Order dictated by:

Sh.S.S. Panesar, President

1.       Smt.Radhika Sethi, has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that her husband Krishan Lal Sethi (proposer) got health insurance for family on 30.5.2011 from Opposite Parties bearing No. 2952200757583301000 and it is still inforce. The husband of the complainant had also individual Health Suraksha policy bearing No. 50202622 with Opposite Party since 5.4.2010 and when the said policy was due for renewal in the year 2011, the  husband of the complainant requested the Opposite Parties  to add his family also in the same policy, but the Opposite Party refused and issued a separate policy in the month of May, 2011. In the month of November, 2015 the husband of the complainant had to go in for kidney transplant (right) the donor being the complainant only due to the emergent situation as it demanded, at Kidney Hospital & Lifeline Medical Institutions, Jalandhar. Thereafter, the complainant submitted the claim for Rs.78,535/- with the Opposite Parties  under the policy in dispute and also supported all relevant bills and vouchers of the hospital, but the Opposite Parties  denied the claim of the complainant after 2 ½ months. It is pertinent to mention over here that before denial, the Opposite Party  raised an irrelevant query for providing some more documents which were to be collected from Kidney Hospital, Jalandhar and sending one investigating officer Mr.Amol Kumar to the residence of the complainant to collect the documents. The aforesaid act of the Opposite Party  is act of deficiency in service, mal-practice & is not sustainable in the eyes of law. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party  be directed to pay the amount of Rs.78,535/- which has been denied from my claim without any rational.

b)      Opposite Party be directed to pay a sum of Rs.10 lacs as compensation on account of agony & harassment.

b)      Opposite Party  be also directed to pay the actual cost of litigation necessitated due to their own fallacy & inadequate of thought & action. 

Hence, this complaint.

2.       Upon notice, Opposite Party  appeared and contested the complaint by filing  written statement taking preliminary objections therein inter alia that  the complaint is filed in respect to the Health Suraksha Policy bearing No. 2952200757583300001 covering risks of three insured namely Radhika Sethi, Vineet Sethi and Saakar Sethi. The coverage are subject to the terms and conditions of the policy in question which were duly supplied to the insured and never been objected; that the alleged loss do not cover under the policy, therefore, the present complaint is not maintainable. It is worthwhile to mention over here as per submitted claim documents, the complainant Radhika Sethi underwent hospitalisation for organ donation on 2.12.2015 to her husband Krishan Lal Sethi who is not an insured under the policy. As the claim is in respect to the expenses incurred by the complainant in the capacity of a donor and the organ was donated to the complainant’s hsuaband who is not covered under the policy bearing No.2952200757583301000, as such the claim of the complainant was repudiated under section 1 vi (ii) as per which the donor expenses are covered only when the organ donated is for the  use of the insured person, therefore, the Opposite Party is not liable to pay the amount claimed in the present complaint and the present  complaint is liable to be dismissed on this short ground; the complainant has concealed the material facts from this Forum, therefore, he is not entitled to any relief as claimed; the complainant has filed the present complaint without any cause of action against the Opposite Party; that the complainant has no locus standi to file the present complaint. On merits, it is submitted that the best service are being provided by the Opposite Party in its field and no irrational approach has been adopted by the Opposite Party towards the complaint. The claim of the complainant has been processed and denied within the terms and conditions of the policy in question and there is no question arises regarding any apathetic or irrational approach to settle the claim of the insured. As the claim of the complainant was not covered under the terms and conditions of the policy in question, therefore, it was rightly repudiated vide letter dated 24.7.2016. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       In her bid  to prove the case, complainant tendered into evidence  affidavit Ex.C1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C12  and closed her evidence.

4.       On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Pankaj Kumar, Manager Legal Ex.OP1 alongwith copies of documents Ex.OP2 to OP5 and closed the evidence on behalf of the Opposite Party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

6.       The authorised  representative of the complainant has vehemently contended that  it is not disputed that the complainant is holder of Health Suraksha Policy bearing No. 2952200757583300001, copy whereof is Ex.C2 on record, which was in operation during the period w.e.f. 30.5.2015 to 29.5.2016. In the month of November, 2015 husband of the complainant namely Krishan Lal Sethi had to undergo for kidney transplant (right). The complainant stood donor for her husband. Subsequently, the complainant submitted a claim for herself to the tune of Rs.78,535/- under the policy, supporting all the relevant bills, vouchers of the hospital. But to her utter surprise, the Opposite Party denied the claim of the complainant after 2½ months under section 1 vi (ii) vide repudiation letter, copy whereof is Ex.OP5. A perusal of the insurance policy reveals that donor was covered under the policy in question, therefore, the Opposite Party was deficient in service. It is further contended that the insurance amount to the tune of Rs. 78,535/- may be granted in favour of the complainant alongwith compensation to the tune of Rs.10 lacs as well as expenses for litigation to be assessed by this Forum.

7.       But however from the appraisal of the evidence on record, it becomes evident that the repudiation of the claim of the complainant  has fully been made by the Opposite Party as per terms and conditions of the policy in question. Section 1 vi (ii) (iii) is reproduced as under:-

ii.       The organ donated is for the use of the Insured Person, and

iii.      We will not pay the donor’s pre-and post-hospitalisation expenses or any other medical treatment for the donor consequent on the harvesting. 

A perusal of the aforesaid terms & condition clearly state that organ donated has to be for the use of the insured person, but in the case in hand, Krishan Kumar Sethi donee of the kidney was not insured person under the insurance policy in dispute.   Since the terms and conditions of the policy in question are binding  inter se parties  and no party can wriggle out therefrom. We seek support on this point from M/s. V.K. Karyana Store Vs. Oriental Insurance Co. Ltd. 2014(3) CLT page 47 wherein it has been held that it is well settled principle of law that parties are bound by terms and conditions of the insurance policy and none of the parties can seek any  relief beyond those terms and conditions.

Since the repudiation of the claim has been rightly made because donor in this case was an insured person, whereas donee to whom organ was donated for transplantation was not an insured person. In such a situation, the donor being insured person was not entitled to be reimbursed by the insurer and there is absolutely no illegality or deficiency in service on the part of the Opposite Party. In our considered opinion, the instant complaint is nothing, but an abuse of the process of law and therefore, the instant complaint fails and the same is ordered to be dismissed. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum