In an insurance contract, the court must strictly interpret the explicit terms and exclusions provided in the policy. When an exclusion clause is clearly defined and the policyholder had the opportunity to return the policy within a 'free look period', the insurer is not liable for claims falling within the exclusion.

ORDER

1. Two separate complaints (i.e. CC No. 274 of 2020 Joydeep Banerjee & Anr. v. Religare Health Insurance Co. Ltd. & Ors; and CC No. 428 of 2020 Ponkumar & Anr. v. Religare Health Insurance Co. Ltd. & Ors.) have been separately preferred on behalf of the complainants aggrieved against the repudiation of claim by the Insurance Company in respect of treatment undertaken by Joydeep Banerjee in CC No. 274 of 2020 and Vinodh Kumar in CC No. 428 of 2020 at Kendall Regional Medical Centre, Miami, Florida, US despite availing Health Insurance Policy under the plan “Student Explore Super”.

For convenience, CC No. 274 of 2020 Joydeep Banerjee & Anr. v. Religare Health Insurance Co. Ltd. & Ors. is taken as a lead case.

CC No. 274 of 2020

2. In brief, complainant no.1 Joydeep Banerjee in CC No.274 of 2020 had procured admission in the Professional Pilot Training Course at Dean International INC Flight School, Miami (pro-forma opposite party no. 5). In order to secure the risk which the complainant no.1 might face during the course of his training, the father of complainant no.1 Sanjoy Kumar Banerjee obtained a Health Insurance Policy from Religare Health Insurance Corporation Ltd. (opposite party no. 1) for an insurance coverage of US$ 3,00,000 towards the emergency medical expenses and other benefits based on the representations made by opposite party no. 3 Mr. Bharat Bhooshan Rodhe, an intermediary of opposite party no. 1.

3. As per the complainants, Mr. Bharat Bhooshan Rodhe (opposite party no. 3) represented to the complainants that Religare premium includes adventure sports ADD and the same covers the injuries to travelers outside India taking part in adventure and hazardous sports activities like piloting non-commercial aircrafts among other things. However, post-purchase, when the complainants were presented with the terms and conditions of the policy, they came across Clause 5.33 of the General Exclusions which exempted Insurance Company from any liability arising out of “any claim relating to aviation training”.

4. It is further the case of the complainant that when this issue was raised with Mr. Bharat Bhooshan Rode (opposite party no.3), complainants were verbally assured that when it has been specifically mentioned in the said policy that the course which the insurance policy covers is ‘Pilot Training Course’, the Insurance Company (opposite party no. 1) had full knowledge of the purpose for which the policy had been issued. As such, the same would override the general exceptions incorporated in Clause 5.33 of the policy. In the aforesaid background, the complainants decided to go ahead with the policy.

5. During the course of training, complainant no.1 Joydeep Banerjee met with an accident during a regular flight training course and was admitted in Kendall Regional Medical Centre, Miami, Florida, US (proforma opposite party no. 7). Consequently, parents of complainant no. 1 visited USA, wherein after multiple surgeries and treatment, complainant no.1 was discharged and brought back to Kolkata on 16.06.2018. Complainant no.1 continued to receive the treatment thereafter at Kolkata. Complainant no.2 also claims to have signed a bond of liability for payment of medical expenses in USA, in the event of failure of Insurance Company to honour the same.

6. Complainant no.2 after the accident of complainant no.1 exchanged