Date of filing:      04.07.2019

                                                                                                                                   Date of disposal:31.01.2023

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

THIRUVALLUR

 

 BEFORE  TMT. Dr.S.M. LATHA MAHESWARI, M.A.,M.L, Ph.D (Law)                    .…. PRESIDENT

               THIRU P. MURUGAN. M.Com., ICWA(Inter), B.L.,                                 ….. MEMBER-II

 

RBT/CC. No.111/2022

THIS TUESDAY, THE 31th DAY OF JANUARY 2023

(CC.No.47/2019 sent from DCDRC, Chennai North)

 

Dr.V.Purushothaman, S/o.V.Ellayya,

No.9/2, Golden Treasure Apts,

Vanagaram to Ambattur Main Road,

Adayalampattu, Chennai 600 095.                                                   ……Complainant.     

                                                                          //Vs//

 

M/s.Bajaj Allianz General Insurance Company Limited,

Rep. by its Manager,

No.497/498, 5th Floor,

Isana Kattima Building,

Poonamallee High Road,

Arumbakkam, Chennai 600 0106.                                           .......Opposite parties. 

 

Counsel for the complainant                                   : M/s.V.Rengarajan, Advocate.

Counsel for the opposite parties                            :  M/s.M.B.Gopalan Associates.

                         

This complaint has been filed before DCDRC, Chennai (North) as CC.No.104/2019 and transferred to this commission by the order of the Hon’ble State Consumer Disputes Redressal Commission, Chennai and taken on file as CC.No.111/2022 and this complaint coming before us on various dates and finally on 23.01.2023 in the presence of M/s.V.Rengarajan, Advocate for the complainant and M/s.M.B.Gopalan Associates  counsel for the opposite party  and upon perusing the documents and evidences of both sides, this Commission delivered the following: 

ORDER

PRONOUNCED BY TMT. Dr.S.M. LATHA MAHESWARI,   PRESIDENT.

 

This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act, 1986 alleging deficiency in service in repudiating the insurance claim citing the exclusion clause along with a prayer to direct the opposite party to settle the claim of the complainant in respect of the "Travel Insurance Travel age elite Policy" No.OG-18-1501- 9910-00000306 issued on 07.4.2017, covering the period from 09.4.2017 to 07.6.2017 and extended policy covering period from 08.6.2017 to 21.8.2017 issued by Bajaj Allianz Insurance Company Limited,  to pay a sum of Rs.11,11,390/- equivalent to US$ 15877/- together with interest @ 12% p.a. from 22.06.2017 till date of payment and to pay a further sum of Rs.5,00,000/ towards compensation for suffering of mental agony and torture with interest @ 12% p.a. till date of payment. 

Summary of facts culminating into complaint:-

 

The complainant submits that in connection with his proposed tour to United State of America, he took "Travel age elite Policy with the Opposite party for his Travel to United State of America, covering the period from 09.4.2017 to 07.6.2017 and he was issued with Policy No.OG-18-1501-9910-00000306 on 07.4.2017 and another extended Policy issued on 03.6.2017 for the period 08.6.2017 to 21.8.2017. The complainant was specifically told that the said policy assured Cashless Benefit Geographical Coverage for Medical treatment throughout the world especially United States of America and Canada. The complainant particularly preferred this policy since it was assured cashless medical treatment in times of exigencies and it was expressly stated in the policy Kit also and also that in case of any treatment availed by the complainant in any hospital or medical centre in United State of America and Canada, all expenses for the treatment would be paid by the Opposite party up to a limit of US $ 50,000/-. He stayed in United Sates of America from 09.04.2017 to 20.08.2017. During his stay at United States of America in Irving, he suffered injury in the spine resulting in severe back pain and he needed immediate medical care. Complainant immediately contacted the overseas assistance department of the Opposite party over phone No. 186 658 76903 for guidance. But he did not succeed in his attempt. The complainant therefore sent an e-mail on 05.06.2017 to the Chennai office of the Opposite party about the illness before resorting to any treatment. The complainant visited the State run hospital viz. UT Southwestern University Hospital and they were not willing to accept Bajaj Allianz Policy for giving cash less treatment. The complainant attempted to get treatment with other 'Back Pain clinics' in Irving. But none of them were willing to give the complainant even an appointment for consultation except Dr. Steve, a Physician, for the simple reason that they were not willing to accept the 'Bajaj Allianz Policy for cash-less treatment. Though the said Physician gave the complainant an appointment, he informed that the complainant would need surgical intervention which would cost more than US $1,50,000/- and he was also not prepared for Bajaj Policy for cash-less treatment. He therefore advised the complainant to go for chiropractic treatment and orally referred the complainant to Maximal Health Centre at Irving. Fortunately, Maximal Health Centre was considerate in giving treatment on partial cash payment and the balance to be paid after clearance by the Insurance Company. Accordingly, the complainant received treatment at Maximal Health Centre on 05.06.2017 and he got immediate relief from the ailment. After receiving necessary treatment, Maximal Health Centre raised a bill for US $15877/-out of which the complainant paid US $3000/- in cash. Complainant preferred a claim on 22.06.2017 along with all required documents to the Opposite Party viz. M/s. Bajaj Allianz General Insurance Company Limited. But by e-mail dated 03.10.2017 issued by the opposite party, his claim was repudiated. The complainant therefore escalated the issue to the next level on 08.11.2017 by giving a detailed account of the sequence of events and the perceptions about the 'chiropractic treatment‘. However, the same was once again repudiated on 08.12.2017 on the same ground that the Policy does not cover 'chiropractic treatment‘. The complainant therefore once again represented on 24.12.2017 and 10.02.2018 seeking reconsideration in the light of the fact that 'chiropractic treatment' is also very popular in USA and 'chiropractic treatment' is also covered by several insurance companies in USA. But, ultimately, they have expressed via e-mail dated 17.03.2018 that the claim stands repudiated on the ground that the Policy did not cover expenses incurred towards any treatment arising out of or traceable to any system other than allopathic mode of treatment and that Chiropractic mode of treatment does not come under modern medicine/Allopathy. Complainant submits that clause 2.4.10 of the policy excludes treatment by any other system other than modern medicine (also known as Allopathy). But there is no explicit exclusion of 'Chiropractic treatment‘. As could be seen, the procedure for the treatment relies upon X-ray and scan and other related diagnostic procedures which were procedures regularly relied upon by 'allopathy' system. In particular, 'chiropractic treatment' is not another system of medicine like Homeopathy, Ayurveda or Siddha form of medicine. Chiropractic treatment is also dependent of Allopathic procedures and it cannot be treated as a different system of medicine and therefore the claim of the applicant cannot be repudiated entirely on this ground. If the policy does not cover 'chiropractic treatment' it should have been mentioned specifically in the Policy document. In the absence of any such explicit exclusion, the claim of the complainant for the expenses incurred in receiving treatment for physical ailments caused by accident cannot be repudiated in its entirety. The opposite party has thus misled the complainant about the acceptance of the Policy throughout USA and having collected a hefty premium, the opposite party has acted arbitrarily in repudiating a genuine claim without ever taking positive steps to provide the right guidance and support in moments of distress. Thus aggrieved by the act of the opposite party the present complaint was filed to direct the opposite party to settle the claim of the complainant in respect of the "Travel Insurance Travel age elite Policy" No.OG-18-1501- 9910-00000306 issued on 07.4.2017, covering the period from 09.4.2017 to 07.6.2017 and extended policy covering period from 08.6.2017 to 21.8.2017 issued by Bajaj Allianz Insurance Company Limited,  to pay a sum of Rs.11,11,390/- equivalent to US$ 15877/- together with interest @ 12% p.a. from 22.06.2017 till date of payment and to pay a further sum of Rs.5,00,000/ towards compensation for suffering of mental agony and torture with interest @ 12% p.a. till date of payment.

Crux of defence made by the opposite party:-

The opposite party filed version disputing the allegations contending interalia that the claim of the complainant was repudiated on 30.06.2017 and the same was reiterated by email on the same day but the complainant had suppressed the repudiation letter. It was further submitted that the complaint was filed on 04.07.2019 more than 2 years after the repudiation of claim and thus the complaint was filed time barred. The complainant had approached the Ombudsman before filing the complaint.  The Ombudsman had examined the Policy terms and the nature of treatment and concluded that the claim was clearly excluded. It was submitted that the complainant obtained Travel age Elite Silver Policy No.OG-18-1501-9910-00000306 for a period of 09.04.2017 to 07.06.2017 to cover his stay in the USA during the period.  The coverage under the policy pertains to overseas travel and was strictly subject to terms, conditions and exclusions mentioned in the policy.  Under the policy expenses incurred for treatments other than modern medicines were not covered under the policy vide Exclusion clause 2.4.10 which clearly states as “Treatment by any other system other than modern medicine (also known as ALLOPATHY)”. While complainant was in the US, he reported claim for treatment of spinal injury at Maximal Health Centre, Irving. As per the medical records of Maximal Health, LLC insured was diagnosed with a Segmental and somatic dysfunction of cervical region, b) Segmental and somatic dysfunction of thoracic region, c) Segmental and somatic dysfunction of lumbar region, d) Radiculopathy, lumbosacra region. Medical documents produced by complainant reveals that he had taken chiropractic treatment, and it further shows that he does not have a document to show reference given by any doctor to take chiropractic treatment. Medical document reveals that expenses incurred towards chiropractic treatment. The policy issued by them does not extend coverage for any expenses incurred towards any treatment arising out of or traceable to any system other than allopathic mode of treatment.  Hence claim made by the complainant was repudiated under exclusion clause No.2.4.10. The medical records revealed that the complainant underwent spinal decompression which was chiropractic treatment without the involvement of any medicine or drug.  Also the physician consulted by the complainant Dr.Jason Black was a licensed chiropractic and not a Physician as defined under the policy.  No allopathic treatment was involved.  Since chiropractic is a science of healing without drugs and involves therapy, especially manipulation of the spine, other joints and soft tissues and may also include exercises and healthy lifestyle counseling, it is more similar to physical therapy, osteopathy.  It clearly does not involve the use of modern medicines/allopathic treatment.  Hence the claim for such treatment was totally outside the coverage of the policy and the opposite party justifiably repudiated the same by letter dated 30.06.2017. Thus they sought for the complaint to be dismissed. 

The complainant had filed proof affidavit and submitted documents Ex.A1 to Ex.A10 were marked on their side.  On the side of opposite party proof affidavit was filed and submitted documents Ex.B1 to Ex.B7 was marked on their side. 

Points for consideration:

Whether the act of opposite party in repudiating the insurance claim citing the exclusion clause amounts to deficiency in service?

If so to what reliefs the complainant is entitled?

Point:1

On the side of the complainant the following documents were filed in support of the complaint allegations;

Policy issued by the opposite party for the period from 09.04.2017 to 07.06.2017 was marked as Ex.A1;

Policy issued by the opposite party for the period from 08.06.2017 to 21.08.2017 was marked as Ex.A2;

Extract of the brochure issued by the opposite party with reference to the policy was marked as Ex.A3;

Copy of the intimation sent by the complainant to the opposite party through email dated 05.06.2017 was marked as Ex.A4;

Hospital bills relating to the treatment received during the period from 05.06.2017 to 17.08.2017 was marked as Ex.A5;

Copy of the claim preferred by the complainant to the opposite party dated 22.06.2017 was marked as Ex.A6;

Copy of email sent by UT southwestern Medical Centre Dallas TX 75247 dated 22.07.2017 was marked as Ex.A7;

 Copy of email sent by opposite party repudiating the claim of the complainant dated 03.10.2017 was marked as Ex.A8;

Copy of the representation given by the complainant seeking reconsideration was marked as Ex.A9;

Copy of email sent by opposite party repudiating the claim of the complainant dated 17.03.2018 was marked as Ex.A10;

On the side of opposite party the following documents were filed in support of their contention;

Copy of Policy with terms and conditions was marked as Ex.B1;

Copy of claim Form was marked as Ex.B2;

Copy of Medical Documents was marked as Ex.B3;

Copy of repudiation letter dated 30.06.2017 was marked as Ex.B4;

Complaint before Ombudsman was marked as Ex.B5;

Reply of the opposite party before Ombudsman dated 08.01.2019 was marked as Ex.B6;

Ombudsman Award dated 28.03.2019 was marked as Ex.B7;

 The crux of the oral arguments adduced by the learned counsel appearing for the complainant is that the complainant took a travel insurance policy No.OG-18-1501-9910-00000306 covering the period from 09.04.2017 to 07.04.2017 during his travel to USA.  The complainant took the policy on assurance that the policy gives cashless benefit for medical treatment throughout the world especially USA & Canada.  During the stay in USA as he suffered injury in the spine resulting in severe back pain he contacted the overseas assistance department of the opposite party for guidance but he could not contact them and hence he sent an email to the Chennai Office.  After several efforts one maximum health care centre gave necessary treatment on partial cash payment and the balance to be paid by the insurance company.  With all required documents he approached the opposite party, but his claim was repudiated on the ground that the policy does not cover chiropractic treatment which is a very popular in USA and which treatment was covered by several insurance companies in USA.  He argued that the chiropractic treatment is very popular treatment which depends upon procedures like X-ray and scan and other similar procedures as in Allopathy system.  Further it is not a treatment similar to Homeopathy, Siddha, Ayurveda etc. Thus he sought for the complaint to be allowed as prayed for.

On the other hand, the opposite party argued that the complainant as per medical records underwent Spinal Decompression which is a chiropractic treatment without any medicine or drug.  Also the physician consulted by the complainant Dr.Jason Black is a licensed chiropractic practitionerand not a physician as defined under the policy.  No Allopathic treatment was involved.  Thus arguing that the said treatment was not covered under the policy, the counsel sought for the dismissal of the complaint.

We perused the pleadings and materials. It is apparently seen that under the exclusion clause of the policy Ex.A3/ Ex.B1 it has been specifically provided under clause 2.4.10 that 

“the company shall be under no liability to make payment hereunder of any claim directly or indirectly caused by based on arising out of or howsoever attributable to any of the following “treatment by any other system other than modern medicine (also known as Allopathic)”. 

 Even as per complainant his own version the treatment chiropractic is not a system of Allopathic or modern medicine.  Thus in such circumstances repudiation of policy relying upon the exclusion clause 2.4.10 could not termed as deficiency in service  when the complainant failed to produce any literature or any other evidence to show that the chiropractic  treatment comes within modern medicine.   As the parties are bound by the contract of insurance and as the terms and conditions are agreed upon by both parties, the complainant cannot reap out any benefit in violation of the admitted terms and conditions.  Thus we answer the point holding that there is no deficiency in service on the part of opposite party.

Point No.2:-

As we have held above that the complainant failed to prove the opposite party had committed any deficiency in service to the complainant, he is not entitled any relief from the opposite party.

In the result, the complaint is dismissed.  No order as to cost.  

Dictated by the President to the steno-typist, transcribed and computerized by him, corrected by the President and pronounced by us in the open Commission on this the 31th day of January 2023.

 

    Sd/-                                                                                                              Sd/-

  MEMBER-I                                                                                               PRESIDENT

 

List of document filed by the complainant:-

 

 

Ex.A1 07.04.2017 Policy issued by the opposite party for the period from 09.04.2017 to 07.06.2017 Xerox

Ex.A2 03.06.2017 Policy issued by the opposite party for the period from 08.06.2017 to 21.08.2017. Xerox

Ex.A3 .............. Extract of the brochure issued by the opposite party with reference to the policy. Xerox

Ex.A4 05.06.2017 Copy of the intimation sent by the complainant to the opposite party through email. Xerox

Ex.A5 05.06.2017 Hospital bills relating to the treatment received during the period from 05.06.2017 to 17.08.2017. Xerox

Ex.A6 22.06.2017 Copy of the claim preferred by the complainant to the opposite party. Xerox

Ex.A7 22.07.2017 Copy of email sent by UT southwestern Medical Centre Dallas TX 75247. Xerox

Ex.A8 03.10.2017 Copy of email sent by opposite party repudiating the claim of the complainant Xerox

Ex.A9 08.11.2018

24.12.2017

10.02.2018 Copy of the representation given by the complainant seeking reconsideration Xerox

Ex.A10 17.03.2018 Copy of email sent by opposite party repudiating the claim of the complainant Xerox

 

List of document filed by the Opposite party:-

 

 

    Ex.B1 .............. Policy with terms and conditions. Xerox

Ex.B2 22.06.2017 Claim Form. Xerox

Ex.B3 ............ Medical Documents. Xerox

Ex.B4 30.06.2017 Repudiation Letter. Xerox

Ex.B5 ............ Complaint before Ombudsman. Xerox

Ex.B6 08.01.2019 Reply of the oppostie party before Ombudsman. Xerox

Ex.B7 28.03.2019 Ombudsman Award. Xerox

 

 

      -Sd-                                                                                                               -Sd-

MEMBER-II                                                                                                    PRESIDENT