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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
V.B. Gupta, P.M and Rekha Gupta, Member
DR. S.P. SINGLA - Appellant
Versus
NEW INDIA INSURANCE CO. LTD. - Respondent
Revision Petition No. 799 of 2007. (Against the Order dated 20/11/2006 in Appeal No. 632/2006 of the State Commission Chandigarh).
Decided on : 25-03-2015
G.C. Dhuriwala, Advocate, for the Appellant; B.S. Taunque, Advocate, for the Respondent
The insured's compliance with the notification requirement and provision of original authenticated bills for medical expenses are crucial for the admissibility of a claim under an overseas Medi-claim policy. Additionally, understanding the coverage limitations of the policy is essential for the insured.
Headnote:
Insurance - Overseas Medi-claim Policy - General Conditions Applicable to all Sections - [Section A - Medical Expenses and Repatriation] - The court upheld the rejection of the claim as the insured failed to notify 'Coris' immediately and did not produce original authenticated bills for medical expenses incurred in Dubai. The policy did not cover treatment taken in India, and the insured was aware of the terms and conditions of the policy.
Fact of the Case:
The petitioner, Dr. S P Singla, filed a complaint against the insurance company for rejecting his claim under an overseas Medi-claim policy. The petitioner had taken an overseas Medi-claim Policy for a trip overseas and incurred medical expenses in Dubai and India. The insurance company rejected the claim on the ground that the insured failed to notify 'Coris' immediately and did not produce original authenticated bills for medical expenses incurred in Dubai. The policy did not cover treatment taken in India.
Finding of the Court:
The court found that the insured failed to comply with the policy's notification requirement and did not provide original authenticated bills for medical expenses incurred in Dubai. The court also found that the policy did not cover treatment taken in India.
Issues: The issues were whether the insured complied with the notification requirement and provided original authenticated bills for medical expenses incurred in Dubai, and whether the policy covered treatment taken in India.
Ratio Decidendi: The insured's failure to notify 'Coris' immediately and provide original authenticated bills for medical expenses incurred in Dubai led to the rejection of the claim. Additionally, the policy did not cover treatment taken in India.
Final Decision: The court upheld the rejection of the claim, as the insured failed to comply with the policy's notification requirement and did not provide original authenticated bills for medical expenses incurred in Dubai. The court also affirmed that the policy did not cover treatment taken in India.
ORDER
Rekha Gupta, Member - Revision petition no. 799 of 2007 has been filed against the judgment dated 20.11.2006 passed by the State Consumer Disputes Redressal Commission, Union Territory, Chandigarh ('the State Commission') in First Appeal no. 632 of 2006.
2. The facts of the case as per the petitioner/ complainant are that the petitioner Dr S P Singla had taken an overseas Medi-claim Policy no. 2003/353000/16/3/80084 for a trip overseas and the policy was to stay in operation for the period 22.11.2003 to 07.01.2004. At the time of issuance of the policy only a cover note was supplied to the petitioner.
3. During the operation of the policy the petitioner visited Dubai and on 04.12.2003 the petitioner complained of chest discomfort and was rushed to Dr Ramachandran at Al Rafa Poly Clinic. After conducting the ECG and Blood test Dr Ramachandran referred the petitioner to Dr. A.K. Kapoor at Get Well Medical Center. After conducting certain investigations, Dr Kapoor advised further investigations like angiography and catheterization which were conducted at Well Care Hospital, Dubai by Dr Shoaib Podaria and the petitioner was put on medicine and rest after which the petitioner was further referred to get CABG done at Escort's Heart Institute and Research Centre at New Delhi.
4. The petitioner was flown back to India on 10.12.2003 and he was rushed from Indira Gandhi Airport to Escorts Heart Institute and Research Centre at New Delhi by an Emergency van manned by a team of Specialists and CABG was performed on him by Dr Naresh Trehan and he was advised rest for three months.
5. The information regarding petitioner's illness was given to the respondent - insurance company on 17.12.2003 by telephone and guidance was sought from the concerned person Mr D P Singla, in the present case, as to what additional information had to be supplied and to whom it had to be supplied, as the concerned person expressed ignorance regarding the policy.
6. For this purpose the mobile number of the attending person was given to Mr D.P. Singla. However, no information was forthcoming either on the mobile number supplied to the respondent or at the policy address. More calls were made to the office of the respondents after the petitioner reached Chandigarh on 31st December 2003, however, the respondents did not bother to guide the petitioner satisfactorily.
7. On 23.01.2004, after failing to get any satisfactory guidance, from the respondent on phone, a letter addressed to the respondent was sent by the petitioner reiterating the factum of his illness, with a request to send him the necessary claim papers for completion and filling of his claim.
8. In the absence of any reply to the phone call dated 17.12.2003 and letter dated 23.01.2004 another registered letter was sent to the respondent on 22.03.2004 along with Photostat copies of various investigations and expenses incurred during the treatment.
9. In reply to the letter, a letter dated 24.03.2004 was sent to the petitioner by the respondent wherein they rejected the claim of the petitioner on the ground that it was a condition precedent to liability hereunder that in the event of any occurrence insured person must notify their representative "CORIS" immediately, and further stating that in no event should a claim be notified to "CORIS" later than 31 days after the end of the insured trip.
10. The petitioner stated that he was not provided with any guide kit along with the policy stating the terms and conditions governing the aforesaid policy and it was for this purpose that a telephone call was made to the respondent's office on 17.12.2003 seeking guidance for filing the claim papers and the call was well within the aforementioned 31 days period. At that point of time a heavy responsibility was cast upon the respondent to guide the petitioner properly. However, this was not done in gross violation of the contractual obligations and the principle of utmost good faith, applicable to both the parties
