Chandigarh

DF-II

CC/647/2017

Ram Singh - Complainant(s)

Versus

United India Insurance Company - Opp.Party(s)

Mukand Gupta Adv. & Geeta Gupta Adv.

02 Mar 2018

ORDER

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

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Consumer Complaint  No	:	647 of 2017
Date  of  Institution	:	28.08.2017
Date   of   Decision	:	02.03.2018

 

 

 

 

Ram Singh son of Jamit Singh, aged 77 years, resident of near PWD Rest House, Mander Cottage, Baba Farid Nagar, Barnala, District Barnala (Punjab).     

             …..Complainant

Versus

1]  United India Insurance Company, SCO No.123-124, Sector 17-B, Chandigarh through its Regional Manager.

2]  Karvat Cover More Asstt. Private Limited, Office No.202, 2^nd Floor, SCO No.139-140, Sector 9, Chandigarh through its Area Manager.

                          ….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

         MRS.PRITI MALHOTRA        MEMBER

                                SH.RAVINDER SINGH         MEMBER 

 

Argued by: Sh.Mukand Guta, Adv. for complainant

 Sh.Madan Lal Chaudhary, Adv. for OP No.1.

 Opposite Party NO.2 exparte.

 

 

PER RAVINDER SINGH, MEMBER

 

 

         The facts in issue are that the complainant planned  to visit overseas along with his wife and as such has purchased Overseas Travel Insurance Policy bearing No.02160046143990295953 (Ann.C-3) valid from 1.4.2015 to 27.9.2015 by paying premium of Rs.92,230/-.  It is averred that under the said policy the complainant and his wife was covered having sum insured for maximum US $50000 which covers medical expenses, personal accident death, delay of baggage, personal liability and life threatening situations etc.  It is also averred that the complainant and his wife visited initially UK from 1.4.2015 to 13.8.2015 and thereafter went to Canada w.e.f. 14.8.2015 to 29.9.2015 and then came back to India. 

         It is submitted that in UK, the complainant had some medical problem, as such he was admitted in Frimlay Health (NHS Foundation Trust), Hospital and was diagnosed coronary angiography and he was given medical treatment in the said hospital where he was admitted on 16.7.2015 and discharged on 30.7.2015.  It is also submitted that the said Hospital at UK raised the bill of UK£7362 for medical treatment given to the complainant, out of which the United India Insurance company had paid only UK £5687.46 and the balance payment of UK£1674.45 was not paid by it, which was paid by the complainant (Ann.C-6 & C-7).  Thereafter, the complainant visited Canada and there he was again hospitalized in Alberta Health, Alberta, Canada as he was suffering from breathlessness and remained admitted there from 15.8.2015 to 16.8.2015. The Alberta Health raised a bill of Canadian $773, which was paid by the complainant and Opposite Party did not make the said payment.  Thereafter, the complainant lodged a claim with the Opposite Party for the balance payment of medical expenses incurred by him in UK & Canada, but the same was declined by the OP Insurance Company vide letter dated 11.4.2016. Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The Opposite Party No.1 has filed reply and while admitting the factual matrix of the case, stated that the insurance cover under the life threatening situation is limited to US$7500.  It is stated that on receipt of information about the complainant’s admission in Frimley Health (NHS Foundation Trust), Berkshire (UK) from 16.7.2015 to 30.7.2015 and thereafter, in Alberta Health, Alberta, Canada from 15.8.2015 to 16.8.2015, the Opposite Party Insurance Company had settled the claim for maximum limit of US$7500 (upto life threatening clause limit) as per policy terms & conditions, which was equal to UK£5687.46 at the prevailing rate of US $ at the time of making payment.  It is submitted that the Opposite Party has paid the maximum eligible amount as per policy and rest of the amount, if any, has to be borne by the complainant himself and the Opposite Party is not liable for payment of amount more than US$7500.  It is also submitted that the claim lodged by the complainant has been settled according to the policy terms & conditions. Pleading no deficiency in service and denying rest of the allegation, the Opposite Party No.1 has prayed for dismissal of the complaint.  

 

3]       Opposite Party NO.2 did not turn up despite service of notice, hence it was proceeded exparte vide order dated 8.12.2017.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       The complainant had Overseas Travel Insurance Policy bearing No.02160046143990295953 (Ann.C-3) valid from 1.4.2015 to 27.9.2015. The complainant got this insurance policy through Opposite Party No.2 after paying premium of Rs.92,230/- vide receipt dated 28.3.2015   (Annexure C-1). The policy covered the complainant himself as well as his wife.  The Policy plan covers the medical expenses upto US $50000.  The complainant suffered cardiac problem while in United Kingdom with effect from 1.4.2015 to 13.8.2015.  He was admitted in Frimlay Health - Wexham Park Hospital, Wexham Street, Slough, Berkshire on 16.7.2015 and after treatment was discharged on 30.7.2015.  On 21.7.2015 while in Frimlay Health -Wexham Park Hospital, UK, the angiography of the complainant was conducted.  The complainant has paid UK £7362 on medical treatment in the said hospital.  Surprisingly, the OPs by way of mis-interpretation of insurance policy plan terms & conditions has paid only UK £ 5687.46 on 31.8.2016 and withheld the rest of the amount of UK£1674.45 spent on the medical treatment by the complainant. 

 

7]       Similarly, the complainant during his stay in Canada, was again hospitalized in University of Alberta Hospital, Alberta, Canada on 15.8.2015 and discharged on 16.8.2015 after treatment.  The complainant paid Canadian $773 for the treatment in the Alberta Hospital, Canada, but his claim for reimbursement of bill has not been honoured by the OPs. 

 

8]       As per the policy plan, the expenses on medical treatment upto US$50000 are covered whatsoever the intensity of the disease may be.  The expenses on medical treatment cannot, at all, be curtailed by just treating it to be life threatening situation. The life threatening situation cannot abrogate the actual expenses on medical treatment.  The complainant has suffered illness by way of Cardiac Arrest, which definitely comes under the wide connotation of medical.

 

9]       The decision of the OPs curtailing the claim of the complainant only upto US $7500, is misconceived, unsustainable and against the provisions of policy terms & conditions applicable therein.  The OPs did not consider the genuine claim of the complainant in right perspective and rejected the claim, which amounts to unfair trade practice and deficiency of service on their part. 

 

10]      The contentions raised by the Opposite Party No.1 against territorial jurisdiction before District Forum, Chandigarh, are misconceived and without merits.  The complainant has got the insurance policy through Opposite Party NO.2/Karvat Cover and paid the premium of Rs.92,230/- vide Receipt issued at Chandigarh (Ann.C-1). Hence, this District Forum at Chandigarh has jurisdiction to adjudicate this matter.  

 

11]      The Hon’ble Supreme Court in Oriental Insurance Co. Ld. Vs. Sony Cheriyan, 1999(6) SCC 451 has held that:

 “The insurance policy between the insurer and the insured represents a contract between the parties….

… the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer.”

        

12]      Keeping into consideration the facts in issue in the present matter, the complaint is allowed against Opposite Party NO.1 with directions to pay to the complainant UK£1674.45 and Canadian $773, in Indian Rupee at the conversion rate as applicable on 11.4.2016 (i.e. date of repudiation of the claim of the complainant Ann.C-11) along with compensation amount of Rs.10,000/- and litigation expenses Rs.5,000/-, within a period of 30 days from the date of receipt of copy of this order.

 

13]      However, the complaint qua Opposite Party NO.2 stands dismissed.

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

Announced

2^nd March, 2018                                                  

                                                                                                Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER