ORDERS:
Charanjit Singh, President;
1 The complainant has filed the present complaint under Section 34, 35 and 36 of the Consumer Protection Act (herein after called as 'the Act') against the opposite parties by alleging that the complainant’s husband Gurwinder Singh was employee of the Opposite parties No. 1 and 2 and his appointment was effective from 12.6.2018 vide letter No. DBL/CO/HR/APPT/13/2018/102552. The employee code of the complainant is 102552 as provided by the opposite party No. 1 and the opposite party No. 1 also got group insurance from the complainant from the opposite party i.e. the New India Assurance Company Ltd. Having Policy No. 450100/34/21/04/0000000/4. The opposite parties never read over and explained the terms and conditions of the policy before issuing or after issuing the same. On 12.1.2022, the complainant’s husband Gurwinder Singh was on his duty and during the course of his job, he suddenly fell ill and developed severe pain in head and stomach and was admitted to the Local Hospital i.e. Guru Nanak Dev Super-Specialty Hospital, Goindwal Sahib Road, Tarn Taran. The concerned doctor diagnosed and advised for his proper and immediate treatment by Neuro Surgeon. An expenditure of Rs.4,47,511/- was incurred by the complainant for medical treatment and also Rs. 1,00,000/- was incurred for his transportation and special diet. The complainant’s husband Gurwinder Singh is still under medical treatment as he has movement disorder and sergen disorder. Gurwinder Singh is a poor person and now he is under huge loan so taken by him from his relatives and others. Even the complainant’s husband Gurwinder Singh was only bread earner for his whole family. The whole family members of the complainant are fully dependent upon Gurwinder Singh. At present the complainant’s husband Gurwinder Singh is not able to do any job because of his illness and due to that reason, the complainant and her family members are suffering from starvation, harassment and mental agony. The complainant has three children i.e. two daughters and one son, who are minor and are school going children. But because of illness of the husband of the complainant during the course of his job, the complainant and her family members are not able to maintain as well to pay educational expenses of their above said children. The complainant’s husband Gurwinder Singh became ill during the course of his job and the opposite parties No. 1 and 2 are employer of the complainant’s husband. The complainant also approached through opposite party No. 3 to get medical claim of Gurwinder Singh and also sent complete file for the same but insurance company accepted the claim of Gurwinder Singh just Rs. 1,00,000/- vide claim No. 2993364. But in actual, the complainant has spent huge amount for the treatment of her husband Gurwinder Singh, which has already been mentioned above. All the opposite parties are interconnected/ have tie up with each other and all the opposite parties are jointly and severally liable to pay the entire medical expenses of complainant’s husband. The complainant through his family members have approached and requested the opposite parties for reimbursement of medical expenditure and to pay other expenses so incurred by the complainant. But the opposite parties intentionally and deliberately linger on the matter by making lame excused. The complainant through his counsel has already served a legal notice dated 5.5.2022 to opposite parties through registered post having postal receipts but the opposite parties have failed to give sufficient reply upon the legal notice. The opposite party No. 4 alleged that the complainant has not sent original bills of medical treatment of the complainant, but actually the complainant had sent all the original bills through courier and e mail to the opposite party No. 3 who further forwarded to the opposite party No. 4. The opposite party No. 4 made reply to the notice of the complainant and as per their version they have deducted number of charges of treatment illegally. The complainant has prayed that the following relieves may kindly be granted to the complainant.
- That the opposite party may kindly be directed to disburse the full medical claim of Rs. 4,47,511/- alongwith interest up to date.
- The opposite party may kindly be directed to pay Rs. 1,00,000/- as compensation as well as Rs. 15,000/- litigation expenses for causing harassment to the complainant by demanding illegal amount, in the interest of justice, equity and fairplay.
Alongwith the complainant, the complainant has placed on record his affidavit Ex. C-1, self attested copy of authorized letter Ex. C-2, Self attested copy of appointment letter Ex. C-3, Self attested copy of employee Card Ex. C-4, Self attested copy of insurance policy Ex. C-5, Self attested copy of insurance card Ex. C-6, Self attested copy of final bill of hospital Ex-C-7, Self attested copy of legal notice dated 5.5.2022 Ex. C-8, Self attested copy of postal receipt of legal notice dated 5.5.203 Ex. C-9 to Ex. C-12, Self attested copy of aadhar Card of complainant Ex. C-13, Self attested copy of Aadhar Card of authorized person Prabhdeep Kaur Ex. C-14, Self attested copy of courier receipts Ex. C-15 and Ex. C-16, Self attested copy of e mail record Ex. C-17, Self attested copy of file of bills Ex. C-18.
2 Notice of this complaint was sent to the opposite parties and the opposite party No. 5 appeared through counsel and filed written version by interalia pleadings that the complaint is not legally maintainable. The complainant is not come under the ambit of consumer under the Consumer Protection Act and is not maintainable. The present dispute has not come under the preview of the Consumer Protection Act. The alleged Prabhdeep Kaur has no locus standi nor authorized under the law to file the present complaint on behalf of Gurwinder Singh. It is Gurwinder Singh who can only has locus to file the present complaint, the alleged Prabhdeep Kaur under the law cannot file the present complaint on behalf of the complainant. The alleged authority letter is not a legal and valid document nor it is duly stamped or attested, under the law. No particulars of the alleged illness have been given in the present complaint. The present complaint is not maintainable. The complainant has not come to the court with clean hands and suppressed the true and material facts from this commission, as such, is not entitled to any relief as claimed for. The complainant has got no cause of action to file the present complaint. The complainant is guilty of his own act and conduct and is estopped from filing the present complaint. The opposite party No. 1, the employer of the complainant has obtained a new India Flexi Floater Group Mediclaim Policy from opposite party the New India Assurance Company and the sum assured for the complainant Gurwinder Singh EMP ID 102552 was Rs. 1,00,000/- and against the reimbursement claim of the complainant, the opposite party No. 5 duly settled the claim of the complainant on 6.4.2022 and paid the same via NEFT with UTR No. CITIN22255224719 for Rs. 1,00,000/- as full and final, which is the total sum assured of the complainant/ employee under the Policy. The copy of the insurance policy is Ex. OP/ , copy of insurance interest pertaining to complainant is Ex. OP5/2, Affidavit of Sh. Ashish Pal, Senior Divisional Manager of the New India Assurance Company is Ex. OP5/3. The present complaint is merely an abuse of process of this Commission. The present complaint is nothing but to the misuse of process of the court. The complainant has no locus standi to file the present complaint. The complainant has no has no remedy against the insurance company nor any cause of action arise in favour of complainant and against the opposite party to file the present complaint. The claim made is highly exaggerated one and without any basis. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has not come to this commission with clean hands. The complainant has concealed and suppressed material from this this commission and the present complaint is not maintainable legally and factually. The sum assured for the complainant employee code No. 102552 was Rs. 1,00,000/-. All the parties to the contract of insurance are bound by the terms and conditions of the insurance contract. The sum insured for the complainant Gurwinder Singh EMP ID 102552, under the policy in question is Rs. 1,00,000/- and against the reimbursement claim of the complainant, the opposite party No. 5 duly settled the claim of the complainant on 6.4.2022 and paid the entire sum insured via NEFT with UTR No. CITIN22255224719 for Rs. 1,00,000/- as full and final. The copy of insurance policy is Ex. OP5/1 and copy of the insured interest pertaining to complainant is Ex. OP5/2. The alleged legal notice is based wrong and incorrect one and based on false and baseless allegations and was duly replied. The entire sum insured under the policy pertains to complainant has already been paid/ released in favour of the complainant and under the law, the complainant is only entitled for the sum insured under the policy and prayed that the present complaint may be dismissed.
3 Notice of this complaint was sent to the opposite parties No. 1 to 4 and 6 but none appeared on behalf of opposite parties No. 1 to 4 and 6 and consequently, the opposite parties No. 1 to 4 and 6 were proceeded against exparte.
4 We have heard the Ld. counsel for the complainant and opposite party No. 5 and have carefully gone through the record.
5 Ld. Counsel for the complainant contended that the complainant’s husband Gurwinder Singh was employee of the Opposite parties No. 1 and 2 and his appointment was effective from 12.6.2018 vide letter No. DBL/CO/HR/APPT/13/2018/102552. The opposite party No. 1 also insured the husband of the complainant under group insurance scheme i.e. belongs to New India Insurance Company Ltd. having policy No. 450100/34/21/04/0000000/4. Ld. Counsel for the complainant further contended that on 12.1.2022 her husband was on his duty and he suddenly fell ill and developed severe pain in head and stomach as such he was admitted to the Local Hospital i.e. Guru Nanak Dev Super-Specialty Hospital, Goindwal Sahib Road, Tarn Taran. An expenditure of Rs. 4,47,511/- was incurred for the treatment and Rs. 1,00,000/- were incurred for his transportation and special diet. Thereafter, complainant approached to the opposite party No. 3 to get medical claim of Gurwinder Singh i.e. husband of complainant and sent the complete file to the insurance company but the insurance company accepted the claim of Gurwinder Singh to the tune of RS. 1,00,000/- vide claim No. 2993364 and further requested to disiburse the full medical claim i.e. to the tune of Rs. 4,47,500/- alongwith interest.
6 Ld. counsel for the opposite party No. 5 contended that the complainant is not maintainable under consumer protection Act as only Gurwinder Singh can file the present complaint under Consumer Protection Act. The opposite party No. 1 i.e. employer of the complainant has obtained a New India Flexi Floater Group Mediclaim Policy from opposite party i.e. New India Assurance Company and the sum assured for the complainant Gurwinder Singh was to the tune of Rs. 1,00,000/- and the opposite party No. 5 duly settled the claim of the complainant on 6.4.2022 and paid the same via NEFT with UTR No. CITIN22255224719 for Rs. 1,00,000/- as full and final, which is the total sum assured of the complainant/ employee under the Policy.
7 From the combined and harmonious reading of documents and pleadings it is going to prove on record that Gurwinder Singh was employee of opposite party No. 1 and it is also proved on record that he was insured with the opposite party No. 5 i.e. New India Insurance Company having Policy No. 450100/34/21/04/0000000/4. Gurwinder Singh husband of complainant was admitted on 12.1.2022 in Guru Nanak Dev Superspeciality Hospital Goindwal Road, Tarn Taran, where he was treated and an expenditure of Rs. 4,47,511/- were incurred on the treatment. The medical claim was submitted with the opposite party No. 5 and they settled the claim to the tune of Rs. 1,00,000/- as full and final. As per opposite party No. 5 the claim of Rs. 1,00,000/- was rightly settled as per terms and conditions of the policy, Gurwinder Singh is insured under Group Medical Scheme and sum assured was Rs. 1,00,000/- only. This fact has been proved by Ex. C-5 as well as Ex. OP5/1 and Ex. OP5/2, whereby it has been clearly mentioned that sum assured is to the tune of Rs. 1,00,000/- under New India Flexi Floater Group Medi claim Policy. As such the opposite party No. 5 has rightly settled the claim of Rs. 1,00,000/- as full and final as per terms and conditions of the policy which has been received by husband of the complainant from the opposite party No. 5. 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.”
8 In view of the above discussion, we do not find any merit in the complaint and the same is hereby dismissed. The parties are left to bear their own costs. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission
8.8.2024
