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.
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.
