DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

PATIALA.

                                      Consumer Complaint No. 195 of 10.5.2016

                                      Decided on:   15.2.2019

Dr. Richa Aggarwal (aged about 25 years) daughter of Sh.Raman Aggarwal, resident of 147, Punjabi Bagh, backside Columbia Asia Hospital, Patiala.(PB),India.

                                                                   …………...Complainant

                                      Versus

1.       Birla Sun Life Insurance Company Limited having its registered office at One India Bulls Centre, Tower 1. 15&16^th Floor Jupitar Mill Compound 841, Senapati Bapat Marg Elphinstone Road, Mumbai 400 013.

2.       Branch office: Birla Sun Life Insurance Company Limited, Leela Bhawan Market, Near 22 No. Railway Crossing above State Bank of Patiala, SCF-33, First Floor, Patiala, District Patiala (Punjab)-India.

                                                                   …………Opposite Parties

                                      Complaint under Section 12 of the

                                      Consumer Protection Act, 1986.

QUORUM

                                      Sh. M.P.Singh Pahwa, President

                                      Smt. Inderjeet Kaur, Member

                                      Sh.B.S.Dhaliwal, Member      

ARGUED BY

                                      Sh.Rahul Kamboj, counsel for complainant.

                                      Sh.Pankaj Verma, counsel for OPs No.1&2.

 ORDER

                                     M.P.SINGH PAHWA, PRESIDENT               

1. This is the complaint filed by Dr.Richa Aggarwal (hereinafter referred to as the complainant) against Birla Sun Life Insurance Company Limited and another (hereinafter referred to as the OPs).
2. Briefly the case of the complainant is that  she had purchased from Birla Sun Life Insurance Co. Ltd. ( OP No.1) an insurance policy of the product Saral Health Plan for whole life vide policy No.005202105 dated 11.11.2011 with benefit expiry date  11.11.2031 for a pay term/ health insurance benefit term 20 pay/20 years with nominee Smt. Sangeeta Aggarwal. The annual policy premium is Rs.12405/-.The premium installment is to be paid on 11^th of every month. The complainant has already deposited/paid all the installments up to date. She is paying the installments regularly since insurance policy was purchased.
3. It is also revealed that it is clearly mentioned in the policy that after completion of five years, the complainant can claim reimbursement for health and medical related expenses incurred by the life assured during the policy term to an extent of 100% of fund value and the policy fund value will be reduced by the claim amount of each health reimbursement benefit paid by the insurance company. It is also mentioned that health and medical related expenses include cost of medical tests, prescription, drugs, medicines (Ayurvdic, homeopathy included) consultation fee for physician, surgeon, dental, ophthalmic, orthopedic treatments and any other treatment and surgery otherwise do not cover under health insurance benefits.
4. As per complainant, in the month of September, 2015, she suddenly fell ill. She firstly consulted doctor at Kasturba Hospital, Manipal for getting treatment but did not find treatment in that hospital satisfactory. Thereafter on 29.9.2015, she went to Sri Sri college of Ayurvedic Science and Research Hospital, for her treatment and remained admitted in the said hospital from 29.9.2015 to 4.10.2015. During this period, several tests were got conducted by the doctors of the hospital. Some tests were conducted in the hospital. Some tests were conducted from outside the hospital. Complainant incurred expenses for getting tests conducted and hospital charges for treatment, to the tune of Rs.13611/-.The complainant paid this amount from her pocket. Thereafter the complainant submitted the bill original for expenses and detail of the report of the tests to the OPs for reimbursement as per terms and conditions of the insurance policy, but the OPs have not reimbursed the expenses despite repeated contacts from time to time.
5. It is alleged that at last the OPs did not return the claim form but reimbursement of the expenses was rejected on the ground that as per claimed document the patient was on Ayurvedic treatment. As per policy terms and conditions non allopathic treatment is excluded from the scope of the policy. Hence claim is rejected.
6. It is alleged that the insurance policy does not mention that the expenses incurred due to the treatment in an ayurvedic hospital was not be reimbursed. The OPs have wrongly rejected the claim of the complainant for reimbursement.
7. On this background of the facts, the complainant has alleged unfair trade practice and deficiency in service on the part of the OPs. Hence this complaint for direction to the OPs to pay Rs.13611/- with interest @18% per anum. Complainant also claimed Rs.50,000/- as compensation for mental agony, physical harassment etc. and Rs.20,000/- for legal expenses.
8. Upon notice OPs appeared through counsel and contested the complaint by filing written reply. In reply the OPs raised preliminary objections that the complaint is not maintainable. Complainant has attempted to misguide and mislead the Forum; that the policy under question was issued by the OPs on 11.11.2011 on the basis of information provided by the life assured in the proposal form. Since the treatment  taken by the complainant was not covered under the policy terms and conditions, hence the OPs were well within their right to repudiate the claim. OPs have acted within the four corners of the statutory provisions. No case of deficiency in service can be said to have arisen. As such the complaint is not maintainable before this Forum. The complainant has tried to challenge the veracity of the decision of the OPs. OPs have repudiated the claim under the policy by a speaking order. The decision cannot be brought under the umbrella of deficiency of service. The complainant should approach the civil court to challenge the veracity of the decision of the OPs; that this Forum has no jurisdiction to entertain the complaint. The complainant has failed to demonstrate any deficiency in service on the part of the OPs. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. The Forum cannot pass any order in contravention to the terms and conditions of the policy; that after receiving the claim documents, OPs have investigated the matter from the complainant. From the documents submitted by the life assured, it was found that the complainant had taken the treatment from Ayurvedic hospital. The same was excluded from the scope of the policy. Hence claim was rejected. The complaint is devoid of any material particulars. It has been filed merely to harass and gain undue advantage  and unjustified money from the OPs. The complainant has not acted in good faith with respect to subject of the complaint. The complainant was having option to review the policy within 15 days (free look period) but she has not exercised this option. Now the policy documents are binding on both the parties; that the complainant has failed to set up a nexus with the damages claimed and damages suffered by her. The compensation claimed is arbitrary, without basis and is an abuse of the process of law. The complaint is liable to be dismissed with special costs.
9. On merits, the issuance of the policy in question is not denied. It is also admitted that the policy holder has paid regularly annual premiums. It is admitted that the complainant intimated the claim regarding medical treatment. In further reply the OPs have reiterated their stand as taken in the preliminary objections and detailed above .In the end the OPs prayed for the dismissal of the complaint.

It is relevant to mention that the OPs have also quoted some case law to support their version, the reference  of which is not considered necessary at this stage.

10. Parties were afforded opportunity to produce their evidence.
11. In support of her case, the complainant tendered into evidence her affidavit, Ex.CA, copy of claim form, Ex.C1, copy of claimant statement, Ex.C2, declaration, Ex.C3, prescription slip, Ex.C4, bill, prescription slips, test reports, receipts, Exs.C5 to CF10, copy of envelop, Ex.C11, copy of policy, Ex.C12, policy details, Ex.C13, copy of complaint, Ex.C14, copy of e-mail, Ex.C15, Ex.C16, copy of pass book, Ex.C17.
12. OPs tendered into evidence affidavit of Kshama Priyadarshini, Ex.OPA, copy of application for insurance, Ex.OP1, copy of claimant statement, Ex.OP2, copy of policy with terms and conditions, Ex.OP3, copy of repudiation letter dated 28.1.2016, Ex.OP4 and closed the evidence.
13. We have heard the ld. counsel for the parties and gone through the record of the case carefully.
14. The ld. counsel for the complainant has submitted that the material facts are not in dispute. It is not disputed that the complainant availed the policy as revealed by the complainant. The medical treatment was also covered under this policy. The complainant took treatment from 29.9.2015 to 4.10.2015 by spending
    Rs.13611/-.The OPs have repudiated the claim vide letter dated 28.1.2016 on the ground that non allopathy mode of treatment is excluded from scope of policy. The complainant has taken treatment from Ayurvedic hospital. Copy of the policy Ex.C13 contains the reimbursement benefits. It is categorically mentioned that, health & medical related expenses include costs of medical tests, prescription drugs, medicines (ayurvedic/homeopathy included), consultation fees for physician/surgeon, dental/ophthalmic/orthopedic treatments and any other treatment and surgery otherwise not covered under Health insurance Benefits. The OPs cannot deny the claim only on the ground that the non allopathy treatment is excluded. Of course later part of the policy contains exclusions which includes non allopathy treatment but it does not mean that  ayurvedic and homeopathic medicines are also excluded. Therefore, the repudiation is patently illegal and unjustified. Deficiency in service stands proved. As such the complaint is to be accepted.
15. On the other hand, the ld. counsel for the OPs has submitted that the contract of insurance is like other contracts. Parties are bound by the terms and conditions mentioned in the policy documents. The courts are not to substitute its own terms and conditions. Complainant herself has relied upon the policy. Of course   Health Reimbursement Benefits include expenses for medicines excluded ayurvedic homeopathic but this document also contains exclusion clause. It is categorically mentioned that non allopathic treatment is excluded. Therefore, there is no doubt that the ayurvedic treatment is not covered and stand excluded. The OPs have acted strictly in accordance with the terms and conditions. There is no illegality in t the decision taken by the OPs. The complaint is abuse of process of law. It may be dismissed with costs.
16. We have given careful consideration to the rival submissions.
17. The admitted facts are that the complainant availed life insurance policy from the OPs. Due to life insurance policy complainant was also entitled to get benefits regarding medical treatment as claimed by the complainant. It is admitted that the complainant took treatment from 29.9.2015 to 5.10.2015 by spending Rs.13611/-. The OPs have repudiated the claim on the ground that non allopathic treatment is excluded from the scope of the policy.
18.  Therefore, the only point to be decided is whether treatment (ayurvedic) is excluded from the scope of the policy or not. Copy of the policy document is on the file as Ex.C13 and Ex.OP3. The Health Reimbursement Benefits are mentioned in the document. For the sake of convenience it is relevant to be reproduced:                                                                                                                                           …...........................Health and Medical related expenses include costs of medical tests, prescription drugs, medicines (ayurvedic, homeopathy included), consultation fees for physician, dental ophthalmic, orthopedic treatments and any other treatment and surgery otherwise not covered under Health Insurance Benefits.

Therefore aforesaid clause leaves no manner of doubt that the medicines include ayurvedic /homeopathy also. The complainant has taken treatment by ayurvedic medicines.

19. Of course later part of the policy contains exclusion which also includes the non allopathic treatment but when medical reimbursement benefits specifically includes ayurvedic medicines the non allopathic treatment cannotbe interpreted as excluding ayurvedic treatment also.

20. For the reason recorded above, the conclusion is that the repudiation of the claim is unjustified and the complainant was entitled to benefit of reimbursement. Resultantly the complaint is partly accepted with costs and compensation of Rs.5000/-.The OPs are directed to comply with the order by paying Rs.13611/-. As the claim was illegally rejected, therefore, the complainant is held entitled to interest as compensation on this amount @12% per annum from the date of repudiation i.e. 28.1.2016 till realization. Compliance of the order be made by the OPs within a period of 45 days from the date of the receipt of the certified copies of this order.

Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.

ANNOUNCED

DATED:15.2.2019       

 B.S.Dhaliwal                         Inderjeet Kaur              M. P. Singh Pahwa

       Member                                 Member                                      President