para 1 of the schedule. The terms and conditions of the policy are as below:<br /> a. Hospital room and board and hospital misc. expenses – maximum USD 1,600 per day up to 30 days<br /> b. Intensive care unit – maximum USD 3,000 per day up to 7 days<br /> c. Surgical treatment – maximum up to USD 12,000<br /> d. Anesthetist services – up to 25% of surgical treatment<br /> e. Physician’s visit – maximum USD 75 per day up to 10 visits<br /> f. Diagnostic and pre-admission testing – maximum USD 750<br /> g. Ambulance services – maximum USD 500<br /> 8. As per the hospital records the complainant was admitted to the hospital first time on 19.11.2006. As per Annexure A (14)(a) produced by the complainant total charges of admission including Laboratory, Chemistry, Hematoloy, Chest X-ray, Emergency Ward is shown as USD 2695. Out of this Insurance Company has paid USD 989. Balance is USD 1706. As per the terms and conditions of the policy the opposite party No. 1 could have paid the entire bill. Nothing has been explained or shown in the defence version or affidavit of the opposite party that what was the basis. The opposite party No. 1 had admitted the claim only to the extent of USD 989. No reasons are forth coming for not allowing the entire bill. The terms and conditions clearly specify that for ICU maximum payable is USD 3,000 per day up to 7 days. In this bill USD 1,235 is charged for emergency ward. Therefore, it is within the limit of USD 3000. As per the policy conditions emergency ward and ICU can be considered as one and the same. In Indian terms or practice it may be called as ICU. In USA it may be called as emergency ward. Therefore, opposite party cannot take advantage of some change in using the term. Emergency ward and Intensive Care Unit may be one and the same. Therefore, the opposite party cannot deny to allow the entire claim because maximum limit is USD 3000 per day for Intensive Care Unit. Within that limit only the hospital has charged. The complainant has produced another disputed bill at Annexure A-16. As per this bill hospital total charges is USD 6911. The opposite party has made payment of USD 1469. Balance is USD 5441. As per this bill the complainant was admitted on 21.11.2006 and discharged on the same day. As per the terms and conditions of the policy the limit restricted to maximum for hospital room and board, and hospital miscellaneous expenses USD 1600 per day up to 30 days. The opposite party No.1 has paid USD 1469 for bill A-16. The balance to be paid USD 5441. As per terms and conditions of the policy the opposite party has to pay USD 1600 per day for hospital room and board, and hospital miscellaneous expenses and diagnostic and pre-admission testing maximum USD 750 i.e. 1600 + 750 = USD 2350. The complainant was admitted on 21.11.2006 and discharged on the same day. Admittedly, there is no surgical treatment to the complainant and there was no anaesthetist service and even it is not the case of the complainant for physician’s visit. Therefore, the complainant is not entitled for any amount under surgical treatment, Anaesthetist services. Only admissible amount payable by opposite party under the bill Annexure A-16 is for one day admission to the hospital and diagnostic and pre-admission testing USD 750. In this way the opposite party could have paid USD 2350 under bill A-16. But inspite of that the opposite party paid USD 1469. The balance payable would be USD 882. Taking into consideration of the terms of the policy I am of the opinion that complainant is entitled for USD 2350 under Annexure A 16 bill and the complainant is entitled USD 1726 under bill Annexure A-14. In this way the total amount payable by the opposite party No. 1 comes to USD 5045. As per the case of the opposite party it has allowed the claim to the extent of USD 3618 including undisputed bill amount of USD 1129. So the Balance payable comes to USD 1726 + USD 882 = USD 2608. The opposite party shall have to be directed to pay USD 2608 to the hospital. Taking into consideration of the facts and circumstances, all the documents, complaint and terms and conditions of the policy the liability of the opposite party No. 1 will be USD 2608. The complainant has claimed Rs. 2,00,000/- as compensation. But there is no basis to claim the compensation. Therefore, the claim of the complainant for compensation is rejected. In the result I proceed to pass the following:<br /> ORDER<br /> 9. The Complaint is partly allowed. The opposite party No. 1 is directed to pay USD 2608 to Massachusetts General Hospital, PO Box 9693, Boston, USA within 30 days from the date of this order.<br /> 10. The complainant is entitled for Rs. 3,000/- as costs of the present proceedings from the opposite party No. 1.<br /> 11. Send the copy of this Order to both the parties free of costs immediately. <br /> 12. Pronounced in the Open Forum on this 30TH DAY OF MAY 2009. <br /> Order accordingly,<br /> <br /> <br /> PRESIDENT<br /> We concur the above findings.<br /> <br /> <br /> MEMBER MEMBER<br />