CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)x
New Delhi – 110 016
Case No. 511/2013
INDER MOHAN TANEJA
S/O LATE SHAM LAL TANEJA
R/O 120/3, SILVER OAK APARTMENTS,
DLF PHASE-I, GURGAON -122002
………. COMPLAINANT
Vs.
TATA AIG GENERAL INSURANCE COMPANY LTD.
LOTUS TOWER, 1ST FLOOR,
NEAR SURYA HOTEL AND COMMUNITY CENTRE
NEW FRIENDS COLONY
NEW DELHI-110025
ALSO AT
TATA AIG GENERAL INSURANCE COMPANY LTD
A-501, 5TH FLOOR, BUILDING NO-4 INFINITY PARK
GEN A.K VAIDYA MARG, DINDOSHI MALAD EAST
MUMBAI-400097
ALSO AT
PENINSULA CORPORATE PARK, PIRAMAL TOWER,
9TH FLOOR G.K. MARG, LOWER PAREL
MUMBAI-400013
………….RESPONDENTS
Date of Order: 06/12/2018
O R D E R
Ritu Garodia-Member
The complainant had taken TATA travel guard policy while he was travelling to London with effect from 1/6/2012 to 14/08/2012. He suffered a heart attack during his stay in London. He was treated in Barts Health NHS, Royal London hospital which is known as London Chest Hospital. The complainant received a total bill from the hospital amounting to GBP 10,025/- out of which GBP 7,765.85/- was paid to hospital directly to OP. The balance amount was not paid. It is also stated that an extra premium of Rs. 2,905/- was charged as his age was above 70 years.
The complainant was hospitalised from 19/7/2012 to 21/7/2012. The complainant submitted all the documents for reimbursement on 26/7/2012 and estimated expenses were submitted directly by the hospital to the insurer on 26/7/2012. OP had also placed initial guarantee for payment to the hospital.
The complainant was informed that the balance amount was not paid due to limits on the policy. Mails were exchanged between the parties. Complainant prays for the refund of balance amount with interest and compensation.
The complainant has filed insurance policy, boarding pass and discharge summary dated 21/7/2012.
OP in its reply has admitted the policy. It is further stated that the claim was paid as per the coverage and benefit stated in the policy in accordance with terms and conditions.
It is further admitted that the claim for hospitalisation of the complainant was made on 3/8/2012. On receipt of treatment record, the claim was processed and payment of 7,765.85 GBP which was equivalent to 12,266 USD was made to Barts Health NHS trust.
It is stated that the complainant was 74 years of age. The coverage under his policy was subject to sub limits. OP has given a detailed table explaining the payment made to the hospital.
The complainant has also filed an application for amendment of compensation. This application states that his visa has been rejected as part of the hospital bills is still outstanding and not paid by OP. The application was allowed on 12/8/2015.
We have perused the pleadings and documents filed by both the parties. It is admitted by both the parties that travel guard policy was issued to the complainant on 12/5/2012. The insurance policy also states that the details of the sub limit for insured between the age of 56 to 79 years has been provided in schedule of benefits.
It is further admitted by both the parties that complainant was hospitalised on 19/7/2012 and discharged on 21/7/2012 from Barts Health NHS, Royal London Hospital. It is also admitted that a claim has been filed. The complainant has annexed hospital bills which is as under:
Account no | Invoice Type | Payment Terms | Invoice No. | Invoice Date | Due Date |
48990 | Invoice | 30 NET | 140114 | 15-AUG-12 | 14-SEP-12 |
Line No. | Description | Ref. No | Quantity | Price in £ per Item | Value In £ | Vat Code |
1. 2. 3. 4. 5. 6. 7. | Cardiology – Dr. Dawson- The London Chest Hospital Inpatient admission 19/07/12 to 21/07/12 – 2 nights stay Percutaneous Transluminal Coronary Angioplasty 1 Drug Eluting Stent Inpatient in lab blood test 19/07/12 to 21/07/12 as Follows: Chemical biochemistry tests x 29 Haematology tests x 7 Microbiology tests | | 0 2 1 1 1 1 3 | 0.00 5,90.00 5,550.00 2225.00 620.00 300.00 50.00 | 0.00 1,180.00 5,550.00 2,225.00 620.00 300.00 150.00 | E E E E E E E |
VAT | TOTAL ex VAT (£) | VAT RATE | VAT VALUE (£) | TOTAL Ex. VAT | £ 10,025.00 | |
| | | | | | | | | | | | | | | | |
E EXEMPT Z ZERO D DOMESTIC S STANDARD O OUTSIDE THE SCOPE | 10,025.00 | 0 | 0.00 | TOTAL VAT | £ 0.00 |
TOTAL INVOICE | £ 10,025.00 |
The sub limit has specified by OP are as follows:
Part F: Schedule of Benefits provides for sub-limits are reproduced hereunder.
“Sub Limits: The following Maximum eligible expenses per Sickness or Disease are applicable to Insured Persons Aged 56-70 (amended to 56-79 as per schedule attached to the policy), regardless of the plan/option purchased.
- Hospital Room and Board and Hospital misc. Maximum $1,500 per day up to 30 days.
- Intensive Care Unit Maximum $ 3,000 per day up to 7 days.
- Surgical Treatment Maximum $10,000.
- Anaesthetist Services Upto 25% of Surgical Treatment.
- Physician’s Visit Maximum $ 75 per day up to 10 visits.
- Diagnostic and Pre-Admission Testing Maximum $500.
- Ambulance Service Maximum $400.”
The payment has explained by OP is as follows:
Sub limits Benefit | Total Invoice Receiving | Maximum Payable as per sub limit USD |
Hospital Room & Board and Hospital Misc-Daily Maximum $1500.00 upto | | |
20 days USD 1500 @ x 2 = 3000 | GBP 590x 2 days = GBP 1180 | GBP 1899.30 =USD 3000 |
Surgery charges USD 10000 | GBP 5550 | GBP 5550=USD 8766.39 |
Diagnostic & pre admission Testing Maximum $500.00 | GBP 1070 | GBP 316.55=USD 499.92 |
Total | | GBP 7765.85 = USD 12266.39 |
The payment made for the room as per the bills was 1,180 GBP which was completely covered and paid in full. The diagnostic testing and investigations amounted to 1,070 GBP. However only 316.55 GBP was paid as the limit for investigation charges were 500 dollar which amounts to 316.55 GBP.
The surgical treatment as per sub limit was 10,000/- USD. However OP has only paid 8,766.39 USD equivalents to 5,550 GBP. OP has not provided any reasonable explanation as to how 1233.61 USD was not paid when the coverage was up to 10,000 USD. The amount of USD 8,766 was passed in an arbitrary manner without verification.
Hence we find OP guilty of unfair trade practice in not making the full payment as per the sub limit provided in the policy and direct it to refund USD 1,230.61 which is equivalent to Rs.76,863/- at the time of filing of complaint with 9% interest from date of filing of complaint till payment. Complaint was filed on 27/09/2013. We also award compensation of Rs. 10,000/- and Rs.5,000/- towards litigations costs.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(RITU GARODIA) (H.C SURI) (A.S YADAV)
MEMBER MEMBER PRESIDENT
