Dated: 24/02/2016

Jagannath Bag , Member

   ORDER

The complaint petition has been filed praying for direction upon the OP Insurance Company to reimburse medical expenses as covered by the insurance policy issued by the OP, together with cost and compensation on the ground of deficiency in service, delay in payment and causing agony and mental consternation.

            The Complainant obtained an Overseas Travel Insurance Policy, bearing  No. OG-12-2401-9910-00000666 for  $ 200,000/- equivalent to Indian Rs.1,00,00,000/- ( One Crore ) to cover any medical expenses for any ailment which the Complainant might have suffered during her foreign trip. The Policy was valid from 18^th April, 2011 to 14^th September, 2011. During her U.S. tour she suffered from acute coronary syndrome and myocardial infraction and had to be hospitalized on 26.07.2011 at Sturdy Memorial Hospital, 211, Park Street, Attleboro, MA 02703 and was thereafter shifted to Rhode Island Hospital, 593, Eddy Street, Providence, RI 02903 as Sturdy Memorial Hospital did not have advanced cardiac facilities. She was discharged from the Hospital on or about  6^th August, 2011. The  Hospital raised medical bills of $2,18,156.06. The bills were directly submitted by the hospital to the Insurance Company. The Complainant submitted duly filled in claim Form with signature of attending doctor. The OP insurance company repudiated the claim vide their letter dated 24^th August ,2011, on the ground of pre-existing disease of the Complainant. Attending doctors opined that the patient did not have any prior cardiac history. A legal notice was sent on  September, 2011. The OP by their letter dated 14^th September, 2011  cited the same ground of repudiation, i.e. pre-existing diabetic condition causing the heart attack of the .

 Further allegation of the Complainant is that she is lawfully entitled to the entire coverage of the policy, but as the malafide denial of the just and bonafide mediclaim by the OP was telling upon her fragile health and as her mental tension was compounded, she was againhospitalized for which Hospitals raised further medical bills, which have been annexed.  Alleging deficiency in service and dereliction of duty the Complainant has prayed for direction upon OP to pay full coverage of $2,00,000/- equivalent to Indian Rs. 100,00,000/- (one crore) apart from payment of compensation and cost.

       The complaint is contested by the OP who filed their Written Version. It has been contended that the claim is beyond the pecuniary jurisdiction of this Commission as the value of $ 2,00,000  in terms of Indian currency  is much more than Rs. 1 crore together with the sum total of compensation and costs. It has been stated that the Complainant suffered acute coronary syndrome S.T. elevation, myocardial infraction for which she was hospitalized and underwent medical treatment for a long period. It transpired from the medical history that the insured was a longstanding patient of diabetes for last 15 years and the said diabetic condition is the proximate cause of her cardiac ailment. The exclusion clause 2.4 of the Policy debarred the claim which was referred to a competent and qualified doctor and it has been opined by him that the heart ailment of the insured was a direct outcome of her diabetic status. The claim falls under the exclusion clause of the Policy. Further, it has been contended that there is no explanation as to how $218156 was provided for. The claim of the Complainant without actually incurring  such expenditure is frivolous and not tenable.  The claim has been rightly repudiated and such repudiation is not tantamount to deficiency in service. The complainant is liable to be dismissed.

            The Complainant submitted evidence on affidavit and questionnaire being put by the OP Insurance Company, replies were furnished by the Complainant. Affidavit of evidence was filed on behalf of the OP, questionnaire was put by the Complainant and replies were submitted by the OP. All such materials on record have been perused carefully.

            The Complainant filed MA/647/2014 seeking amendment of prayer part (a) of the petition of complaint along with an amended petition of complaint for directing the OP to pay full coverage amounting to ‘about Rs.90,00,000/- ( Rupees Ninety Lakhs only ) ( The amount equivalent in Indian currency of $ 200,000 as per the claim form dated 3^rd August, 2011) of the insured amount in respect of the Policy   and RS.10,00000/- ( Rupees Ten lakhs ) as compensation/punitive damages’. The M.A. was not allowed.

Ld. Advocates appearing for both parties were heard.

Ld. Advocate appearing for the Complainant submitted that during her overseas treatment, the insured was hospitalized as she suffered insured peril during subsistence of the insurance policy. The bills were submitted by the hospital directly to the Insurance Company. But the claim was repudiated in a mechanical way stating that the ailment for which the Complainant underwent treatment was related to pre-existing diabetic condition, though the attending doctor opined that coronary syndrome and elevation myocardial infraction are acute event and the patient did not have any prior cardiac history.  The claim was bona-fide and legitimate. The repudiation of the claim by the OP Insurance Company is arbitrary and illegal. The OP Insurance Company is liable to make payment of Rs.90,00,000/- as insurance coverage and also Rs.10,00,000/- as compensation for mental agony and harassment. The Ld. Advocate cited the decisions of the Hon’ble Madras High Court dated 20.04.2012 in CRP(PB)(MD) No. 2005 of 2011, Order of the Hon’ble National Consumer Disputes Redressal Commission in Tarlok Chand Khanna – Vs. – United India Insurance Co. Ltd., and  Order of the Hon’ble National Consumer Disputes Redressal Commission ( 1996) stating that there was no evidence produced by the OP establishing that the Complainant had suffered a pre-existing decease which shows that the complainant was otherwise eligible for reimbursement of her medical expenses as per her claim.

            Ld. Advocate appearing for the OP submitted that the Complainant’s case was repudiated on the ground of pre-existing condition which was related to the ailment for which she was hospitalized. As per policy exclusion  clause 2.4 read with exclusion clause 2.4.12 the company is not liable to make payment in respect of any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any  medical condition or complication arising from it which existed before the commencement of the policy period  or for which care, treatment or advice was sought, recommended by or received from a physician a claim cannot be entertained by the OP Insurance Company. Again the present complaint is beyond the   pecuniary jurisdiction of this Commission as the total value of claim exceeds Rs.1 crore which can not be entertained by the  State Commission under Section 17 of the Consumer Protection Act. The prayer of the Complainant vide her MA application, A/647/2014 was rejected by this Commission and no appeal against that order was filed. In that situation the Complainant has little option to withdraw from her original prayer as put in the petition of complaint. Ld. Advocate cited orders of the Hon’ble National Consumer Disputes Redressal Commission as reported in (1996) CPJ 103 (NC), wherein it has been held that  the pecuniary jurisdiction of Consumer Forum is to be determined on the basis of aggregate value of services as well as that of compensation claimed. It has been ascertained that the total value of services availed, compensation and cost claimed exceeds Rs. 1,00,00,000/- ( One crore )  keeping in view the conversion rate of U.S. Dollar into Indian currency together with compensation and  cost prayed for by the Complainant. Accordingly, the complaint case does not come within the pecuniary jurisdiction of this Commission and the complaint is liable to be dismissed on that score alone. Again the complaint is frivolous in nature as not supported by cogent evidence showing that the Complainant incurred so much expenses as to be eimbursed on the strength of the insurance Policy. The complaint is liable to be dismissed.

            Upon hearing of the Ld. Advocates of both sides and perusal of materials on record two important points are found to have emerged for  adjudication of the complaint case:

1) Is the complaint hit by  pecuniary jurisdiction of this Commission ?

2) Is the Complainant eligible for relief including compensation and cost as prayed for ?

Decision with reasons

            There is no dispute that the Complainant obtained a foreign travel insurance policy from the OP for   a coverage of $ 2,00,000 during her foreign tour and the Policy was valid  between 18^th April,2011 and 14^th September,2011. Hospitalization of the Complainant took place for which her claim for medical reimbursement stood at $ 218156.06. Her claim for medical reimbursement was repudiated as it was opined that the Complainant’s ailment was linked with pre-existing decease of diabetes.

            Being aggrieved by repudiation of the claim, the complainant preferred the complaint with prayer for payment of full coverage i.e. $ 2,00,000. On this point, the OP has raised their objection, inter alia, that the complaint is not maintainable  as in terms of Section 17(1) (a)(i) of the Consumer Protection Act the State Commission shall have jurisdiction to entertain complaints where the value of the goods or services and compensation, if any, claimed exceeds Rs.20,00,000/- but does not exceed Rs. 1,00,00,000/- ( One crore ) only which means the State Commission shall have no pecuniary jurisdiction if such value exceeds  Rs.1 crore.

            The fact goes that at the time of filing of the petition of complaint, the total value  of the services availed by the Complainant  being  the full coverage of $2,00,000/- which was stated to be equivalent to Indian Rupees 1,00,00,000/- apart from further compensation on ground of delay in payment, agony and mental consternation of the Complainant along with cost of hospitalization for two times and other medical bills related to such hospitalization as well as cost of the proceedings putting the total claim above the maximum pecuniary limit of Rs. 1 crore in case of the State Commission. As per affidavit of evidence as submitted on behalf of the OP vide annexure R-1  the conversion of Rupee to $ was  Rs.50.19 = $1. Such statement has not been controverted by the Complainant. In that case, the total value of the claim stands beyond the pecuniary jurisdiction of Rs.1,00,000,00/- and renders the complaint non-maintainable before this Commission.

The Complainant in his MA application No. MA/647/2014 prayed for amendment of her prayer  to pay the full coverage of Rs.90,00,000/- said to be equivalent to $2,00,000/- purportedly with a view to keeping her total value of the claim within the limit of the pecuniary jurisdiction of this Commission. Such prayer was not found to be tenable as her Policy was obtained in terms of U.S. Dollar instead of  Indian currency. The MA, therefore, was rejected. In that position, it is clear that the Complainant has prayed for such a claim, total value of which is beyond Rs.1,00,00,000/-. This Commission having no pecuniary jurisdiction to adjudicate such claim, we are inclined to hold that the present complaint is not maintainable and consideration of the point as to whether the Complainant is entitled to the relief including reimbursement of her medical bills, compensation for mental agony and also for cost is not relevant. The complaint is liable to be dismissed for lack of jurisdiction. Hence

ORDERED

That the complaint be and the same is dismissed on contest as found to be not maintainable. The Complainant shall, however, be at liberty to move the appropriate Consumer Forum/Court as permissible under law. There shall be no order as to cost.