Consumer Forum Asks Oriental Insurance to pay Rs7.38 lakh for Joyride Injury
A personal accident policy and a happy family floater policy are usually sufficient for most individuals and families to head out for a holiday. Or that’s what a honeymooner thought. 
 
The following is a case of a person holding all relevant policies but different interpretation of certain clauses by the insurer could have denied him reimbursement. Maintaining all relevant receipts, bills and records probably too came in handy for the insured. 
 
For Hiren B Joshi, a resident of Mira Road, the holiday was also his honeymoon within a fortnight of his marriage on 28 November 2014. He selected Manali in Himachal Pradesh after consulting Heena Tours & Travels. Lakhs of people visit Manali each year for adventure sports including paragliding from India and abroad, newspaper reports say. {https://www.thrillophilia.com/cities/manali/tags/paragliding}
 
The Joshis were part of a group of 100, in which they would go up in the air through a non-motorized, foot launched flying glider with an inflatable wing, which would gradually descend with the help of a parachute. In the case of Mr Joshi, the parachute did not open fully, despite attempts by the pilot. On descent he hit the rocky portion of the surrounding hills and was grievously injured, says a South Mumbai District Consumer Disputes Redressal Forum order dated 1 June 2019. 
 
The paragliding, on 10 December 2014, was being operated by an expert and Mr Joshi had no role in operating it and was no more than what a passenger would be in an airplane.
 
For his injuries, Mr Joshi was admitted the same day to Lady Wellingdon Hospital at Kullu. He was moved to Fortis Hospital at Mohali the next day and was discharged on 6 January 2015. Soon after reaching Mumbai, he was hospitalized again at the Borivali Orthopaedic Clinic from 6 February 2015 to 9 February 2015 and again from 1 April 2015 to 4 April 2015. 
 
“The complainant lodged the claim claiming compensation of Rs6 lakh under the happy floater policy and in support of it he had submitted a duly completed claim form and the original medical and investigation reports, case papers, bills, memos, which was received by the opposite party on 12 January 2015,” said the order by the South Mumbai District Consumer Disputes Redressal Forum. 
 
Happy family floater policy from Oriental Insurance gives a fairly comprehensive cover to a family against illness and injury. For details on Happy Family Floater Policy, please read under -- {https://orientalinsurance.org.in/documents/10182/45621/HFF_Policy_wording/6ad2772c-5efc-4cc9-a46a-b2def73f9493
 
Mr Joshi also filed a claim under the personal accident policy issued to him by the insurance company. 
 
Mr Joshi sought Rs6 lakh plus Rs1.28 lakh for the settlement of his claims under the happy family floater policy and personal accident policy and compensation. He also asked the insurance company to pay him Rs60,000 towards payment of fees to a senior advocate.
 
He submitted every single piece of document that could be relevant for the case including brochures given by the travel operator, medical and hospitalisation bills, communications with Raksha TPA, among others.
 
The insurance company rejected his claims on 25 March 2015 and the order was confirmed by the ombudsman on 26 October 2015. One of the key grounds for rejection of his claims by the insurer was Clause 4.19 of the policy.
 
Clause 4.19 of Oriental Insurance Co states “Any treatment arising from Insured’s participation in any hazardous activity including but not limited to scuba diving, motor racing, parachuting, hang gliding, rock or mountain climbing etc. unless specifically agreed by the Insurance Company.”
 
However, Joshi contended that he himself did not indulge in any risky activities, he was not operating any equipment and was just like a passenger being navigated by a trained pilot. 
 
At the Consumer Forum, the insurance company “appeared and filed a written statement through their authorised signatories and the divisional manager Jaysurya Rapaka ,stating that, the complaint is false and bad in law, reliefs prayed for are not maintainable and there is no cause for action and the complaint is time barred, hence dismissed with cost.”
 
“…taking part in paragliding is itself risk, knowing the same complainant has taken the risk and hence the injury cause due to taking such risk is not covered,” the insurer contended.  
 
The insurer could not provide any material evidence to back up the contention that paragliding is a hazardous activity, and that injuries were sustained because of Joshi’s own negligence, Joshi contended. 
 
Mr Joshi’s request to Raksha TPA for cashless facility on 12 December 2014 too had come a cropper, with Raksha replying that as per clause 4.19 the injury has been sustained during a hazardous sport. Raksha assured Joshi that he could seek a review later.
 
The bench finally decided that Joshi is entitled to Rs6 lakh under happy family floater policy, Rs1.28 lakh under personal accident policy, along with 3% interest from the date of filing the complaint. Mr Joshi also got Rs7,000 as compensation for mental agony and Rs3,000 for the proceedings. 
  • Like this story? Get our top stories by email.

    User

    COMMENTS

    P M Ravindran

    2 months ago

    The relevant question is whether the insurance co has paid the compensation or gone on appeal.

    shivkumar

    2 months ago

    Insurance companies are very fast while issuing a policy, on the other hand they look for all sorts of excuses to reject the claims. I will not be surprised that the insurance company in the said case goes in appeal before the State Commission. By the way what is 3% interest? Is it a joke?

    Personal Finance   Sponsored Post
    “Why You Should Always Purchase US-based Visitors Insurance When Traveling to the USA” By Rajeev Shrivastava, CEO and Founder, VisitorsCoverage
    The number of Indians traveling to the United States is expected to hit 1.19 million this year and grow to an estimated 1.41 million by 2022. Many of you reading this may have heard stories of family and friends who have traveled to America without visitors insurance and ended up with huge medical bills, or worse, financial insolvency. America does not have a universal medical system and it is well-known that it has some of the highest medical costs in the world. Traveling for business or personal reasons without adequate visitors travel insurance is a risk not worth taking for yourself and your family.
     
    How do I know if I need visitors insurance? 
     
    Visitors insurance is always recommended for international travel, but especially for travel to the United States. While the US does not require travel medical insurance for entry, many other countries do. Some countries and regions, like Cuba and the Schengen region of Europe, require certain citizens to have a visitors insurance policy to gain entry. In the Schengen countries, at least 30,000€ of medical travel insurance coverage is required to obtain the Schengen visa. While this may be adequate coverage for a minor illness or injury in the EU, it would be woefully inadequate for any hospital visit or stay in the United States. 
     
    When traveling to the United States, you always want to purchase your travel insurance from a US-based travel insurance provider so that you can have numerous policy options and pricing to choose from. 
     
    Don’t think that you will be a “lucky” traveler and be safe from having a medical mishap 
     
    Travelers have been known to injure themselves while traveling to the airport or while at the airport waiting for their flight. Injuries have occurred while disembarking from tour buses or cruise ships, but most injuries that happen abroad are no different than injuries or illnesses that could happen at home – but you won’t be at home, and if in the United States you would be looking at a minimum of 105,000 INR (1,500 USD) just to be admitted to an emergency room. 
     
    What kind of travel insurance coverage do I need to have when traveling to America? 
     
    The most important travel coverage you will need when traveling to the United States is medical coverage. It is recommended to have up to $2 million USD in coverage when traveling to the United States. If you can afford more, purchase more—it is not uncommon to accrue $2 million USD if a serious illness or injury requires hospitalization and surgery in the US. 
     
    Travelers need to think about flight cancellations, emergency evacuation for both medical and global incidents such as California earthquakes, Florida hurricanes and Midwest tornadoes when visiting the United States. 
     
    In addition to medical mishaps, foreign visitors could potentially be denied border entry, have their luggage or passports lost or stolen and need to consider being covered for emergency evacuation and emergency reunion with a family member in the US if they fall seriously ill or seriously injured. Repatriation back to your home country in the case of serious injury or illness or repatriation of your remains is sobering, but a necessary coverage option to consider, as is “Cancel for Any Reason” coverage which is the only coverage that will repay a portion of your prepaid expenses due to civil unrest.
     
    How does trip insurance differ from travel insurance?
     
    “Travel insurance” is often used interchangeably with “trip insurance” which is protection for a travelers’ financial investment made for a trip. Travel medical insurance provides different benefits than trip or travel insurance. Trip insurance generally does not provide medical coverage, but rather coverage for trip-related mishaps, such as flight and trip cancelations or interruptions. All airlines offer trip insurance to their customers before paying for their flight, typically with only one provider offered, and many travelers will click this option, not realizing that there are many more options for purchasing trip insurance with more comprehensive coverage. 
     
    Trip insurance would cover the aforementioned scenarios including loss of passports and luggage, border entry denial and Cancel for Any Reason coverage, which allows cancellation of your travel up to two days prior to departure due to family illness or death, work reasons, a natural disaster or civil unrest in the city you are planning to visit. Cancel for Any Reason coverage allows you to recoup up to 75 percent of prepaid expenses should you cancel your travel plans. 
     
    Benefits of purchasing a US-based visitors travel insurance policy:
     
    • While policies purchased in India are typically less expensive than US-based policies, this is usually because the coverage limits are lower and you may not have coverage for cancellation of your trip should there be an emergency such as family death or illness. 
       
    • Your medical coverage protection will be more comprehensive because they are based in the US and can negotiate fees directly with the providers without any middlemen.
       
    • Your options range from less expensive policies that have a range of deductibles to purchasing comprehensive plans within preferred provider networks (PPOs) where you may only have to pay a reasonable co-pay or pay nothing at all should you or a family member require medical treatment. 
       
    • If you need immediate assistance you may not be able to reach the Indian company due to different time zones, secondly, you will have to pay all medical or trip cancellation costs up front and file for reimbursement when you return home, which could take months.
     
    Purchasing a travel insurance policy in India may seem like a good deal as your vacation costs add up, but this is one expense you can’t afford to “go cheap” with. 
     
    Rajeev Shrivastava, is CEO of VisitorsCoverage Inc., an InsurTech company operating in the travel insurance space with a mission to simplify travel insurance for travelers. 
     
  • Like this story? Get our top stories by email.

    User

    COMMENTS

    SURESH NAIR

    2 months ago

    The author has not given any concrete proof that the policies bought in US are way better than policies sold in India. This piece is full of insinuations and also highly misleading! Policies in India come with sum assured as high as 10 lakhs US Dollars. It is quite comprehensive and covers passport land luggage loss, flight cancellations, emergency evacuations, repatriation, family member reunion in case of emergencies etc . All the points mentioned by the author. Also to state that upfront payment is needed for policies taken in India is outright false! And another false point he makes when he states that due to different time zones you won’t be able to contact the Indian company! Customer care works 24 hours and also you can contact the service provider in US with whom the insurance company has entered into a tie up!

    Policybazaar fined Rs 10 lakh for concealing facts
    The Delhi High Court has slapped a Rs 10 lakh fine on Policybazaar, an online platform that aggregates insurance plans and serves as a marketplace for policies, for concealing facts to obtain a favourable order in a trademark infringement case filed by it against an insurance company.
     
    "The stature of a party or enormity of the claim should not be a constraint for the court to advance the cause of justice. Courts should not allow a party to get away with concealment of material facts when it comes to matters relating to grant of relief that are founded on principles of equity," Justice Sanjeev Narula said in a May 28 order while imposing fine.
     
    The court asked the firm to deposit Rs 5 lakh with the Prime Ministers Relief Fund and other Rs 5 lakh with Delhi Legal-Aid Services Authority. 
     
    On May 16, the court had restrained Acko General Insurance from using the trademark 'policy bazaar' in any manner or form or combination or as an adword/key word programme through Google.
     
    Later, Acko approached the court saying the Policybazaar had concealed and distorted material facts, made misrepresentations and false statements before this court to obtain the ex-parte ad-interim injunction order. 
     
    Acko told the court the Policybazaar had clandestinely approached this court alleging infringement on the part of Acko for making reference to 'POLICYBAZAAR' as a keyword when policybazaar themselves were making reference to Acko and its group company's registered trade mark 'ACKO' as a keyword.
     
    The Policybazaar admitted to doing so, but told the court it had stopped that since April 23.
     
    "I have no hesitation to say the concealment has been deliberate in this case. Plaintiffs (Policybazaar) could have easily mentioned the true and correct facts before the court. Plaintiffs ought to have candidly disclosed all material facts which have a bearing on the issues of the present case," the court said.
     
    Moreover, the Policybazaar owed a duty to the court and concealment of facts amounted to making an attempt to pollute the pure stream of justice, the court said adding the judiciary had repeatedly instructed that a party who didn't disclose all material facts wont have a right to be heard. 
     
    "Plaintiffs themselves for nearly one year were bidding for defendant's trademark 'ACKO' and were therefore acting in an unfair manner. This critical factor would have certainly weighed upon the court while granting ex-parte ad-interim injunction," the court said. 
     
    The court said by concealment of this material fact, the Policybazaar had taken unfair advantage over the Acko and directed that the May 16 order of injunction should remain suspended till July 11, the next date of hearing.
     
    Disclaimer: Information, facts or opinions expressed in this news article are presented as sourced from IANS and do not reflect views of Moneylife and hence Moneylife is not responsible or liable for the same. As a source and news provider, IANS is responsible for accuracy, completeness, suitability and validity of any information in this article.
     
  • Like this story? Get our top stories by email.

    User

    We are listening!

    Solve the equation and enter in the Captcha field.
      Loading...
    Close

    To continue


    Please
    Sign Up or Sign In
    with

    Email
    Close

    To continue


    Please
    Sign Up or Sign In
    with

    Email

    BUY NOW

    online financial advisory
    Pathbreakers
    Pathbreakers 1 & Pathbreakers 2 contain deep insights, unknown facts and captivating events in the life of 51 top achievers, in their own words.
    online financia advisory
    The Scam
    24 Year Of The Scam: The Perennial Bestseller, reads like a Thriller!
    Moneylife Online Magazine
    Fiercely independent and pro-consumer information on personal finance
    financial magazines online
    Stockletters in 3 Flavours
    Outstanding research that beats mutual funds year after year
    financial magazines in india
    MAS: Complete Online Financial Advisory
    (Includes Moneylife Online Magazine)