DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Rajinder Mohan Mehta, #3464, Sec.38/D, Chandigarh.

                   ---Complainant

Vs

[1]  Sheetal Travels, SCO No. 154-156, Opp. D.C. Office, Sector 17-C, Chandigarh.

[2]  The Oriental Insurance Company Limited, Division IX, Empire House 214 D.N. Road, Fort, Mumbai – 400023.

---- Opposite Parties

BEFORE:    SH.LAKSHMAN SHARMA              PRESIDENT

MRS.MADHU MUTNEJA               MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Complainant in person.

Sh. Barjesh Mittal, Counsel for Opposite Party No.1.

Sh. Rajesh Verma, Counsel for Opposite Party No.2.

PER MADHU MUTNEJA, MEMBER

1.        The instant complaint relates to non-payment of medical insurance claim by the Opposite Party No.2 to the Complainant and his wife.

          Factually speaking, the Complainant had purchased air tickets from Opposite Party No.1 for himself and his wife for travel to Canada. He had also obtained an insurance policy from Opposite Party No.2 for himself and his wife to cover the risk of belongings, life and medical reimbursement, for the aforesaid trip. The Complainant had paid Rs.14965/- and Rs.9,346/- for the two policies issued in the name of Complainant and his wife. An additional sum of Rs.6,922/- was also paid by the wife of the Complainant when she extended her stay.

          The Complainant has stated that during the stay at Canada, they had to undergo medical treatment, for which an expenditure of $167.73 and $149.26 were incurred by the Complainant and his wife. Bills and payment receipts have been placed on record. The Complainant has alleged that the insurance was done within 15 minutes, but when claim was filed, the Opposite Parties have not reimbursed the amount payable.  The Complainant has filed this Complaint with a prayer that the Opposite Parties be directed to reimburse the medical claim, along with interest, besides compensation and cost of litigation.

2.        After admission of the complaint, notice was sent to the Opposite Parties.

3.        Opposite Party No.1 in reply has taken the preliminary objection that the complaint is not maintainable, due to non-joinder of necessary parties as M/s Karvat Travels Services Private Limited (TRAWELLTAG), who had arranged the insurance policy on behalf of the Complainant were also party to the dispute. Also, the Complainant has not disclosed any deficiency in service by the Opposite Parties. It has also been submitted that Opposite Party No.1 vide ‘All Risk Policy Schedule’ (Annexure R-1), sub-letted the Overseas Mediclaim Policies to Karvat Travels Services Private Limited for the period from 7.1.2010 to 6.1.2011. During the said period of one year all the Overseas Mediclaim Policies were issued by the Marketing/ Promoting agency of Karvat Travels Services Private Limited operating by the name of TRAWELLTAG. The said TRAWELLTAG has further associated Opposite Party No.1 M/s Sheetal Travels as a business partner and were paying commission for selling the Overseas Mediclaim Insurance Policy of Opposite Party No. 2 (Oriental Insurance Company Ltd.). The business partner agreement between TRAWELLTAG and M/s Sheetal Travels (Opposite Party No.1) is at Annexure R-2. Opposite Party No.1 is only an agent of TRAWELLTAG and has no role to play in sanctioning/ settlement of insurance claim. The insurance claim was lodged by the Complainant with Opposite Party No.2 and Opposite Party No.1 has only processed the claim with TRAWELLTAG as a goodwill gesture to the Complainant.       

          On merits, Opposite Party No.1 has reiterated that Overseas Mediclaim Policies of Opposite Party No.2 are being sold by TRAWELLTAG and the Complainant had purchased the policy after fully satisfying himself about the same. Also, for issuance of the policy, no medical check-up or medical document is required to be checked or verified by the Agent. The Complainant on his return to India tried to forcibly submit his insurance claims with Opposite Party No.1. However, he was informed by Opposite Party No.1 that the claim is to be sent directly to Opposite Party No.2 or to TRAWELLTAG. But still as a goodwill gesture to the Complainant, Opposite Party No.1 has provided all forms required for claiming the reimbursement to the Complainant. The duly filled in forms of the Complainant were personally referred by Opposite Party No.1 to TRAWELLTAG for settlement. Hence, reiterating that there is no liability on its part for payment or settlement of claim, Opposite Party No.1 has prayed for dismissal of the Complainant.    

4.        Opposite Party No.2 in reply has submitted that the complaint is pre-mature, as the Complainant failed to fulfill the terms of the Policy. He has not submitted the required formalities and the documents of bills attached with the complaint do not prove the fulfillment of the terms of the policy for which the payment was made by the Complainant. The circumstances leading to the medical assistance as alleged by the Complainant are also not on record. There is no certificate or affidavit of any doctor from whom the medical treatment has been taken.      

          In the para-wise reply the Opposite Party No.2 has admitted the issuance of the relevant policy to the Complainant. It is also submitted that when the claim was submitted by the Complainant, the Complainant was asked to submit all relevant documents to process the claim. The Complainant submitted the copies of air tickets and policy, but he has not submitted any diagnosis of the doctor or the disease for which the treatment was taken. Hence, Opposite Party No. 2 was unable to pay the claim. Opposite Party No.2 has, therefore, prayed for dismissal of the Complainant.

5.        In the replication filed by the Complainant to the averments of Opposite Party No.2, it is stated that the Complainant is a policy holder of Opposite Party No.2. He has taken the medical assistance against the insurance policy, so cause of action has arisen in his favour. The prescription slip of the Canadian doctor and payment slip of the Drug store have been submitted with the claim. The papers have also been attached with the present complaint. The Complainant is unable to provide a physician’s report as demanded by the Administrator Heritage Health TPA Pvt. Limited, Mumbai, for processing the claim. The Complainant has, therefore, once again prayed for payment of claim.   

6.        Parties led evidence in support of their contentions.

7.        We have heard the Complainant in person and learned counsel for the opposite parties and have perused the record.

8.        The case of the Complainant is that after obtaining a medi-claim policy from the Opposite Party No.2 through Opposite Party No.1, he was denied payment of claim, despite submission of relevant documents. Copies of all documents submitted have also been placed on record of the instant complaint.

          Surprisingly, the claim documents placed on record by the Complainant are only receipt from the doctor and a bill from Shoppers Drug Mart. No detail of the ailment/ disease has been given. The need for taking the treatment has also not been given. The prescription, as well as, the details of visit, to the doctor, if any, is not part of the record and even the details of the medicines purchased from the Drug Store are not part of the record.

9.        The Complainant has stated that the same documents have been submitted to the Opposite Parties for payment of claim. The Insurance Company has contended that it is the duty of the Complainant to furnish the diagnosis of the doctor and the disease for which the Complainant has taken treatment; otherwise, it is not possible to process or pay the claim. We agree with this contention of the Opposite Parties. How can they be expected to make payment to the Complainant for a medical insurance without submission of any documentary proof to show that the Complainant suffered from an ailment during his trip to Canada, for which the doctors advised a particular plan of treatment and medication. In the absence of any such evidence on record the claim filed by the Complainant, in our opinion, is definitely not payable. Furthermore, Opposite Party No.1 has no role to play, as they are only the intermediaries, who had issued tickets and introduced the Complainant to the insurance company for taking the insurance policy.  

10.       Hence, to our mind, looking at the entire the situation, the Complainant has not been able to substantiate the claim to prove any allegation of deficiency in service or harassment against the Opposite Parties. In the absence of any specific proof of claim, we do not feel that any amount is payable by the Opposite Parties to the Complainant or his wife. The present complaint is, therefore, dismissed with no order as to costs.

11.       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

17^th September, 2012.                                              

SD/-

 (LAKSHMAN SHARMA)

PRESIDENT

SD/-

(MADHU MUTNEJA)

MEMBER

SD/-

(JASWINDER SINGH SIDHU)

MEMBER