(Passed this on 15th November, 2016)
Shri. S.P. Muley, President –
This is a complaint of deficiency in service against an Insurance Company, Health Services, and a Hospital regarding insurance claim.
Facts in short are that the complainant is a businessman. The Opposite Party No.1 is Royal Sundaram Insurance company, and OP2 is Crescent Hospital and Heart Centre, Nagpur. The complainant is Mediclaim policy holder since 2008 and was consumer of the OP1. The policy was valid from 28.5.2008 to 27.5.2010. Accordingly he was to get Rs. 1,50,000/- for cost of hospital admission, and Rs.1500/- per day hospital expenses. He was medically fit person. On 2.5.2010 he suffered severe pain in the chest and was admitted to the hospital of OP3, which was enlisted with the OP1. His mediclaim policy was in force. On examination it was found that he had suffered heart stroke and was therefore to undergo angioplasty. On urine examination no sugar was detected and he never was a diabetes patient. From time to time he paid total Rs.2,50,000/- to the OP3. Accordingly his angioplasty was done and on 13.5.2010 he was discharged. He was given a bill of Rs.3,17,140/-. After adjusting deposited amount of Rs.2,50,000/- he paid balance Rs.67,150/-.
When he made claim of Rs.3,18,250/- to the OP1 along with all necesary papers, his claim was repudiated after about 5 months on a false ground that he has been suffering from diabetes since one year. Hence he has claimed insurance amount Rs.3,18,000/- with 18% interest along with compensation and litigation cost Rs. 1 lakh.
The OP1 filed its written version and admitted mediclaim policy on certain terms and conditions. It is stated that the complainant was admitted to Crescent Hospital of OP2 for treatment of coronary heart disease from 2.5.2010 to 13.5.2010. He lodged claim in respect of the same treatment. Upon investigation it was found that he was admitted for coronary artery disease. All heart ailments are excluded from cover of the policy issued to him during first two years of policy inception. Hence the claim is not admissible and payable. It is denied that the claim was denied on account of pre-existing diabetes. Further the complint is said to be barred by limitation and non disclosure of material facts. Besides the claim of Rs.3,18,000/- is not tenable because the sum assured was Rs.1,50,000/- only and so liablity of the OP1 cannot exceed the said sum. It is therefore urged to dismiss the complaint.
The OP2 failed to appear despite service of notice. Hence, the matter is heard ex-parte against it.
We have heard rival submissions in the light of documents filed on record. Upon considering the same we record our findings with reasons as under.
FINDINGS AND REASONS
It is not in dispute that the complainant had taken mediclaim policy of the OP1 and during its subsistance he was admitted to the hospital of the OP2. The complainant has alleged that his mediclaim was repudiated on the ground of his pre-exiting ailment of diabetes. He, however, denied having diabetes. The OP1, on the other hand, asserted that the claim was not repudiated on pre-existing diabetes, but on the ground that he had taken treatment for coronary heart disease and during first two years of operation of the policy any heart disease is not covered under the policy. Considering the submissions, we have perused the repudiation letter. It reads thus,
¨The hospitalisation has been for coronary Artery disease, which is not covered for the first two years of operation of the policy. Further the patient is a known case of diabetes since last one year before inception of policy and therefore diabetes is pre-existing. Present admission for Heart ailment is directly related complication of pre-existing diabetes.¨
Thus the main ground of repudiation was heart ailment which was not covered during first two years of inception of the policy. The complainant was also found to be diabetic patient since last one year of inception of policy. However, on perusal of medical papers and discharge card we do not find him a diabetic patient. Because before Angioplasty his urine and other tests were done and no blood sugar was detected in urine or blood. There is no medical paper to show that he was suffering from diabetes. We therefore have no hesitation to conclude that the complainant had no diabetes. The OP1 could not bring evidence to show diabetic condition of the complainant. Even otherwise the OP itself stated that claim was not repudiated on the ground of pre-existing diabetes.
We, therefore, concentrate on the ground of heart disease. The counsel for the complainant invited our attention to the Certificate of Insurance wherein at the bottom the list of various diseases is given and heart disease is included. Therefore it is contended that heart disease is covered under the mediclaim policy. The complainant was admitted to the hospital on 2.5.2010 and was discharged on 13.5.2010. His hospitalisation was during the policy period. The counsel for the OP1 referred to the policy document and particularly Exclusion for Hospitalisation Benefit Clause. As per the Clause No.(2) two year exclusion is provided. It means the company shall not be liable under the policy for any claim in connection with treatment for particular diseases, as mentioned therein, during the first two years of the operation of the policy and heart diseases are included in this clause. This exclusion clause is in addition to clause of pre- existing disease which is also not covered under the policy. Admittedly the complainant was hospitalised within two years of the inception of the policy.
Both the counsels have placed reliance on reported judgments in support of their submissions. The judgment relied on by the counsel for the complainant is on the condition of pre existing disease. But since the case does not pertain to this clause, the judgment is not relevant. On behalf of the OP1 following judgments are placed on record.
- Oriental Insurance Co. Ltd. v/s Sony Cheriyan II (1999) CPJ 13 (SC)
- United India Insurance Co. Ltd. v/s Harchand Chandan Lal IV (2004) CPJ 15 (SC)
- Sudama Lal Madhwani v/s New India Assurance Co. Ltd. IIV(2007) CPJ 144 (NC)
- Vikram Greentech (I) Ltd. v/s New Indai Assurance Co. Ltd. II (2009)CPJ 34 (SC)
The judgments at Sr. No. 1, 2 and 4 are on the interpretation of insurance contract. It is held that policy is a contract between parties and both parties are bound by terms of contract. It is further held that in interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however, reasonable, if the parties have not made it themselves. It is to be noted that the complainant has not alleged anything contrary to the terms of the policy contract. He is bound by the terms of the policy. Since his heart disease occurred within two years of operation of the policy, the OP, under the policy, is not liable to indemnify his medical expenses. The repudiation on this ground is therefore legal and no fault can be found in repudiation.
The OP has also raised the point of limitation and relied on the judgment of Sudama Lal Madhwani at Sr. No. 3. It is contended that the claim was repudiated on 26.11.2010 and the complaint was filed on 14.5.2013 i.e. after a gap of 2 years and 6 months. Therefore the complaint is barred by limitation u/s 24A of the Consumer Protection Act, which provides two years limitation from the cause of action. As held in Sudama Lal Madhwani case limitation starts from the date of repudiation of insurance claim. As per the complainant himself and repudiation letter the claim was repudiated on 26.11.2010 and from that date limitation started. The complaint should have been filed on or before 26.11.2012. The record shows it was filed on 5.11. 2012, though it was registered on 6.12.2012. On 5.11.2012 it was taken up for scrutiny. That means it was filed within two years and therefore not barred by limitation.
However, in view of Exclusion Clause the disease of the complainant occurred within two years from operation of the policy, he is not entitled to claim expenses. The complaint is thus liable to be dismissed. Hence, the order.
ORDER
- The complaint is dismissed with no order as to cost.
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