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Complaint filed on: 29.01.2015 Complaint disposed on: 13.03.2026 BEFORE THD I(ARITTATAI{A STATE CONSUMER DISPUTES REDRESSAL COMMISSION, BANGALORE. (ADDL. BENCH)

DATED THIS THE 13th DAY OF MARCH, 2026 scl2e lcclse l2ols PRESENT CORAM: Hon'ble SRI RAVI SHANI(AR, JUDICIAL MEMBER Hon'ble SMT. SUI{ITA C.BAGEUIADI, LIIDY MEMBER Radhakrishan Pattabiraman, S/o S.Pattabiraman, R/a B-101, Vaswani Pinnacle, White Field, ...Complalnant/s Bangalore-560066 EgS,fi-PSxegandhan -Versus-

Bajaj Allianze General Insurance Company Ground floor, No.31, TBR Towers, Mission Road, ...Oppostte Party/s Near Bangalore Stock Exchange, Bangalore-560027 @g ^{Srl. ManoJ Kumar, Ad,aocate)}

ORDER BY HON'BLE SRI. RAVISHANI(AR. JUDICIAL MEMBER The Complainant frled this complaint against Opposite Party alleging deficiency in service for not settling the claim towards his hospitalization at St. Vincent Health Services Hospital at 9205 SW, Barnes Road, Portland hence, prays for an amount of USD 746.26. Hence, prays for payment of the said amount as from 27.1O.2O11 at the rate of Rs.50/- per USD with interest @ l8o/o p.o.., compensation of Rs. 5,OO,OOO / - atrrd Rs. 50,000/ - towards litigation expenses and other reliefs.

2. The brief facts of the complaint is that;

The complainant took a Mediclaim policy known as Travel Overseas Insurance Policy on 08.06.2011 for a period commencing from 14.06.2011 to 28.08.2011, or ttre date of return to India whichever is earlier. The plan chosen by the complainant is a Travel Age Elite Gold (US $ZOOOOOI Geographical coverage being worldwide. Such being the case on 14.08.2011 while the complainant at Portland USA, he was admitted in emergency room in Providence St. Vincent Health Services Hospital, Portland for atherosclerotic coronar5r artery disease with acute non-ST Segment elevation myocardial infarction resulting in coronary angiography with left heart catheterization and insertion of intra aortic balloon pump for emergency artery bypass. He was admitted on 14.08.2011 and discharged on 31.08.2011. During his hospitalization the complainant spent nearly US $1,37,167.83 out of the said amount the complainant paid US $ OZtl- being treatment towards emergency laboratory services LLC providence Health and Service Bil1, Tuality Health Care Bill, Coram BS and different dates amount into 621.26 IJS $. The balance amount was directed to be paid by this complainant amounting to Rs.137063/- US $ and the insurer directed to pay the said amount as per the direction the amount was paid. There afterwards the complainant sought for reimbursement by virtue of the policy. The Opposite Party confirmed the claim medically admissible and restricted the limited liability to US $15,000/- with a deductable of US $ 100. The Opposite Party instead of covering the entire liability up to US $ 1S,OOOT- as restricted to US $ 15,0OO/- without any reasons. In this regard, so many correspondences were made by the complainant for reimbursement, but no fruitful response made by the Opposite Party. The Opposite Party even admitting the liability as restricted to the US $ 1S,OOOT- only witJrout any valid reasons. The reason for restricting to US $ 15,000/- liability that tlre ambiguity in the policy. Mere ambiguity in the policy will not sufficient. The policy clearly discloses the liability up to US $ SO,OOOT-. The grounds urged for restricting the liability up to US $15,000/- is an untenable ground. When the party admitted the claim up to US $ 30,000/- on 05.10.2011 there is no scope for restricting the claim up to US $ 15,0OO/-. It is a clear case of deficiency in service not setding the claim. Hence, prays to settle the claim as per the merno of calculation filed and also direction be given to pay the interest @ 18% on unpaid tlre amount along with compensation of Rs.5,00,000/- for deficiency in service and mental agony with litigation expenses as per above.

3. After service of notice the Opposite Party appeared through his counsel and filed version contending