Mumbai Ombudsman Centre
Case No. : GI-322 of 2005-2006
Shri R.N.Talcherkar
V/s
ICICI Lombard General Insurance Company Limited
Shri R.N.Talcherkar who was on a tour with his family and friends to Moscow and St.Petersburg had taken an Overseas Leisure Travel Insurance policy for the period 20.9.05 to 5.10.05 from ICICI Lombard General Insurance Company Ltd. On 28.09.2005, when he was sightseeing at Moscow he experienced chest pain in the morning and again in the evening for which he got admitted to the American Clinic. After the treatment and other investigations, he was discharged on 29.9.2005 with advice to visit a doctor on his arrival to India.
After his return to India on 4.10.2005, when Shri Talcherkar preferred a claim to ICICI Lombard General Insurance Company Ltd., the Company repudiated the claim invoking pre-existing conditions under exclusion clause (1) (3) of the policy. Aggrieved by the decision of the Company, Shri Talcherkar approached the Forum seeking intervention of the Insurance Ombudsman for settlement of his claim. His contention was that at the time of taking the policy, the Advisor of ICICI Lombard had assured him that the pre-existing diseases were covered as per clause 8 of the policy.
The Company pointed out that there was no criticality in his health status and that the treatment received at the hospital was more of evaluation of the health status than providing minimum medical relief to sustain the patient and help him in recovering with the emergency medical support.
All the annotations and observations by the doctors at American Clinic indicated that they were comfortable after examining the patient and there was no untoward situation to call for an emergency life saving medical support which would have qualified for reimbursement as per the terms and conditions of the policy specially read in conjunction with condition 8 of the policy. Accordingly, the decision of the Company to reject the claim is sustainable.
