Date of Filing:30.03.2022

Date of Disposal:20.03.2023

BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

ORDER

SRI CHANDRASHEKAR.S.NOOLA,

MEMBER

1. This complaint is being submitted in accordance with Section 35 of the Consumer Protection Act of 2019. The complaint requests that this Commission direct the first respondent to pay the hospital costs of "HOPITAL DU SACRE-COEUR DE MONTREAL, 5400 BOUL, GOUIN OUEST,MONTREAL QC H4J IC5", which treated the complainant's father from 4/10/2019 to 14/10/2019.

To direct the op to pay interest on the amount of CAD 27046.89 at 2% above the interest rate from the date necessary documents were presented on 14/10/2019 until the claims are settled, and to pay any additional relief as this commission considers appropriate.

2.   The following are the complaint's key facts: 

Panduranga Handanhal Keshavaiah, the complainant's father, is the insured. He had purchased group Overseas travel insurance from Op1 with certificate number SX2309053 dated 20.05.2019, and had paid travel tag assist charges of Rs.1,01,214/- inclusive of GST at 18% to OP-3. The OP-1 produced a certificate of such insurance dated 20.05.2019 recognizing receipt of Rs.33,155/- on behalf of the insured, and the complainant was paid the money. The insurance provides geographical coverage that includes the United States and Canada. Prior to accepting the insured's policy, the insured was subjected to medical tests at CELARA diagnostics on May 17, 2019. The report relating to the laboratory tests and reports are supplied, and it is clear from the report that the insured was not suffering from tuberculosis, cancer, cough, or cold. The testing did not reveal the presence of CA lung. The patient's physician statement from May 2018 to May 2019 also does not indicate the presence of CA lung. On May 28, 2019, the insured travelled to Montreal. He felt uneasy while staying with the complainant on the 3rd of October 2019 and was rushed to the emergency care on the 4th of October 2019 to Hospital DU SACRE-COEUR DE MONTREAL 5400 BOUL, GOUIN OUEST,MONTREAL QC H4J IC5. The doctors insisted on many medical tests to determine the specific nature of the problem. First, tuberculosis was suspected, but following test results on 11.10.2019, they found that it was CA lung and not TB, and the insured was discharged on October 13th, 2019 without any medical treatment after he was deemed stable.

3. The total cost payable to the OP-4 was CAD 27046.89, of which CAD 925.00 was paid by the complainant. The insurer must additionally pay the interest for late payment. The insured became ill while in Montreal and returned to India on November 4th, 2019. He was hospitalized in the Apollo Hospital on 05/11/2019 for treatment of lung cancer with brain metastasis and died on 6/11/2019.

4. After numerous emails to the op and even persuasion from the OP-3, the complainant was finally informed on 15 July 2020 that the insurance company would cover the expenses till the cancer was diagnosed on 4th October 2019 and that CAD 721.5+150+501.39 aggregating to CAD 1372.89 could be allowed against CAD 27046.89. The insurance company also determined that only CAD 925 was payable and the remainder was a write-off. The insurance company provided no reason for the write-off.

5. The complainant claims that the ailment was not pre-existing and only existed within the insurance's validity term. As a result, the insurance company must reimburse the emergency medical expenses incurred in this scenario. According to the certificate of insurance, the total insured for emergency medical expenses is USD 500000. This is far more than the insured's medical expenses.

6. The OP 1 in their email to the complainant states that as per policy terms and conditions it can pay only the expenses incurred till CA diagnosed and there is no explanation for not allowing remaining amount of CAD (Canadian dollar) 25824.

7. The OPs  were served with the complaint notice, but they did not file their response within the stipulated period of time, so they were placed ex-parte. There was no response whatsoever from the opposing sides. In addition, the complainant asserts that OP-1 is the primary OP and that OP-2 to 4 were constituted for the sake of clarification.

8. The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency of service on the part of the OPs as alleged in the complaint and thereby prove that he is entitle for the relief sought?
2. What order?

9. The findings on the above points are as under:

Point No.1               :       Negative

Point No.2               :       As per final order

REASONS

10. POINT NO.1:- Upon examination of the documentation, the complainant has taken treatment during the currency of policy period. The sum covered for medical bills, emergency medical evacuation, and repatriation of mortal remains is indicated as $500000 in Annexure "A" of page 2 of the insurance certificate. In Annexure "B" consisting of 17 pages, the complainant has provided the medical laboratory test and report given by Celara diagnostics, in which there is no mention of cancer, and the OP-1 has accepted payment and issued an insurance policy. On this report, OP-1 has not expressed any objections. Subsequently, when the complainant travelled to Canada, he became unwell and was admitted to "HOPITAL DU SACRE-COEUR DE MONTREAL, 5400 BOUL, GOUIN OUEST,MONTREAL QC H4A IC5", where he was initially suspected of having tuberculosis and eventually diagnosed with CA Lung. The OP-1’s email response to the complainant notes that according to the policy terms and conditions, the firm can pay only the expenses incurred until the cancer was discovered, totaling CAD $1,372.89, and that according to the available claim document, the company has received payment receipts totaling CAD $925. The insurance company also requests clarification and informs the complainant if the hospital offered any discounts.

11. In  the case of ICICI Lombard General Insurance co Ltd vs Sunil Kumar Bansal the NCDRC ruled in favour of the policy holder, Sunil Kumar Bansal and held that an insurance company cannot deny a travel insurance claim on the grounds of a preexisting condition unless the condition is specifically excluded in the policy. This case is significant because it clarifies the rights of policy holders to receive reimbursement for medical expenses during international travel, and highlights the importance of clear and specific policy language in travel insurance policies. It also emphasizes the need for insurance companies to conduct thorough underwriting and risk assessments before issuing travel insurance policies to ensure that they are able to honor the claims made by the policy holders.

12. In the present case concerning the fact that there isn't a hospital demand notice or discharge report for the medical treatment the insured received in Canada, the complainant hasn't provided any evidence except the bills from the hospital in Canada where the insured was treated. There is no understanding about the bills that are made. Further, the complainant was requested to translate the hospital bill into English because it was written in an unknown foreign language. This request was ignored. The complainant may need to provide additional evidence to support up their claim, such as medical records or additional documentation proving the nature and extent of the treatment they received.

13. In light of the evidence presented, it appears that the complainant was unable to provide the necessary documentation to support their claim for reimbursement. Due to this, the complaint made by the complainants has become without substance and is hereby dismissed. Accordingly, the Point No.1 we answer in Negative.

14. POINT NO.2:- In the result, we passed the following:

                             ORDER

1. The complaint filed by the Complainant U/s.35 of the Consumer Protection Act, 2019 is dismissed. No costs.

2. Furnish free copy of this order to both the parties. 

 (Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 20^th March 2023)

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)             (CHANDRASHEKAR S.NOOLA)       

         MEMBER                                        MEMBER

Witness examined on behalf of the complainant by way of affidavit:

Smt.Sandya.H.P.-who being the complainant

Documents produced by the complainant:

Witness examined on behalf of the OP by way of affidavit: Nil

Documents produced by the OP: Nil

(RAMACHANDRA M.S.)

PRESIDENT

(NANDINI H KUMBHAR)          (CHANDRASHEKAR S.NOOLA)

         MEMBER                                     MEMBER

SKA*