PER SHRI.S.B. DHUMAL – HON’BLE PRESIDENT.
1) In brief consumer dispute is as under -
That Complainant had obtained Overseas Mediclaim Policy known as Vides Yatra Mitra Policy bearing No.2001/122000/46/01/80013 plan type g from the Opposite Party No.1 on payment of premium of Rs.4,648/-. The policy was for the period from 12/04/01 to 06/06/2001. The said policy known as Vides Yatra Mitra World Wide including USA and Canada, alongwith the complaint, the Complainant has produced photo copy of the said policy, copy of receipt of payment premium and terms and conditions of the said policy alongwith important slip annexed to the policy. Under the said policy the Opposite Party had given separate insurance cover for illness & accident, personal accident, loss of checked baggage, delay of checked baggage, loss of personal liability etc. In the complaint para No.5 the Complainant has given particulars of insurance cover given by the Opposite Party No.1 and name & address of doctors and clinic.
2) It is the case of the Complainant that since, the Complainant was feeling uneasy during the flight from Singapore to Mumbai on 05/06/2001, immediately on arrival he was taken to the clinic of Dr. P.K. Maheshwari, Consulting Physician and Cardiologist. After his arrival on 06/06/01, E.C.G. was taken out and it was revealed that the attack in fact had taken place on 03/06/01 in Singapore flight. After ECG the Complainant and advised immediate hospitalization. However, by way of abundant caution the Complainant decided to take a second opinion of Dr. Jamshed J. Dalal. The prognosis proved the same and the Complainant was admitted to the Intensive Care Unit of Lilavati Hospital and Research Center of Bandra Mumbai. On 08/06/2001, a operation was conducted by Dr. Jamshed J. Dalal on the Complainant for angiography and angioplasty. On 12/06/2001, Complainant was discharged from the hospital. The Complainant has paid hospital bill for his treatment amounting to Rs.2,58,745/-. The follow up treatment continued till filing of this complaint which cost the Complainant approximately Rs.22,000/- per month initially and thereafter Rs.10,000/- per month.
3) On 04/09/01 Opposite Party No.1 provided claim form to the Complainant which was duly filled up and submitted the same with relevant certificates, papers and documents to Opposite Party No.2 through Opposite Party No.3. Subsequently Complainant received letter from Opposite Party No.2 and by the said letter Complainant’s claim was rejected. It is alleged by the Complainant that the Opposite Party have malafide and without application of mind have rejected his genuine claim. Thereafter, from time to time the Complainant wrote letters to Opposite Party No.1 & 2 but there was no response. So on 24/12/01, the Complainant sent letters to Opposite Party through his advocate. Opposite Parties did not reply to his notice therefore, the Complainant has filed his complaint. Initially the Complainant had filed this complaint before Hon’ble Consumer Disputes Redressal Commission, Maharashtra State, Mumbai and it was numbered at 286/2002. On 07/04/2005, the Hon’ble President of State Commission passed order to return the complaint to the Complainant for being presented before appropriate Forum. Thereafter, the Complainant had filed this complaint before this Forum.
4) The Complainant has requested to direct Opposite Parties to pay to the Complainant an amount of Rs.2,58,745/- spent by him towards his hospitalization and treatment. The Complainant has claimed Rs.1,00,000/- as compensation towards the loss of interest. Further he has prayed to direct Opposite Parties to pay Rs.2,00,000/- as a damages caused due to mental torture and agony and Rs.10,000/- towards the cost of transportation. Alongwith complaint the Complainant has produced document at Exh. ‘A’ to ‘C’ & affidavit of evidence in support of complaint.
5) Opposite Party No.1 has filed written statement and thereby resisted claim of the Complainant contending that there is no deficiency in service on the part of Opposite Party No.1. It is submitted that complaint is false and frivolous and therefore, complaint is liable to be dismissed with cost. It is further submitted that in the contract between Complainant and Opposite Party No.1 there is a provision to refer dispute to the arbitrator and therefore, this Forum has no jurisdiction to entertain and try this complaint. It is further alleged that dispute between the parties is a commercial nature and therefore, the Complainant is not entitle for any protection under the Consumer Protection Act, 1986.
6) Opposite Party No.1 has admitted that the Complainant had applied to the Opposite Party No.1 for a Overseas Mediclaim Policy and paid premium of Rs.4,648/- While applying for the said policy the Complainant had entered into an agreement with Opposite Party No.1 and so also Complainant had been provided a important slip covering all the terms, conditions, rules which are binding on the parties. The Opposite Party has recited the general conditions applicable to all sections stated in the policy in written statement para no.7.
7) It is submitted that it is a condition president to liability hereunder that in the event of any occurrence likely to give rise to a claim under this Insurance, that the Insured person or his representative must notify ‘Coris’ immediately. The Insured person or his representative should quote ‘Coris’ as much information concerning the illness, accident or occurrence as is available, including the name of treatment doctor, name and telephone of the hospital, CMP Policy No. and its date of issue.
8) It is submitted by Opposite Party No.1 that this is policy is not general health Insurance Policy. Coverage under the medical expense section of this Insurance is intended for use by the Insured person in the event of sudden and unexpected sickness or accident arising when the Insured person is outside the Republic of India. No claim will be paid in respect of medical treatment and related services obtained within the Republic of India.
9) Opposite Party No.1 has denied each and every allegation made in the complaint. It is submitted that as per the Complainant attack had taken place on 3rd June, 2001 in Singapore and therefore, the Complainant would have taken proper medical treatment at Singapore but certainly not in India, which is against the guidelines and conditions laid down in the said Insurance Policy.
10) It is submitted by Opposite Party No.1 that the Complainant has committed breach of several terms and conditions of the policy and therefore, the Opposite Party is not liable to reimburse the hospitalization expenses incurred by the Complainant. Further Opposite Party No.1 is not liable to pay any compensation or cost of this proceeding to the Complainant and therefore, the complaint deserves to be dismissed with cost.
11) Notice of this complaint sent to Opposite Party No.2 but it was returned un-serve. Thereafter, the Complainant on 13/05/2010 requested to grant permission to delete name of Opposite Party No.2 from the complaint. Accordingly permission was granted and name of Opposite Party No.2 deleted from the complaint.
12) Opposite Party No.3 has filed application for discharge contending that Opposite Party No.3 has not issued any policy to the Complainant. There is no privity of contract between Complainant and Opposite Party No.3. Complainant is not a consumer of Opposite Party No.3 and therefore, complaint should be dismissed against Opposite Party No.3.
13) It is submitted that Opposite Party No.3 are only claim forwarding/servicing agent of Opposite Party No.1 and/or 2 (essentially for correspondence). Opposite Party No.3 are only assisting in dealing with the claims through Mercury, arising out of Overseas Mediclaim Policy issued by Opposite Party No.1. Opposite Party No.3 has no authority to pass any claim and Opposite Party No.3 are also not liable to pay any claim. Opposite Party No.3 are not party to the contract of insurance.
14) According to Opposite Party No.3, only the hospitalization in a foreign country is covered under the present mediclaim policy. The Complainant is claiming reimbursement for hospitalization in Lilavati Hospital, Bandra, Mumbai. The same is not covered under this policy. Hospitalization after completion of voyage/return to India is not covered under Overseas Mediclaim Policy. It is submitted that Opposite Party No.3 is not liable to pay any sum to the Complainant, contending that Opposite Party No.3 is not Claim settling agency of Opposite Party No.1. Opposite Party No.3 has denied allegation that Complainant’s claim was rejected malafide and without application of mind. It is alleged that Complainant is misleading this Forum. Overseas Mediclaim Policy taken by the Complainant terminates automatically on completion of voyage. Therefore, according to Opposite Party No.3 complaint deserves to be dismissed with cost.
15) Complainant has filed affidavit of evidence. On 16/07/2010, Complainant has produced copy of letter dtd.17/09/01 received from Opposite Party No.3 and copy of letter dtd.19/11/01 received from Opposite Party No.2. The Complainant has filed written argument. The Opposite Party No.1 & 3 has also filed their respective written arguments. On 01/07/2011, Opposite Party No.3 has passed pursis that their written argument may be treated as oral argument. Heard oral submissions of Ld.Advocate Tarsem Singh for Complainant and Ld.Advocate Mr. Bhandari for Opposite Party No.1.
16) Following points arises for our consideration and our findings thereon are as under -
Point No.1 : Whether the Complainant has proved deficiency in service on the part of Opposite Party ?
Findings : No
Point No.4 : Whether the Complainant is entitled for relief from Opposite Parties as prayed for ?
Findings : No
Reasons :-
Point No.1 :- Following facts are admitted fact that the Complainant obtained Overseas Mediclaim Policy known as Vides Yatra Mitra Policy World Wide including USA & Canada, bearing No.2001/122000/46/01/80013 plant type g from the Opposite Party No.1 on payment of premium of Rs.4,648/-. The Complainant has produced photo copy of the aforesaid policy. The policy period was from 12/04/2001 to 06/06/2001. Policy sum assured for illness & accident is US$ 5,00,000, personal accident US$ 25,000, etc. It is stated in the policy that it is subject to specific exclusion of all medical expenses incurred directly due to the excluding Disease Diabetes.
It is the case of the Complainant that he was feeling uneasy during the flight from Singapore to Mumbai on 05/06/01, immediately on arrival at Mumbai he was taken to clinic of Dr. P.K. Maheshwari, Consulting Physician and Cardiologist on 06/06/01. The ECG was taken out and it was revealed that the attack in fact had taken place on 03/06/01 in Singapore flight. It is submitted that by way of abundant caution decided to take second opinion of Dr. Jamshed J. Dalal, Cardiologist. The prognosis proved the same and the Complainant was admitted in the Intensive Care Unit at Lilavati Hospital and Research Centre of Bandra, Mumbai. On 08/06/01, the operation conducted by Dr. J.J. Dalal on the Complainant for Angiography and Angioplasty. On 12/06/06, the Complainant was discharged from the hospital. For medical treatment in the hospital the Complainant spent Rs.2,58,745/-. After discharge form the hospital follow up treatment continued till filing of this complaint. Initially cost of follow up treatment was approximately Rs.22,000/- per month and thereafter, Rs.10,000/- per month. Under the aforesaid Videsh Yatra Mitra, vide policy the Complainant has claimed recovery of medical expenses of Rs.5,68,745/- from the Opposite Party.
According to the Complainant, Opposite Party No.2 is Claim Settling Agency of Opposite Party No.1 and Opposite Party No.3 has entered into correspondence with the Complainant. According to the Complainant, on 04/09/01, he dully filled-up claim form provided by Opposite Party No.1 and submitted the same with relevant certificate, papers & documents through Opposite Party No.3 to Opposite Party No.2. Opposite Party No.2 has unilaterally dismissed the claim of the Complainant. Ld.Advocate for the Complainant has submitted that Opposite Parties have wrongly rejected genuine claim of the Complainant and therefore, the Complainant was compelled to file this complaint. Ld.Advocate for the Complainant has submitted that the Complainant was feeling uneasy during flight from Singapore to Mumbai on 05/06/01 and therefore, immediately after arrival i.e. on 06/06/01, he was taken to the clinic of Dr. P.K. Maheshwari, Consulting Physician & Cardiologist. ECG was taken that it was revealed that Complainant was attack in fact had taken place on 03/06/01 in Singapore Flight. Therefore, according to the Complainant’s advocate the Complainant as per the terms and conditions of the policy, is entitle for reimbursement of the medical expenses of Angiography & Angioplasty incurred at Lilavati Hospital.
Ld.Advocate for the Opposite Party No.1 has submitted that as per the terms and conditions of the policy, the Complainants claim is not maintainable and therefore, Opposite Parties has rejected the his claim. It is submitted that as per the general conditions applicable to all sections, the policy would be valid only if the Insured journey commences within 14 days of first day of insurance as indicated in the policy. In this case the policy period was commenced on 12/04/01 and for the seek, the Complainant’s contention that on 3rd June, he suffered heart attack in Singapore. Even then there is absolutely no evidence on record to show that the Complainant had commenced journey within 14 days of the first day of insurance as indicated in the policy schedule. Further Ld.Advocate has submitted that the Complainant has not produced medical case papers regarding his medical treatment and documentary proof of medical expenses incurred by him. By referring to the terms and conditions of the policy, it is pointed out that nature coverage provided under the policy is that this policy is general condition applicable to all sections stated in the policy in clause no.10A. It is stated that “this policy” is not general health insurance policy. Coverage under the medical expenses section of this insurance is intended for use by Insured person in the event of a sudden and unexpected sickness or a accident arising when the Insured is outside the republic of India.
It is submitted on behalf of the Opposite Party that in the instance case, it is averred by the Complainant that on 06/06/01 over the Complainant ECG was taken on clinic of Dr. P.K. Maheshwari. Even that the Complainant has alleged that Complainant’s day first heart attack on 03/06/01 in Singapore flight. It is undisputed fact that the Complainant has not taken any medical treatment in Singapore or outside republic of India. Further it is reveals that even for the sake of argument the Complainant contention that on 06/06/01 when ECG was taken it reveals he had heart attack on 03/06/01 in Singapore. It appears that Complainant was not aware till ECG was taken on 06/06/01 he had heart attack. After arrival form Singapore on 06/06/01, the Complainant had taken ECG and thereafter he consulted Dr. J.J. Dalal. Then Complainant was admitted in Lilavati Hospital. The Complainant had not produced discharge summery/card or medical case papers. In support of his contention on 08/06/01 Angiography and Angioplasty done by Dr. J.J. Dalal and he was discharged on 12/06/01. It was possible to the Complainant to produce aforesaid documents before this Forum. Ld.Advocate for Opposite Party No.1 has submitted that very purpose of the Vidhesh Yatra Mitra Policy is to asses the Insured passenger to solve his problem while travelling overseas. If the Complainant had suffered heart attack on 03/06/01 in Singapore, then the Complainant would have taken medical treatment at Singapore.
Ld.Advocate for the Opposite Party has further pointing out special condition no.7 in the policy which is as under -
“No claim will be paid in respect of medial treatment and related services obtained within the Republic of India except as stated under Cover Expenses.” It is submitted on behalf of Opposite Party that this medical policy is not like general health insurance policy and therefore, claim for expenses incurred for medical treatment taken within the Republic of India is not maintainable except cover.
It is submitted that Complainant submitted his claim to Opposite Party No.2 through Opposite Party No.3. At fug at the trial the Complainant has produced copy of letter dtd.14/09/01 received from Opposite Party No.3 which is and copy of letter dtd.19/11/01 received from Opposite Party No.2. Opposite Party No.3 vide letter dtd.13/09/01 informed the Complainant that they have send papers submitted by the Complainant to Mercury International Assistant (Opposite Party No.2), a Claim Settling Agency. In the letter Opposite Party No.3 has pointed out specific condition no.3 which is as under –
“No claim will be paid in respect of expenses for treatment which could reasonably be delayed until the Insured person’s return to Republic of India. The question what can or what cannot be reasonable delayed will be decided jointly by the treating physician and the Medical Advisor.”
Opposite Party No.2 by letter dtd.19/11/2001 rejected claim of the Complainant stating that the policy covers treatment that cannot be deleted until you are returned to India. On this action it appears that the treatment could be delayed and therefore, this would not be covered.
In this case as mentioned above, the Complainant has not adduced evidence that his journey commenced within 14 days of first day of insurance as indicated in the policy. The Complainant has not adduced medical case papers or medical evidence to support his contention that on 3rd June, 01 he had suffered heart attack. Even according to the Complainant for the first time after ECG was taken on 06/06/01 at the clinic of Dr. P.K. Maheshwari, but there is reliable evidence to his contention. The Complainant has not contacted the Doctor and Clinic mentioned in the policy. As per the Complainant he was operated in Lilavati Hospital as Angiography and Angioplasty was conducted by Dr. J.J. Dalal. Angiography and Angioplasty was taken after expiry of mediclaim policy. Opposite Party No.2 Mercury International has not recommended claim of the Complainant but rejected the claim vide its letter dtd.19/11/2001. It appears that the Opposite Parties have repudiated claim as per the terms and conditions of the policy. Name of Opposite Party No.2 is deleted by the Complainant. There is no privity of contract between the Complainant and Opposite Party No.3 and it appears that Opposite Party No.3 has acted as claim forwarding agency for Opposite Party No.1 & 3. Considering evidence on record we hold that the Complainant has failed to prove deficiency in service on the part of Opposite Parties. Hence as a result we answer point no.1 in the negative.
Point No.1 :- As discussed above the Opposite Parties have rejected claim of the Complainant. In accordance with the terms and conditions of Videsh Yatra Mitra Policy, the Complainant has failed to prove deficiency in service on the part of Opposite Parties. Therefore, we hold that the Complainant is not entitled to hospital expenses form the Opposite Party or any other relief from the Opposite Party. Hence, we answer point no.2 in the negative.
For the reasons discussed above, complaint deserves to be dismissed. Hence, we pass following order -
O R D E R
i.Complaint No.124/2005 is hereby dismissed.
ii.No order as to cost.
iii.Certified copies of this order be furnished to the parties.
