The Thane District Consumer Redressal Forum (TDCRF) while admitting a complaint by an 82-year-old resident here, held that a health insurance company and its service provider were deficient in their services and hence ordered them to honor his full claim of USD 13253.
Perhaps this is the first time the Forum has ordered payment in foreign currency to any complainant.
In their order issued recently, Forum President Sneha Mhatre, and members Madhuri Vishwarupe and N D Kadam ordered that ICICI Lombard General Insurance Company and its TPA (Europ Assistance India Pvt Ltd) will jointly and severally pay the claim amount to complainant Ramesh Mohare, a resident of Srirang Society here by end of this year else pay interest at 12% p.A. Till realisation.
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The Forum also awarded a compensation of Rs 3,000 for sufferings of the old man during the last nine years chasing the claim and also Rs 10,000 towards the legal expenses he incurred.
Mohare stated in his complaint that he had taken the overseas insurance policy from ICICI as he had to visit his son in US for a vacation.
He said that it was during his stay with his son on May 02, 2007 he suffered from chest pain and was admitted to the Saint Antonio's University Health Care System Hospital at Texas for treatment and was there for the next two days getting treatment and was discharged on May 04, 2007.
He also said that his son had informed the insurer immediately about the admission and treatment telephonically.
Even though the policy was cashless the insurer had not made any provision to make the payment to the hospital it was stated.
Hence after the complainant gave an undertaking that he would pay the bill after getting the payment from the insurer, he was discharged from the hospital.
It was on May 26, 2007 the claim along with the requisite 14 documents was lodged with the insurer, the receipt of which was acknowledged the next day via email by the insurer.
On August 10, 2007 the insurer again sought certain documents from the complainant which were already provided to them.
The TPA, had in March 2011, asked for some more documents which were already provided along with the claim.
In April 2011, the insurer informed the complainant that he would know about the status of the claim within 7 days which never happened.
Later, after returning to India the complainant repeatedly followed up with the insurer about the claim but as there was no response from them, he sent a legal notice followed by a complaint with the Forum.
The insurance company in its submission said that
there was delay in lodging the claim which the Forum rejected.
The insurer also came up with an argument that the illness of the complainant had not happened during the trip which was also turned down.
In its order, the Forum observed, "Travel is the movement of people between relatively distant geographical locations and can involve travel by foot, bicycle, automobile, train, boat, airplane, or other means, with or without luggage, and can be one way or round trip."
Travel can also include relatively short stays between successive movements, it said.
The Forum also observed that trip duration means the length of time period commencing from the date when the insured travels out of the country of residence (of the insured) and ending on the date of return to the country of residence of the insured.
Taking into account the various provisions and rulings it can be said that the submissions made by the insurer are meaningless and without reference and hence rejected, the forum said while holding that there was deficiency in services by the insurer.
