Toenail injury during US trip, insurer denies claim; 62-year-old woman wins Rs 1.2 lakh

According to The Indian Express, the insurer was directed to reimburse the medical bills worth USD 944.61, equivalent to more than Rs 89,000, and pay Rs 30,000 as compensation for mental agony and harassment, along with litigation costs. The headline figure of approximately Rs 1.2 lakh includes the reimbursement and compensation, besides the litigation costs. In its October 23 order, the commission observed that the woman had suffered an injury to her toenail after reaching the US, purchased medicines and visited Franciscan Hospital, incurring medical expenses.

It held that the insurer's failure to reimburse the eligible amount amounted to deficiency in service and unfair trade practice. However, the commission did not find any deficiency in service or unfair trade practice on the part of the online insurance broker through which the policy had been purchased, IE reported. The policy was valid from February 17 to April 9 this year and provided medical coverage of up to USD 500,000.

She travelled to the US on February 18. On March 5, while closing a door during household work, she injured her toenail. As the pain continued, she purchased medicines from a local pharmacy and visited the emergency department at Franciscan Hospital on multiple occasions for treatment, paying the expenses herself. The complainant said her doctor subsequently advised her to consult a surgeon. However, as she had exhausted her funds, she decided to return to India earlier than planned.

She rescheduled her return flight from April 1 to March 24, incurring additional costs. After returning to India, she submitted her medical bills and sought reimbursement from the insurer and the online insurance broker. She alleged that the insurer failed to release the claim amount despite repeated requests, prompting her to approach the consumer commission. Insurer questions supporting medical documents The insurance company argued that the claim was not valid because the woman had submitted medical bills without the corresponding treatment records to establish the injury.

The online insurance broker, meanwhile, maintained that its role was limited to facilitating enrolment in insurance policies through its digital platform. It argued that decisions on accepting or rejecting claims rested solely with the insurer. The commission noted that the woman had purchased a valid policy covering medical expenses arising from illness or injury during the insured trip. It also recorded that the toenail injury occurred in the US within the policy period and that she had incurred expenses on medicines and hospital treatment.

11 lakh from hotel Rejecting the insurer's defence over the absence of treatment papers, the commission referred to the policy terms, which required the insurer to guarantee reasonable and customary medical charges incurred to relieve acute pain resulting from an accidental injury. Of the total amount claimed by the woman, USD 1,224.61, the commission found that bills worth USD 944.61 were directly related to treatment during the trip and had been wrongly withheld by the insurer.

It held the insurance company guilty of deficiency in service and unfair trade practice, while absolving the online broker of liability. Takeaway Travellers should retain hospital records, prescriptions, pharmacy receipts and medical bills when seeking reimbursement for treatment overseas. It also underlines that insurers must assess claims in accordance with the policy terms and the evidence available, rather than reject eligible expenses without adequate justification.