Foreign travel policies also cover post-hospitalisation OPD cost

It is normal even when insurance companies pay a claim to arbitrarily disallow a part of the amount without a justification. Anila Gupta had taken ICICI Lombard's Overseas Travel Policy for the period of July 29 to August 27, 2011. Under the policy, she was entitled to cashless treatment and other benefits while abroad.

Gupta travelled to Thailand on July 29, where she fell critically ill. She was required to be admitted to a Bangkok hospital on August 23, 2011. The next day, her husband, who was in India, sent an e-mail to the insurance company, intimating it. It was registered as a cashless claim. During her hospitalisation, the insurance company's officials kept in touch with the doctors and hospital authorities. Gupta was discharged on September 26, 2011. However, as the ailment was contagious, she could not leave Thailand and had to continue treatment as an outdoor patient.

The hospitalisation from August 23 to September 26, 2011, cost Thai baht (THB) 12.99 lakh. A substantial part of this was paid by the insurer but the amount fell short by THB 1.14 lakh. So, Gupta was compelled to pay this. After her discharge, she spent another THB 55,994 for treatment as an outdoor patient till October 16, 2011. Yet, she was still not medically fit - she was on a wheelchair, required continuous oxygen support and two attendants. She called her husband from India to help bring her back home.

Once in India, she made a claim for the expenses incurred and also for her husband's needed visit. ICICI Lombard asked her to get a travel recommendation from the doctor. Since the claim was not settled, Gupta filed a complaint before the Central Mumbai District Forum against the insurer and its claim processing agent, Europ Assistance India. She claimed reimbursement for medical expenses, travel expenses incurred by her husband and son, and compensation for mental agony/harassment.

Both ICICI Lombard and its agent did not bother to file their reply or attend the hearing, though the notice was served by the forum. Instead, they sent a cheque of Rs 1.18 lakh (THB 76,234.49), but Gupta did not encash it since the dispute was pending before the forum.

The judgment was delivered this Wednesday by the Forum's president, B S Wasekar, for the bench with member H K Bhaise. It was observed that the dispute was about the short payment of THB 1.14 lakh and non-payment of outdoor treatment expenses of THB 55,994, totalling THB 1.7 lakh. The Forum ruled this amount would have to be reimbursed by the insurer. As regards the travel expenses of her husband and son, the forum noted the policy did not cover reimbursement of these and rejected this claim.

The forum accordingly directed ICICI Lombard and its agent to settle the claim of THB 1.7 lakh, along with nine per cent interest from the date of the complaint till payment. It also awarded a compensation of Rs 10,000 and costs of Rs 5,000.

This judgment establishes that the 'happening of the event' must occur within the policy period. This means the date of admission is relevant for a claim under a policy which covers health insurance. The policy was from July 29 to August 27, 2011, and Gupta was hospitalised from August 23 to September 26, 2011, and continued out-patient treatment till October 16, 2011. Though the policy expired on August 27, 2011, she was entitled to the entire cost of the treatment till October 16, as she was admitted to hospital on August 23, while the policy was in force.

The author is a consumer activist