Order Name: ICICI Lombard General Insurance Co. Ltd. Vs. Rupali Inamdar
Case No.: F.A. No. 1857/2019
The National Consumer Disputes Redressal Commission, led by Mr. Subhash Chandra, recently made a significant ruling about insurance policies and their terms. Insurers cannot rely on fine print to avoid paying claims unless they have clearly communicated those terms to the insured.
In this case, the complainant had a travel insurance policy from ICICI Lombard General Insurance for a trip to Schengen countries with her family, including her two children. During their visit to Jungfraujoch, Switzerland, she slipped on snow and injured her leg, requiring airlift and surgery, which resulted in medical expenses amounting to Rs 33,16,171.70. Initially, the insurer accepted her claim but later denied it, citing that the accident involved riding a sleigh, an activity reportedly prohibited under the policy. Even after clarification that the activity was safe and involved her young children, the insurer denied her claim and additional expenses of Rs 2,37,667.50.
The complainant approached the State Commission of Maharashtra, which partially favored her. This led the insurer to appeal for a modification or reversal of the order.
The insurer contended that the State Commission’s decision was flawed because it did not consider the exclusion clause of the policy. They argued that the micro-printed terms were communicated to the complainant and that she never disputed them. The insurer also pointed out inconsistencies in the complainant’s account of the accident, suggesting the activity was inherently risky and therefore the complainant’s own responsibility.
The National Commission examined whether the State Commission was correct in ruling against the insurer. It noted that insurers cannot evade liability due to the alleged lack of disclosure of the policy’s fine print, referencing earlier cases like Oriental Insurance Co Ltd. Vs. Sony Cheriyan and United India Insurance Co. Ltd. vs M/s Harchand RaiChandan Lal. The key issue was whether the accident arose from a hazardous activity not covered by the policy. The State Commission had not addressed this, so the National Commission set aside its order and returned the case for further examination on whether the activity leading to hospitalization was indeed hazardous and not covered by the policy.
Takeaway: This case underscores the importance of insurers clearly communicating policy terms to policyholders. Insurers cannot rely on fine print to reject claims if those terms were not effectively disclosed to the insured.
