IMPORTANT POINT
Insurance claim has to be of utmost good faith, made with good conscience and clean hands.

ORDER

Dinesh Singh, Member

Heard learned counsel for the appellant – insurance co. and the respondent – complainant, and perused the material on record.

2. The case relates to repudiation of a claim made under an overseas mediclaim insurance policy.

3. In the interest of justice, and for adjudication of the first appeal on merit, on facts and law, the self-admitted delay of 20 days in filing the instant first appeal is condoned.

4. The State Commission partly allowed the complaint vide its Order dated 10.05.2012 and held deficiency in service and unfair trade practice on the part of the insurance co.:

Surely, Opponent NOs. 1 and 2, in the circumstances, were guilty of deficiency in service and unfair trade practice in repudiating the claim of the complainant. We, therefore, record our finding on the point No. 1 in the negative.

Point No. (ii):

Complainant has sought reimbursement under mediclaim policy for overseas treatment at Zurich CHF 98,827.90 (equivalent to Rs.46,64,677/-) and Rs.5,42,829/- for the expenses incurred for going to Zurich second time to consult Doctors at Klinik Hirslanden which also includes air fare charges to and fro of Dr.Chablani because on the advice of Doctors at Zurich Dr.Chablani was called from Mumbai, specifically, so that he could accompany Complainant for return journey to India and in fact, accompanied Complainant on her return journey to Mumbai from Zurich. So her total claim is for Rs.52,07,506/-. She has also claimed compensation of Rs.3,00,000/- but this we are of the view that the said compensation need not be paid. But we would like to award interest on that amount by allowing this complaint partly. The said amount shall be payable with interest @7% per annum though Complainant has claimed interest @18% per annum. Besides, Complainant would be entitled to get Rs.20,000/- as costs of the proceeding. In the circumstances, we are inclined to pass the following order:

Order

(i) Complaint is partly allowed as against Opponent No.1 Insurance Company.

(ii) Opponent No.1 Insurance Company is directed to pay a sum of Rs.52,07,506/- along with interest @ 7% per annum from the date of repudiation of claim i.e. from 20.10.2010 till actual realization.

(iii) Opponent No.1 Insurance Company is also directed to pay a sum of Rs.20,000/- towards cost of this complaint.

(extracts from the State Commission’s Order)

(emphasis supplied)

5. For ready appreciation of the examination being made hereinafter, the following are first being reproduced here:

(i) The relevant terms and conditions of the subject overseas mediclaim insurance policy taken by the complainant:

The New India Assurance Co. Ltd.

Regd. & Head Office: New India Assurance Bldg., 87, Mahatma Gandhi Road, Fort,

Mumbai – 400 001

Important Slip (Overseas Mediclaim Policy)

Please make sure you read and fully understand this document before you travel from the republic of india.

Failure to follow instructions given could result in rejection of any claim that might be made.

The overseas mediclaim policy provides indemnity for expenses incurred for medical treatment for illness, diseases contracted or injury sustained during travel and which is necessary to be undertaken immediately without which the insured is not able to leave the overseas country under medical advice.

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Now this policy provides as follow:

Definitions:

The following definitions apply throughout this Insurance:

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Medical related expenses reasonably and necssarily incurred means expenses that in the opinion of the treating physician and Coris are medically necessary in order to maintain life and / or relieve immedi