Date of filing :13.02.2007
Date of order :15.07.2022
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, VELLORE AT VELLORE DISTRICT.
PRESENT: THIRU. A. MEENAKSHI SUNDARAM, B.A.,B.L. PRESIDENT
THIRU. R. ASGHAR KHAN, B.Sc.,B.L. MEMBER – I
SELVI. I. MARIAN RAJAM ANUGRAHA, M.B.A. MEMBER - II
FRIDAY THE 15TH DAY OF JULY 2022
CONSUMER COMPLAINT NO.10/2007
A. Radhakrishnan,
Son of Appavu udaiyar,
No.1/64, Pillaiyar Koil Street,
Vandaranthangal Village,
TEL. Post, Katpadi Taluk,
Vellore District,
Tamil Nadu. …Complainant
-Vs-
1. I.C.I.C.I. Lombard,
Overseas Leisure Travel Insurance Company
By its Executive,
Office at, I.C.I.C.I Bank,
Annasalai, Chennai.
2. Claim Executive Officer,
International S.O.S Service (India) Private Ltd.,
No.2/B, Second Floor,
Lotus Tower, New Friends Colony,
Community Centre, New Delhi.
3. The General Manager,
I.C.I.C.I. Lombard General Insurance Company,
Jenith House, Kesavarao Khadyamarg,
Mahalakshmi, Mumbai – 34.
4. The Manager,
I.C.I.C.I. Prudential Insurance,
Andra Bank building,
No. 14/A, Officer’s Line, Vellore – 1. …Opposite Parties
Counsel for complainant : Thiru. M. Meganathan
Counsel for first, third, and fourth opposite parties : Thiru. P. Thulasimani Selvam
Second opposite party : Set exparte on (18.04.2007)
ORDER
THIRU. A. MEENAKSHI SUNDARAM, PRESIDENT,
This complaint has been filed under section 12 of Consumer Protection Act 1986. The complainant has prayed for opposite parties to pay a sum of $.1,603 and URS.72,375/- with interest at 18% p.a. from the date of claim 27.02.2006 to till the date of realization and to pay sum of Rs.5,000/- cost to the complaint
1.The case of the complaint is briefly as follows:
The complainant applied for VISA to go USA and thereby insured his trip with the opposite parties under the policy No.4300/2207978/00/000 at Mumbai, through Chennai office. The complainant went to USA, during the period 11.08.2005 to 06.02.2006. The said policy apart from the insurance cover for travel, further covered other benefits like personal accident, medical cover, dental treatment, medical expenses, loss of passport etc. as mentioned in the policy. Accordingly, the complainant visited the United States like California, New Jersey etc. and stayed with his son. During the stay at the States he developed some pain in his right leg and the doctors there treated him on 12.06.2005 and gave medicines. As a result, he incurred an expenditure of $.1,203.31 towards the medical bill. Apart from that he also incurred $.400 towards taxi charges in total $.1,603.31. The complainant made a claim for the same with the opposite party, but there was no reply. As per the terms of the policy, the opposite party cannot repudiate the claim of $.1,603.31 US Dollars. The medical bills were submitted with the opposite party on 27.02.2006. So far there has been no reply, from opposite party. The opposite party intentionally refused the claim of the complainant, despite production of original medical records. On 12.06.2006 the complainant sent a letter to the opposite party calling upon to honour his claim. But they failed to do so, hence this complaint.
2. The Written version of first, third and fourth opposite parties are as follows:
This opposite parties denies all the allegations made in the complaint. The complainant has not given the nature and extent of the injuries and the same was not supported by any medical records. The insurance policy taken by the complainant does not cover any pre-existing medical conditions. It is evident that the complainant was a diabetic patient, much before taking the insurance policy from this opposite parties. The medical records will establish that the complainant was a diabetic patient and for that diabetic ailment, the complainant had taken treatment in U.S. Hospital. Taking advantage of that, the complainant had prepared false complaint. The claim made by the complainant is totally outside the preview of the insurance policy coverage, as per the policy conditions incorporated therein, which the complainant was well aware of and had accepted. Inspite of that the complainant lodged the claim. This opposite party much before this complaint, have suitably repudiated the aforesaid claim. In any event the compensation claimed is evasive and baseless. The complainant has not chosen to file any medical records to prove his contention and the complaint is vague. It is false to state that the complainant had given all original documents to the opposite parties.
3. In this case, even though the notice was received by the second opposite party from this Hon’ble Commission. They did not appear before this Commission. Several opportunities have been given. There was no representation, for the second opposite party. Hence, the second opposite party was called absent set exparte.
4. Proof affidavit of Complainant filed.Ex. A1 to Ex. A5 were marked. Proof affidavit opposite parties filed. Ex. B1 to Ex. B6 were marked. Written argument of complainant not filed. Written argument of opposite parties filed. Opposite parties side oral argument heard.
5. THE POINTS THAT ARISES FOR CONSIDERATION ARE:
1. Whether there is any deficiency in service on the part of the opposite
parties?
2. Whether the complainant is entitled for relief as claimed in the complaint?
3. To what relief the complainant is entitled to?
6. PointNos. 1&2: The complainant has gone to US for a trip. He took an insurance policy for the aforesaid US trip for a period of 11.08.2005 to 06.02.2006, from the first opposite party. During the stay in the US he developed some pain in his right leg and he was treated by the doctors there, on 12.06.2005. As a result, he incurred a total sum of $.1,603 US Dollars including Taxi charges. As per the policy the opposite party should reimburse the said medical bills. The complainant submitted his claim on 27.02.2006 with the opposite party, the opposite party repudiated the claim of the complainant on the ground of any pre-existing medical conditions. According to the complainant, the opposite party is bound to reimburse the medical expenses incurred by the complainant in the overseas. On the other hand, the counsel for the complainant draw attention with regard to the date of treatment i.e. 11.08.2005, which is not covered in the complainant’s insurance policy i.e. 11.08.2005 to 06.02.2006, further on going through the documents submitted by the complainant in particularly Ex.A4 we find that the complainant has taken treatment on 12.06.2005, which is prior to the period in which the policy was taken and therefore it is not covered. Further though he has produced a statement of account with regard to the expenses incurred by the complainant, but he fails to produce any medical records for the same. Therefore, we are not in a position to accept the claim of the complainant, without any valid proof. There are contradictions in the claim which he did not explained by the complainant before this court. Therefore, the complainant has failed to prove that there is a deficiency in service on the part of the opposite parties. Further admittedly, both parties are governed by the terms of the policy. In the present case the opposite party specifically contented that there is a pre-existing condition of diabetic and therefore they are not liable to reimburse the medical bills. So, the terms of the policy should be read as it is. We cannot add or subtract anything to the contract. Therefore, on this ground as well, this complaint liable to be dismissed. This point Nos. 1 & 2 are answered.
7. Point No. 3: In point nos.1&2, we have decided that complainant is not proved any deficiency in service on the part of the opposite parties. Hence, complainant is not entitled for any relief. This Point No.3 is also answered accordingly.
8. In the result, this complaint is dismissed. No costs.
Dictated to the steno-typist transcribed and typed by her corrected and pronounced by us in the open Commission on this the 15th July 2022.
Sd/- Sd/- Sd/-
MEMBER – I MEMBER – II PRESIDENT
LIST OF COMPLAINANT SIDE DOCUMENTS :
Ex.A1 - Copy of Air Ticket.
Ex.A2 - Copy of Visa Passport.
Ex.A3 - Copy of Policy Certificate.
Ex.A4 – 12.06.2005 - Copy of Medical Certificate by U.S.Doctor.
Ex.A5 - Copy of letter sent by complainant.
LIST OF OPPOSITE PARTIES SIDE DOCUMENTS:
Ex.B1 - Copy of Policy and conditions.
Ex.B2 - Copy of claim form.
Ex.B3 - Copy of medical record.
Ex.B4 - Copy of Emergency Department Leaving E.R.
Ex.B5 - Copy of letter issued by third opposite party to complainant for
reporting the claim.
Ex.B6 – 18.03.2006 - Copy of letter issued by third opposite party to the complainant.
Sd/- Sd/- Sd/-
MEMBER – I MEMBER – II PRESIDENT
