IMPORTANT POINT
Insurance Policy cannot be stretched beyond terms and conditions mentioned therein.

Mrs. Vineeta Rai, Member— This revision, petition has been filed by Mrs. Flavia Mary Agnes Pais (hereinafter referred to as the ‘Petitioner’) against the order of the State Consumer Disputes Redressal Commission, Karnataka (hereinafter referred to as the ‘State Commission’) in Appeal No.1388/2007 which was decided in favour of ICICI Lombard General Insurance Co. Ltd., Respondent herein.

2. The facts of the case are that the Petitioner had purchased an individual travel insurance policy on 18.6.2004 from the “Respondent/Insurance Company in respect of her travel to USA to visit her daughter and son-in-law. According to Petitioner, due to the sub-standard food served on the flight between Mumbai and Los Angeles, she suffered from diarrhoea for which she had to be admitted to the Banner Desert Medical Centre Hospital, Phoenix in USA on 24.6.2004 where she remained as an in patient till 26.6.2004. The bill for her medical treatment at that hospital was the equivalent of Indian Rupees 5,00,000. She obtained a discharge from the hospital and decided to travel back to Bangalore for further treatment. Petitioner sent the necessary medical certificate and the charges for expenditure incurred on her treatment to the Respondent/ Insurance Company which despite several letters rejected the same. Petitioner, therefore, filed a complaint before the District Forum for mental agony and personal inconvenience and requested that Respondent/Insurance Company be directed to pay her Rs. 6,91,225 as compensation for financial loss, Rs.1,00,000 for mental agony and personal inconvenience, etc. and Rs.94,512 being the interest amount (@ 10% per annum from 1.7.2004).

3. The above contentions were challenged by the Respondent/Insurance Company who stated that as per medical report from the Banner Desert Medical Centre Hospital at Phoenix dated 26.6.2004, it appears that Petitioner had a history of Arterial Fibrillation diagnosed approximately 8 months prior to her having undertaken the travel to the USA and, therefore, since this was a pre-existing disease the claim was rightly repudiated keeping in view the terms and conditions of the insurance policy. There was thus no deficiency in service.

4. The District Forum after hearing both parties partly allowed the complaint and directed the Respondent/Insurance Company to pay the Petitioner, Rs.6,08,100 towards the medical and air-ticket expenses along with interest @ 6% per annum from the date of complaint till realization and Rs.6,000 as compensation and litigation expenses, within 30 days from the date of the order.

5. Aggrieved by this order, Respondent/ Insurance Company filed an appeal before the State Commission. The State Commission while upholding the order of the District Forum, directed the Respondent/Insurance Company to pay Petitioner Rs.5,00,000 towards medical expenses incurred by her along with interest @ 6% per annum from the date of complaint till realization and set aside the payment for travel expenses. State Commission also awarded Rs.50,000 as compensation for mental agony and hardship. The relevant part of the order of the State Commission is reproduced:

“The complainant has also claimed certain amount as damages towards the money spent by her to purchase the Air Ticket by Malaysian Airlines for herself and her daughter and other expenses. In our opinion, the complainant is not entitled to any damages since the same is not covered under the Policies. But since the Insurance Company has unreasonably denied the claim of the complainant on irrelevant grounds, we are of the view that the Insurance Company is to be directed to reimburse the medical expenses incurred the complainant with interest.”

Since there is a delay on the part of the Insurance Company, the Insurance Company is to be directed to ‘pay certain amount as compensation to the complainant towards mental agony and hardship faced by the complainant in a foreign country. Under this head, we are of the view that the I