CHANDIGARH: A 62-year-old woman who injured her toenail while visiting the US has won a consumer case against her travel insurer, which refused to reimburse her medical expenses despite the treatment being covered under her policy. The Chandigarh District Consumer Disputes Redressal Commission has directed the insurance company to pay USD 944.61 (more than Rs 89,000) towards her medical bills, along with Rs 30,000 as compensation for mental agony and harassment and litigation costs.The commission passed the order on October 23, holding that the insurer was guilty of deficiency in service and unfair trade practice for withholding the eligible claim amount. The dispute arose after the woman injured her toenail while doing household work in the US on March 5. She had travelled to the country on February 18 after purchasing an international travel insurance policy valid from February 17 to April 9.The woman hurt her toenail while closing a door. When the pain persisted, she bought medicines from a local pharmacy and visited the emergency department of Franciscan Hospital several times. She paid for the treatment herself and later sought reimbursement from the insurer. Her medical expenses also included treatment-related bills from her hospital visits.The woman told the commission that a doctor had subsequently advised her to consult a surgeon. However, with her funds running low, she decided against continuing her stay and returned to India earlier than planned.She rescheduled her return flight from April 1 to March 24, incurring additional expenses.After returning to India, the woman submitted her medical bills and sought reimbursement. However, the insurance company refused to settle the claim, questioning the supporting documents.It argued that the bills alone were insufficient to establish the nature of the injury and the treatment received, as the woman had not submitted corresponding medical records. The online insurance broker through which she had purchased the policy also contested the complaint. It maintained that its role was restricted to facilitating the purchase of insurance and that decisions on claim settlement rested with the insurer.The commission, comprising president Pawanjit Singh and member Brij Mohan Sharma, examined the policy conditions and the documents submitted by the complainant. It noted that the policy provided medical coverage of up to USD 500,000 for expenses arising from illness or injury during the insured trip. The injury had occurred within the policy period, and the woman had incurred expenses on medicines and hospital treatment in the US.The commission rejected the insurer’s argument that the absence of additional treatment records was sufficient grounds to deny the claim. It referred to the policy provision requiring the insurer to cover reasonable and customary medical expenses incurred to relieve acute pain resulting from an accidental injury.Of the USD 1,224.61 claimed by the woman, the commission found that expenses amounting to USD 944.61 were directly linked to her treatment during the insured trip and were eligible for reimbursement. It held that the insurer had wrongly withheld the amount, amounting to deficiency in service and unfair trade practice.However, the commission did not hold the online insurance broker responsible, observing that the decision to approve or reject the medical claim rested with the insurance company. The insurer was consequently directed to reimburse USD 944.61, pay Rs 30,000 in compensation for the mental agony and harassment caused to the woman, and bear the litigation costs.
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