Per Dr. Sushma Garg, Member:
1. In this complaint both the complainants, no. 1 and 2 purchased the Travel Age Elite Gold (US $ 2 lacs) insurance policies. The policy number o0f the complainant no. 1 was OG-17-1201-9910-00001381 on account of travel to Canada for period from 08.06.2016 to 29.06.2016. The policies are annexure C-1/1 and Annexure C-1/1/A. During the visit at Canada complainant no. 1 had fall on 26.06.2016 and was diagnosed with hip bone fracture and was advised hip replacement by surgical specialist of Canada. Annexure C-2 is the copy of doctors opinion. The complainant had informed all about the incidence to sh. Sachin Ohri, who is the insurance companys branch head at Panchkula/ Chandigarh. Although both the complainants had tickets in the business class from Toronto Amsterdam Delhi but in emergent situation they had to arrange for fresh tickets on non-stop flights from Toronto to Delhi by paying $8002 (Canadian dollar). Annexure C-10 copies of air tickets by air Canada from Toronto to Delhi for both of the complainants. After arriving India, the complainant immediately got admitted at Fortis hospital, Mohali, on 29.06.2016 and hip transplant surgery was performed there. The complainant no. 1 remained hospitalized till 05.07.2016 and a total amount of Rs.3,75,504/- + Rs.3151/- +Rs.1049/- were spent, out of above,Rs. 1,76,910/- were reimbursed by the HVPN, government department from where the complainant has retired. The complainant has claimed the remaining amount spent on medical treatment and air tickets for travelling back. The OPs have reimbursed only the charges in respect of treatment taken at Canada and the balance amount had been repudiated on account of clause 2.1.2 of the policy which provides at under: 2.1.2 Medical Evacuation to a hospital in the Republic of India required as a result of accidental bodily injury and/or sickness and/or disease occurring of having first manifested itself during an insured journey. The medical evacuation will have to be preapproved by the insurance company/claims administrator of the insurance company. On the other hand, the complainants have pleaded that they were neither provided any terms and conditions of the policy nor they have violated any of those alleged terms and conditions.
2. Upon notice, OP appeared and contest the complaint by filing written statement taking some preliminary objections that complaint is not maintainable; that no cause of action has arisen against the OPs; that complainants have suppressed and misrepresented material facts and information from the Forum; that the complainant has not approached before this Forum with clean hands; that this Forum has no territorial jurisdiction to try and decide the present complaint. On merits, it has been stated that the complainant after understanding the terms and conditions of the policy in question, obtained the same w.e.f. 08.06.2016 to 28.06.2016 subject to policy terms and conditions. Thereafter, the insured/complainants after their visit to Canada, had intimated a claim with the OPs dated 29.06.2016 bearing claim No.OC-17-1002-9910-00000987 by submitting claim documents in support with the claim form for reimbursement of expenses incurred by the complainant/insured on account of medical expenses caused due to treatment, hospitalization, medication done both at Canada and India for hip fracture and emergency travel from Canada to India. The alleged claim of the complainant was duly processed by the OP by way of minutely going through the claim form, supported claim documents, medical records and treatment case history of the complainant/insured and collected the details and related documents. The complainant had suffered with an injury to hip due to some fall and required to be hospitalized and taking medical treatment after expenses to the tune of 1261 Canadian Dollars. The post taking medical treatment from Canada, the complainant along with his wife considering the urgent treatment booked urgency tickets and travelled from Canada to Delhi and then to Mohali Chandigarh without intimating the OP nor enquired if the complainant is eligible to book emergency tickets and can claim for reimbursement for the same or took approval from the OP for the same. Thereafter, the complainant took treatment at Fortis Hospital, Mohali (Chandigarh) and incurred medical treatment expenses to the tune of Rs.3,75,504/- as claimed/stated by complainant in his claim form. Further the complainant was reimbursed to the tune of Rs.1,76,910/- out of the alleged medical treatment expenses borne by the complainant. It is stated that the claim of the complainant will be payable only as per the policy terms and conditions and nothing would be paid to the complainant outside the scope and coverage to the policy. Thus, there is no deficiency in service or unfair trade practice on the part of the insurance company as such, complaint of the complainant may kindly be dismissed.
3. To prove his case, the ld. counsel for the complainants has tendered affidavit as Annexure CA along with documents Annexure C-1, C-1/1, C-1/1/A, C-1/2 and C-1/3 to C-19 in evidence and closed the evidence by making a separate statement. On the other hand, the ld. counsel for the OP tendered affidavit Annexure RA and closed the evidence.
4. The obtaining of the travel insurance policies by both the complainants has been admitted by the OP. As per the coverage, the insured are entitled to claim the medical expenditure as well as expenditure incurred for medical evacuation to any hospital in the Republic of India and further for the expenditure incurred for further medical treatment after such evacuation. There is no evidence that the complainants were ever supplied the terms and conditions of the policy having any exclusion clauses, however the Ops have placed on file a photostat copy of the terms and conditions (unexhibited), certain clauses of which are relevant and the same are reproduced as under:- Section B: Medical Expenses & Medical Evacuation & Repatriation The Company will indemnify the Insured up to the Section B Sum Assured specified in the Schedule in respect of: The Medical and related expenses incurred by the insured for medical treatment outside India. The expenses covered would include physician services, hospital and medical services and local emergency medical transportation. Dental Services for immediate relief of dental pain are covered upto the amount specified in the schedule. However dental care rendered necessary as a result of a covered accident shall be subject to the limit of cover as stated in the policy. Medical Evacuation to a hospital in the Republic Of India required as a result of Accidental Bodily Injury and/or Sickness and/or Disease occurring or having first manifested itself during an Insured Journey. The Medical Evacuation will have to be preapproved by the Insurance Company/Claims Administrator of the Insurance Company. The Cost of repatriating the Insureds remains to India, or up to an equivalent amount for the burial or cremation of the Insured in the country where the death occurred in the event of the Insureds death outside of India as a result of Accidental Bodily Injury and/or Sickness and/or Disease occurring or having first manifested itself during an Insured Journey. These expenses should be preapproved by the Insurance Company/Claims Administrator prior to the remains being prepared for transportation to the Republic of India or for local burial or cremation. In case of Medical Evacuation to hospital in India as per 2.1.2 above and if approved by the Insurance Company/Claims Administrator, and subject to the Section B Sum Assured remaining (if any), the Company will also indemnify the Insured in respect of the Medical Expenses incurred by him within India to continue medical treatment commenced by the Insured outside of India, as a result of the Insured first having sustained Accidental Bodily Injury and/or Sickness and/or Disease during the course of the Insured Journey. The Companys liability to make payment hereunder shall be limited to a period of 90 days from and including the date upon which the aforesaid Accidental Bodily Injury and/or Sickness and/or Disease occurred or first manifested itself, and to Medical Expenses at the Usual and Customary Level. The deductible applicable as per the schedule of the policy would be applicable in respect of each and every claim made under the policy and the companys liability in all claims put together under Section B would be restricted to the Section B Sum Assured as per the schedule of the policy during the policy period. Section I Hospitalization Daily Allowance Subject to all other terms and conditions, it is hereby agreed that following hospitalization of the insured named in the Schedule of the policy due to an accident or illness covered under the policy, a daily allowance as specified in the schedule shall be paid by the Company under this policy. For this purpose a day will be reckoned as continuous 24 hours. All other terms and conditions shall remain unaltered. Now, the only reason for which the claim has been repudiated is that the complainants had not taken prior approval of the company before medical evacuation. In our view, the repudiation on this ground is not justified in this case. Firstly, the complainants were not supplied the copy of terms and conditions of the policy and hence, such unintimated exclusion clause is not binding on the complainants. Secondly, the complainants have specifically pleaded that on the happening of the accident, they immediately informed the officials of the OP regarding the occurrence and emergency medical treatment taken at Canada through email as well as on telephone, which fact has not been specifically denied by the OP. However, the OPs did not respond to the email. Though the complainants, as per the policy terms were entitled to claim Emergency Cash Advance; and even cashless hospitalization for all eligible ailments/conditions as is mentioned in the covering letter of the terms and conditions produced on file, however since no response was coming out from the OPs and the complainants were not possessed of sufficient funds to meet the costly treatment expenses for hip joint replacement, it was thought prudent to shift the patient/complainant No.1 to a hospital in India as it would have not only been cost effective but otherwise also comfortable for the complainants. In view of the complainant No.1 was evacuated to Fortis Hospital in medical emergency and the complainants, under the circumstances, were not supposed to wait for the so-called prior approval from the OP. There is no allegation of any foul play, wrong or false claim or any willful default of the policy conditions on the part of the complainants.
5. The complainants as per the coverage mentioned in the cover note are entitled to claim the expenditure incurred on medical treatment taken at Canada pursuant to the accidental fracture of hip bone. They are also entitled to the expenditure incurred on medical evacuation of insured and also on further treatment in Fortis hospital, Mohali in India. Besides, that the complainant/insured is also entitled to such hospitalization daily allowance as provided under Point 9 schedule I of the conditions, as reproduced above, which otherwise are binding on the OP.
6. Now coming to the question of travelling expenses of the complainant NO.2 who is the wife of complainant NO.1. Admittedly, she had also obtained the identical travel policy in her own name also. Though, she as per her own policy, is entitled to trip curtailment claim, however, in our view, the complainant No.1 is entitled to the reimbursement of expenditure incurred on her Air Tickets because of the fact that it was essentially required her to accompany the complainant no.1 while his medical evacuation from Canada to India. The complainants are old aged persons.The complainant No. 1 had got a
III. hip fracture and for the purpose of Medical evacuation, he could have availed the facility of Air ambulance with medical attendant/staff as well as personal attendant. However, the complainants, instead have incurred minimal bare expenses for medical evacuation. The complainant No.1 having his hip fracture, unable to even move, was certainly and necessarily required to be accompanied with an attendant, which incidentally was his wife, who cantravelled with the complainant No.1 and was also separately insured with the OP. In the absence of any exclusion clause being brought to the knowledge of the complainants at the time of selling of the policy, in our view, the complainant No.1 is entitled to the cost incurred on his medical evacuation which also included the air fare of his only attendant i.e. wife of the complainant. There is a gross deficiency in services on the part of the OP as it has failed to honour its commitment of indemnifying the insurer as per the policy contract.
7. In view of the above discussion, the complaint is partly allowed with the following directions to the That the OP shall pay the balance amount of the expenses incurred by the complainant on account of his hospitalization in Fortis Hospital Mohali i.e. after deducting an amount of Rs.1,76,910/- which the complainant has received from HVPN out of total amount of Rs.3,90,704/- along with interest @ 9% per annum from the date of filing of complaint till realization. That the OP shall compensate the complainant on account of travelling charges from Toronto Hospital to Toronto Airport to the tune of $150 (Canadian) i.e. Rs.7,755/- when converted into rupees @ Rs. 51.7/- prevailing at the time of incident and further from New Delhi Airport to Chandigarh to the tune of Rs.5,500/- as assessed by us in the absence of any bill. That the OP shall pay an amount of $8,002/-(Canadian) i.e. Rs.4,13,703/- (when converted into rupees @ Rs.51.7/-) on account of air tickets charges of the complainants from Toronto to Delhi. That the complainants shall be paid hospitalization daily allowance as admissible as per the terms of the coverage/policy. That the complainant shall be compensated to a lump sum amount of Rs.25,000/- on account of mental agony, harassment and litigation charges.
8. It is made clear that the OP will be entitled to apply thedeductible as applicable as per the policy schedule. The OP shall comply with the directions/order within a period of 30 days from the date of communication of copy of this order to OP failing which the complainant shall be at liberty to approach this Forum for initiation of proceedings under Section 25 and 27 of CP Act, against the OP. A copy of this order shall be forwarded, free of cost, to the parties to the complaint and file be consigned to record room after due compliance. Announced 16.05.2019 Dr.Sushma Garg Dr. Pawan Kumar Saini Satpal Member Member President Note: Each and every page of this order has been duly signed by me. Dr.Sushma Garg Member