PER:
Charanjit Singh, President;
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11, 12 against the opposite party on the allegations that the complainant got health insurance for himself as well as for his wife from the opposite party vide policy No. 2668/00104623/0030/000/00 in loan agreement bearing No. 16500001495 from 29.2.2016 to 28.2.2017 for a sum assured of Rs. 3 Lacs, as such he has availed the services of opposite party and comes under the definition of consumer as defined under Consumer Protection Act. The complainant fell ill and admitted in Anand Hospital and Heart Care Centre on 27.10.2016 and was discharged on 1.11.2016. There the complainant incurred an expenses of Rs. 50,000/- in the hospital for the treatment. The opposite party was informed immediately regarding the admission and provided all the documents required for passing the claim, but till date neither the claim has been decided nor the payment has been released. The complainant has prayed as under:-
(i) The opposite party may kindly be directed to make the payment of claim amount to the tune of Rs. 50,000/- alongwith interest @ 12% p.a.
(ii) Compensation to the tune of Rs. 50,000/- may also be awarded to the complainant.
(iii) The cost of the complaint may also be awarded to the complainant.
3 After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interalia pleadings that the instant complaint is false, malicious, incorrect and malafide and nothing but an abuse of the process of the law and it is an attempt to waste the precious time of this commission. The same has been filed just to avail undue advantage. The complainant has not come to this commission with clean hands and has suppressed the material facts from this commission. On perusal of the claim documents, it is observed that treatment for coronary heart disease (related to heart ailment) which is excluded in the policy for the first two years (29.2.2016). Hence the claim is inadmissible in evidence as per General Exclusion clause Section C-4 which reads as No Indemnity is available or payable in respect of any expenses what so ever incurred by you in connection with during the first two years of continuous operation of insurance cover on surgeries/ procedures relating to Contract/ o Begin Prostatic Hypertrophy/ o Hysterectomy for Menorrhagia or Fibromyoma/ o Hernia/ Hydrocele/ Fistula, Piles/ Sinusitis & related disorders/ Gall stones Spondilitis, Spondilosis/ knee./ Hip joint replacement / heart diseases, o internal congenital disease / o any type of carcinoma/ Sarcoma/ Blood Cander/ o Osteoarthritis of any joint/ o Calculus diseases of gall bladder and urogenital/ o Gastric & duodenal ulcers/ Internal Tumours, cysts, nodules, polyps including breast lumps (each of any kind unless/ malignant/ Gout & Rheumatism/ ENT disorders & Surgery for prolapsed inter vertebral disk o Surgery of varicose veins & varicose uncers/ Surgery on tonsils. The final diagnosis of the complainant is hypertension which cad for medical management. There is no lawful cause of action arisen in favour of the complainant to file the present complaint against the opposite party. This commission has got no jurisdiction over the matter, as there is no office of opposite party at Amritsar. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.
4 To prove his case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. CW1/A alongwith documents i.e. copy of the discharge summary Ex. C-1, copy of the receipts Ex. C-2 to ex. C-5, copy of the bill Ex. C-6, copies of the medicine bills Ex. C-7 to Ex. C-13, copy of claim form Ex. C-14 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence documents i.e. repudiation letter Ex. OP-1, Copy of the group health insurance policy Ex. OP-2, copy of claima form Ex. OP-3, copy of the admission card of Anad Heart Care Hospital Ex. OP-4, copies of medical bills Ex. OP-5 to Ex. OP-16, copy of the laboratory report Ex. OP-17 and Ex. OP-18, copy of echocardiography Ex. OP-19, copy of the X-ray Ex. OP-20, copy of ECG Ex. OP-21, affidavit of Sh. Satyabratta Das, Assistant Manager Legal Ex. OP-22, repudiation letter Ex. OP-23 and closed the evidence.
5 We have heard the Ld. counsel for the parties and have gone through the record on the file.
6 It is the case of the complainant the complainant got health insurance for himself as well as for his wife from the opposite party vide policy No. 2668/00104623/0030/000/00 in loan agreement bearing No. 16500001495 from 29.2.2016 to 28.2.2017 for a sum assured of Rs. 3 Lacs, The complainant fell ill and admitted in Anand Hospital and Heart Care Centre on 27.10.2016 and was discharged on 1.11.2016 and discharge summary is Ex. C-1. There the complainant incurred an expenses of Rs. 50,000/- in the hospital for the treatment. The opposite party was informed immediately regarding the admission and provided all the documents required for passing the claim, but till date neither the claim has been decided nor the payment has been released and prayed that the present complaint may be allowed.
7 On the other hands, it is the case of the opposite party that on perusal of the claim documents, it is observed that treatment for coronary heart disease (related to heart ailment) which is excluded in the policy for the first two years (29.2.2016). Hence the claim is inadmissible in evidence as per General Exclusion clause Section C-4 which reads as No Indemnity is available or payable in respect of any expenses what so ever incurred by you in connection with during the first two years of continuous operation of insurance cover on surgeries/ procedures relating to Contract/ o Begin Prostatic Hypertrophy/ o Hysterectomy for Menorrhagia or Fibromyoma/ o Hernia/ Hydrocele/ Fistula, Piles/ Sinusitis & related disorders/ Gall stones Spondilitis, Spondilosis/ knee./ Hip joint replacement / heart diseases, o internal congenital disease / o any type of carcinoma/ Sarcoma/ Blood Cander/ o Osteoarthritis of any joint/ o Calculus diseases of gall bladder and urogenital/ o Gastric & duodenal ulcers/ Internal Tumours, cysts, nodules, polyps including breast lumps (each of any kind unless/ malignant/ Gout & Rheumatism/ ENT disorders & Surgery for prolapsed inter vertebral disk o Surgery of varicose veins & varicose uncers/ Surgery on tonsils. The final diagnosis of the complainant is hypertension which cad for medical management. There is no lawful cause of action arisen in favour of the complainant to file the present complaint against the opposite party and prayed for dismissal of the complaint.
8 The opposite party has repudiated the claim of the complainant as per terms and conditions of the policy as per General Exclusion clause Section C-4 which reads as No Indemnity is available or payable in respect of any expenses what so ever incurred by you in connection with during the first two years of continuous operation of insurance cover on surgeries/ procedures relating to Contract etc. The complainant has not denied the terms and condition of the policy nor has pleaded in his complaint that the terms and conditions have not been supplied to him. As such, the terms and conditions were in the knowledge of the complainant.
9 Both the parties are bound by the terms and conditions of the policy. The terms and conditions of the Insurance Policy have to be strictly construed. Hon’ble Supreme Court in the case of Export Credit Guarantee Corporation of India vs. Garg Sons International 2013 (1) SCALE 410 (SC) held in Para Nos.8 to 11 as under:
“8. It is a settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567).
9. The insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829).
10. In Vikram Greentech (I) Ltd. & Anr. v. New India Assurance Co. Ltd. AIR 2009 SC 2493, it was held: “An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. (See also: Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).”
11. Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.”
10 While repudiating the claim of the complainant the opposite party has not committed any deficiency in service and unfair trade practice and the claim has been validly repudiated by the oppoise party.
11 In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
25.11.2022
