BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH ======== Complaint Case No : 092 of 2010 Date of Institution : 16.02.2010 Date of Decision : 14.02.2011 Amrit Lal Mahajan s/o Sh. Mukand Lal Mahajan, H.No. 140, Sector 38-A, Chandigarh. ….…Complainant V E R S U S [1] Star Health and Allied Insurance Co. Ltd., through its Branch Manager, SCO No. 257, 2nd Floor, Sector 44-C, Chandigarh. [2] Paramound Healthcare Management Pvt. Ltd., Elite Auto House, 1st Floor, 54-A, M. Vasanji Road, Off. Andheri – Kurla Road, Chakala, Andheri (E), Mumbai – 400093. ..…Opposite Parties CORAM: SH.LAKSHMAN SHARMA PRESIDENT SH.ASHOK RAJ BHANDARI MEMBER MRS. MADHU MUTNEJA MEMBER PRESENT: Sh. Somesh Gupta, Adv. for Complainant. Sh. Rohit Mittal, Adv. for OP No.1. OP No.2 ex-parte. PER ASHOK RAJ BHANDARI, MEMBER Concisely put, the Complainant, along with his wife – Smt. Chand Mahajan, were to visit Canada on a holiday trip from 03.09.2008 to 30.09.2008 and keeping in view their age, they took two separate Star Travel Protect Insurance Policies from OP No.1, by paying a premium of Rs.4430/- for each policy (Total Rs.8860/-). They reached Canada on 05.09.2008. It was averred that in the plane, while going to Canada, Complainant suddenly suffered severe piles problem and on reaching Edmonton, Canada, he contacted helpline of OP No.1 to get information about the name and address of authorized doctor from whom he could take treatment. In response to the phone call, he was informed that company had no tie-up with any doctor for medical assistance at Canada and was suggested to get medical treatment at his own level, for which company would make reimbursement. Having no other alternative, the Complainant himself made arrangement for emergency treatment and spent 123.69 Canadian Dollars on his medical treatment besides spending 200 Canadian Dollars twice on the taxi for taking medical treatment. After coming back to India, the Complainant, lodged claim with OP No.1 for reimbursement of the expenditure incurred on medical treatment, supported by all the relevant documents, but to his utter surprise, his claim was settled by the OP for only Rs.738/-, which he flatly refused to accept since he had spent huge amount on his medical treatment, which otherwise was the responsibility of the OP. Hence, the present complaint has been filed, alleging the above act of OPs as gross deficiency in service and unfair trade practice, directing the OPs to reimburse Rs.24,090/- spent for taking medical treatment, together with compensation for deficiency in service, harassment & mental agony, besides costs of litigation. 2] Notice of the complaint was sent to OPs seeking their version of the case. However, despite service, nobody has appeared on behalf of OP No.2. Therefore, OP No.2 was proceeded against exparte on 17.08.2010. 3] OP No.1 in its written statement/ reply, while admitting the factual matrix of the case/reply, pleaded that the alleged ailment of piles cannot occur all of a sudden and it appears on account of pre-existing disease, which was excluded from the policy. However, inspite of that the OP had immediately processed the claim and discharged its liability without repudiating the claim of the Complainant. It was asserted that as per terms of the policy, the first 100 Dollars was to be deducted in case of any emergency medical expenses and the remaining of 23.69 Canadian Dollars was paid to the Complainant. The alleged expenses of 200 Canadian Dollars on account of taxi charges were not admissible under the medical policy of the Complainant. As such, the claim of 523.69 Canadian dollars made by the Complainant was totally baseless. However, an amount of Rs.738/- was rightly offered to the Complainant, which he was entitled, but it was the Complainant who had refused to accept the same. All other material contentions of the Complainant were controverted. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint with heavy costs. 4] Parties led evidence in support of their contentions. 5] We have carefully gone through the entire case thoroughly, including the complaint and the relevant documents tendered by the complainant / OP No.1 (OP No.2 being ex-parte). We also heard the arguments put forth by the learned counsel for the Complainant and OP No.1. As a result of the detailed analysis of the entire case, the following points/issues have clearly emerged and certain conclusions/arrived at, accordingly:- i] The basic facts of the case in respect of the Complainant having obtained two separate Star Travel Protect Insurance Policies one in his own name and the other in the name of his wife from OP No. 1 by paying a premium of Rs.4430/- for each Policy i.e. total of Rs.8860/- for the period 03.09.2008 to 30.09.2008, covering the travel of the Complainant and his wife to Canada and back, have all been admitted. It is also a fact that the Complainant and his wife reached Canada on 5.9.2008. During the air journey to Canada, the Complainant suffered severe piles problem and on reaching Edmonton, Canada, he contacted the Helpline of OP No. 1 to obtain information about the name and address of the authorized doctor from whom he could take treatment, but he was informed by the OPs that the Company had no tie-up with any doctor for medical assistance at Canada and that the Complainant should take treatment at his own level, for which the Company would make reimbursement. As advised by the OP, the Complainant took an emergency treatment and spent a sum of 123.69 Canadian Dollars on his medical treatment, besides spending 200 Canadian Dollars twice on Taxi for taking the medical treatment. On returning to India, he lodged a claim with OP No. 1 for reimbursement of 523.69 Canadian Dollars, against which the OPs settled the claim by offering him Rs.738/- only i.e. 16.55 U.S. Dollars. Since the Complainant had made a claim for a much higher amount i.e. 523.69 Canadian Dollars and the OPs had offered him only a small amount of 16.55 U.S. Dollars (Rupee equivalent 738/-), the Complainant refused to accept this payment and filed the present complaint, praying for the full payment of Rs.24,090/-, as also compensation for deficiency in service, mental agony and physical harassment, besides costs of litigation. ii] OP No.1 in its written statement/ reply, while admitting the core facts of the case have pleaded that the ailment of Piles cannot occur all of a sudden and that it appeared that it was a pre-existing disease, which was excluded in the terms & conditions of the Policy. Despite that, the OP had immediately processed the claim and discharged its liability without repudiating the claim of the Complainant. It is asserted that as per the terms and conditions of the Policy, first 100 Canadian Dollars were to be deducted as per Excess Clause in case of any emergency medical expenses and accordingly, the balance amount of Canadian Dollars 23.69 (Rupees 738/-) were paid to the Complainant, in full and final settlement of the claim. The alleged expenses of 200 Canadian Dollars spent twice on Taxi charges were not admissible under terms and conditions of the medical policy of the Complainant and accordingly, the same was disallowed. Based on these averments, OP No.1 has prayed that since there was no deficiency of service on their part, the complaint be dismissed with heavy costs. iii] On detailed study of the entire case, we find that the Complainant, along with his wife were holding valid Travel Protect Insurance Policies taken from OP No. 1 and also that the Complainant had filed a genuine medi-claim with OP No. 1 to the extent of Canadian Dollars 523.69, out of which OPs had paid only a small amount of U.S. Dollars 16.55 (Rupees 738/-). The main ground of reducing the claim of the Complainant, as stated by the OP No.1 has been that the Taxi Charges borne by the Complainant twice @ Canadian Dollars 200 each for taking medical treatment were not admissible. During the course of arguments, when the learned counsel for the OPs was confronted with the situation as to how could a patient travel to the doctor without the use of conveyance and thereby incurring certain expenditure, the learned counsel admitted that it was only the use of Ambulance Van, which could be employed by the patient and the Company would have made payment for the use of the Ambulance. The learned counsel for the OP No. 1 have not produced any document and not even the original policy, citing the detailed terms & conditions of the Travel Protect Insurance Scheme stating that the patient is allowed to use only the Ambulance Van and not any Taxi Service in case of any emergency medical treatment. iv] It is not understood as to how the Company could refuse to make payment for the use of Taxi and at the same time was ready pay for the Ambulance charges, if incurred any. It is matter of plain commonsense that whenever an emergency arises, the patient has to use only the mode of conveyance, which is readily available and not wait for an Ambulance Van, which may or may not arrive for considerable time and in the meantime, some severe damage may take place to his health. There is nothing wrong in the Complainant having hired a taxi and getting medical treatment by spending Canadian Dollars 200 each twice. Therefore, the amount of Canadian Dollars 400 is clearly admissible and payable by the OPs on the same basis as in the case of an Ambulance van. v] So far as the Deductible Excess Clause for emergency medical transportation expenses is concerned, the same can be done by OP No. 1 as per the Company Rules, but in any case, the balance amount of the claim amounting to Canadian Dollars 423.69 (523.69 – 100) is clearly admissible for payment by the OPs to the Complainant but the same has not been paid by the OPs without any justification and even quoting any Rule or terms & conditions, so far. 6] Keeping in view the foregoings, in our considered opinion, there is serious deficiency of service, as well as unfair trade practice on the part of the OPs on account of disallowing the genuine and bonafide medical claim of the Complainant in full. As such, the present complaint has a lot of merit, weight and substance and hence, it must succeed. We, therefore, decide the complaint in favour of the Complainant and against the OPs. 7] The OPs shall, jointly and severally, make the following payments to the Complainant:- (i) The OPs shall pay the sum of Canadian Dollars 423.69 (in equivalent Indian Rupee) to the Complainant, in full and final settlement of the Travel Protect Insurance Policy medi-claim preferred by the Complainant with the OPs. (ii) The OPs shall pay a compensation of Rs.10,000/- for causing physical harassment, mental agony and pain to the Complainant, on account of non-settlement of the wholly bonafide and genuine medi-claim preferred by him with them. (iii) The OPs shall pay a sum of Rs.7,000/- as litigation costs to the Complainant. 8] The aforesaid order be complied with by the OPs, within a period of 30 days from the receipt of its certified copy, failing which OPs shall, jointly and severally, pay the aforesaid amounts as at (i) and (ii) in the foregoings, along with interest @18% per annum with effect from the date of filing of the present complaint i.e. 16.02.2010, till the date of realization, besides paying the costs of litigation of Rs.7,000/-. 9] Certified copy of this order be communicated to the parties, free of charge. After compliance, the file be consigned to the record room. Announced 14.02.2011 Sd/- (LAKSHMAN SHARMA) PRESIDENT Sd/- (ASHOK RAJ BHANDARI) MEMBER (MRS. MADHU MUTNEJA) MEMBER
| | MR. A.R BHANDARI, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MRS. MADHU MUTNEJA, MEMBER | |
