Flavia Mary Agnes Pais vs ICICI LOMBARD GENERAL INSURANCE CO LTD

THIS revision petition has been filed by Mrs.Flavia Mary Agnes Pais (hereinafter referred to as the ''Petitioner '') against the order of the State Consumer Disputes Redressal Commission, Karnataka (hereinafter referred to as the ''State Commission '') in Appeal No.1388/2007 which was decided in favour of ICICI Lombard General Insurance Co. Ltd., Respondent herein.

THE facts of the case are that the Petitioner had purchased an individual travel insurance policy on 18.06.2004 from the Respondent/Insurance Company in respect of her travel to USA to visit her daughter and son-in-law. According to Petitioner, due to the sub-standard food served on the flight between Mumbai and Los Angles, she suffered from diarrhea for which she had to be admitted to the Banner Desert Medical Center Hospital, Phoenix in USA on 24.06.2004 where she remained as an inpatient till 26.06.2004. The bill for her medical treatment at that hospital was the equivalent of Indian Rupees 5 lakhs. She obtained a discharge from the hospital and decided to travel back to Bangalore for further treatment. Petitioner sent the necessary medical certificate and the charges for expenditure incurred on her treatment to the Respondent/Insurance Company which despite several letters rejected the same. Petitioner, therefore, filed a complaint before the District Forum for mental agony and personal inconvenience and requested that Respondent/Insurance Company be directed to pay her Rs.6,91,225/- as compensation for financial loss, Rs.1 lakh for mental agony and personal inconvenience etc. and Rs.94,512/- being the interest amount (@ 10% per annum from 01.07.2004). The above contentions were challenged by the Respondent/Insurance Company who stated that as per medical report from the Banner Desert Medical Center Hospital at Phoenix dated 26.06.2004, it appears that Petitioner had a history of Arterial Fibrillation diagnosed approximately 8 months prior to her having undertaken the travel to the US and therefore, since this was a pre-existing disease the claim was rightly repudiated keeping in view the terms and conditions of the insurance policy. There was thus no deficiency in service.

THE District Forum after hearing both parties partly allowed the complaint and directed the Respondent/Insurance Company to pay the Petitioner, Rs.6,08,100/- towards the medical and air-ticket expenses along with interest @ 6% per annum from the date of complaint till realization and Rs.6,000/- as compensation and litigation expenses, within 30 days from the date of the order.

AGGRIEVED by this order, Respondent/Insurance Company filed an appeal before the State Commission. The State Commission while upholding the order of the District Forum, directed the Respondent/Insurance Company to pay Petitioner Rs.5,00,000/- towards medical expenses incurred by her along with interest @ 6% per annum from the date of complaint till realization and set aside the payment for travel expenses. State Commission also awarded Rs.50,000/- as compensation for mental agony and hardship. The relevant part of the order of the State Commission is reproduced: "The complainant has also claimed certain amount as damages towards the money spent by her to purchase the Air Ticket by Malaysian Airlines for herself and her daughter and other expenses. In our opinion, the complainant is not entitled to any damages since the same is not covered under the Policies. But since the Insurance Company has unreasonably denied the claim of the complainant on irrelevant grounds, we are of the view that the Insurance Company is to be directed to reimburse the medical expenses incurred the complainant with interest. Since there is a delay on the part of the Insurance Company, the Insurance Company is to be directed to pay certain amount as compensation to the complainant towards mental agony and hardship faced by the complainant in a foreign country. Under this head, we are of the view that the Insurance Company is liable to pay Rs.50,000/- as compensation. "

Hence the present revision petition filed by the Petitioner seeking restoration of the order of the District Forum. Counsel for both parties made oral submissions. Counsel for Petitioner stated that as per terms of the travel insurance policy under the heading "Benefit 1- Medical Expenses Cover " the insurance claim would also include transportation and any extra costs of medically necessary and prescribed transportation from the foreign country to the Republic of India. Therefore, since the Petitioner had to return to India by Malaysian Airlines since Air India refused to prepone the date of the ticket in respect of Petitioner ''s return journey and her daughter had to accompany her as an attendant, the claim was fully justified in terms of the policy.

COUNSEL for Respondent reiterated that the Respondent ''s claim for enhancing the amount already awarded by the State Commission by restoring the order of the District Forum to include return travel expenses was not justified since these were not a part of the provisions of the insurance policy taken by the Petitioner.

WE have heard learned Counsel for both parties and have gone through the evidence on record. In the instant case, the only issue to be decided is whether the Petitioner is entitled to a claim of Rs.6,08,100/- as awarded by the District Forum which was later modified and reduced by the State Commission to Rs.5 lakhs being the expenditure claim only for her medical treatment. We have gone through the insurance policy and we note that as per the provisions of this policy regarding transportation, this would be admissible only if it was medically necessary and prescribed in respect of both the insuree as well as any attendant accompanying her. In the instant case, there was no such medical advice/necessity for the Petitioner to travel back to India for further treatment. Petitioner had decided to do so on her own because she feared that in case she continued with her medical treatment in the US the expenses incurred would be very high. She thus did not travel back to India on any medical advice nor is there any evidence on record of either the treating hospital or any medical expert that it was necessary for her daughter to accompany her as a medical attendant.9. In view of the above facts, we see no infirmity in the order of the State Commission reducing the compensation amount from Rs.6,08,100/- awarded by the District Forum to Rs.5 lakhs (by excluding the expenditure incurred for travel) along with Rs.50,000/- as compensation for mental agony etc. and uphold the same. The revision petition is, therefore, dismissed. Respondent/Insurance Company is directed to pay the Petitioner Rs.5,00,000/- towards medical expenses incurred by her along with interest @ 6% per annum from the date of complaint till realization and Rs.50,000/- as compensation for mental agony and hardship within six weeks from the date of receipt of this order failing which the entire amount would carry interest @ 9% per annum from the date of filing of the complaint till its realization.