DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA

                                                                   C.C. No.795 of 20.11.2014.

                                                                   Date of decision: 05.09.2016.

Sunil Bajaj son of Shri Om Parkash Bajaj, resident of 9, Rakh Bagh, Mall Road, Ludhiana

IInd address: Brother Polymers, 52-A, Industrial Area-A, Ludhiana.

                                                                             …..Complainant.

                                                Versus

1. HDFC ERGO General Insurance Company Limited, Corporate Office at 6^th Floor, Leela Business Park, Andheri-Kurla Road, Andheri (East), Mumbai-400059, through its Chairman/Managing Director.
2. HDFC ERGO General Insurance Company Limited, registered office at Raman House, H.T. Parekh  Marg, 169, Backbay Reclamation, Mumbai-400020, through its Chairman/Managing Director
3. HDFC ERGO General Insurance Company Limited, Regional/Corresponding Office at 6^th Floor, MBC Tower, Old No.90, New No.199, Luz Church Road, Mylapore, Chennai-600004
4. HDFC ERGO General Insurance Company Limited, branch office, 5^th Floor, Surya Tower, Mall Road, Ludhiana through its Branch Manager.

…...Opposite parties.

(Complaint U/s 12 of the Consumer Protection Act, 1986) 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.KARNAIL SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant                     :        Sh. Pardeep Kapoor, Advocate

For OP1 to OP4            :       Sh. Vyom Bansal, Advocate

PER G.K DHIR, PRESIDENT

1.                Complainant filed complaint under Section 12 of the Consumer Protection Act (hereinafter referred as Act) by claiming that he availed family floater Health Suraksha Insurance Policy vide Policy No.50620892 along with Sarv Suraksha Advantage vide policy No.50620893 from Ops. Under the Health Suraksha Policy (Silver Plan) the coverage provided to the complainant was as following:-

2.                However, under the Sarv Suraksha Policy (Sarv Suraksha Advantage), the coverage provided to complainant was as below:-

So by the insurance policies/covers in question, Ops insured the complainant for his sufferings from illness or accident during the policy period. These insurance policies provided insurance coverage for period from 26.02.2012 to 25.02.2013 and further from 26.02.2014 to 25.02.2015. Total premium was duly received by Ops in due course of the said policies. Complainant suffered from critical illness and was got admitted for the first time on 09.07.2012 in Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi. Complainant was discharged on 18.07.2012, but due to illness, he was again admitted on 30.07.2012 in the same hospital. The illness was again diagnosed by specialist doctors and complainant underwent Bone Marrow biopsy and lymph node biopsy. The bone marrow report dated 03.08.2012 is produced with the complaint. After conducting many tests and going through the reports of bone marrow and histopathology, the treatment of chemotherapy was started.  Thereafter complainant again was discharged on 20.08.2012 in stable condition. Complainant was advised for further follow up treatment regularly. Complainant again got treatment on 25.08.2012 in same hospital, but was discharged there from on 28.08.2012 with same diagnosis of Angio-immunoblastic T-cell lymphoma and Hypertension.

3.                Complainant again was admitted on 14.09.2012 in Haematology-Oncology & Bone Marrow Transplant unit at Christian Medical College & Hospital, Ludhiana. Complainant was discharged there from on 31.10.2012. The medical report in respect of this treatment also alleged to be produced with complaint. Complainant in furtherance of the continuing treatment of the disease got himself admitted on 31.12.2012 in Haematology Department of Christian Medical College, Vellore. Treatment of Stem Cell Transplantation was performed on 23.01.2013 and thereafter, complainant was discharged in stable condition from hospital on 22.02.2013. Complainant again got admitted on 04.03.2013 in department of Haematology in Christian Medical College, Vellore and discharged there from on 07.03.2013 in furtherance of earlier treatment. Complainant was suffering from disease, which is a type of cancer and there is a procedure of treatment. The bone marrow and many other tests were part of that treatment and finally stem-cell transplantation was performed to cure the said disease to the end. Complete treatment of complainant for period from 26.02.2012 to 25.02.2014 was covered by the terms of the policies issued by Ops. Complainant remained in patient for furtherance of the continuing treatment of the disease at Department of Haematology at Christian Medical College, Vellore from 31.12.2012 to 22.02.2013 etc. as referred above. Even complainant got treatment in OPD of CMC, Vellore and finally left said institute on 21.03.2013. Thereafter, till filing of the complaint, complainant has been getting treatment from OPD of CMC & Hospital, Ludhiana. The claim amount for the year 2012-2013 of the policy in name of complainant was released by Ops, but the full claim amount for the year 2013-2014 has not been paid till date. As per terms and conditions of the policy, Ops to provide insurance cover and pay the full amount of in-patient treatment, pre-hospitalisation, post-hopitalisation, day care procedures, domiciliary treatment, organ donor, emergency ambulance, ayush benefit, newborn baby, critical illness benefit, hospital daily cash benefit, some other additional benefits etc. More than Rs.40,00,000/- were spent by complainant for treatment of disease during effective insurance period from 26.02.2012 to 25.02.2014. Complainant applied for claim amount by submitting claim form along iwth requisite documents, but Ops procrastinated the matter resulting in harassment of complainant and as such, by pleading deficiency in service on part of Ops, prayer made for directing Ops to pay Rs.2,30,000/- (the amount spent on treatment as in-patient during period of 2013-2014). Interest @18% per annum on the amount of Rs.2,30,000/- even claimed and compensation of Rs.1,50,000/- on account of mental pain, agony and sufferings even sought along with litigation expenses of Rs.22,000/-.

4.                In joint written statement filed by Ops, it is admitted that complainant was insured for period from 26.02.2013 to 25.02.2014 under Health Suraksha  Policy for the benefit mentioned in Section 1, 2 & 3 of the policy  subject to exclusions contained in Section 4 of the policy. Benefit under the policy are governed by the terms and conditions of the policy and as such, liability of Ops alleged to be limited to the insured perils occurring within the policy period. As per discharge summary dated 07.03.2013 of Christian Medical College, Vellore for the hospitalization period of 04.03.2013 to 07.03.2013, the complainant was diagnosed as “T-Cell Angio Immunoblatic Lymphoma- Postalogenic Hematopoeitic Stem Cell Transplantation Chronic Duodenitis”. After scrutinizing the documents submitted and after thorough application of mind by the officials of the Ops, the claim of the complainant was repudiated vide letter dated 07.09.2013 for the following reasons:-

 “As per submitted documents, patient was admitted with a diagnosis of Angioimmunoblastic T-cell Lymphoma, Post allogenic stem cell transpolantation, Chronic Duodenitis & discharged with follow up advise. According to Policy terms and conditions mentioned in policy schedule, treatment related to stem cell implantation & surgery & related complications is not covered hence this claim stands repudiated under policy clause No.4 e.vi.”

5.                This repudiation was because the stem cell implantation is specifically excluded under Section 4 (e) (vi) of the terms and conditions of the policy. The repudiation alleged to be justified because stem cell implantation treatment not covered by the terms and conditions of the policy. It is claimed that complainant has no cause of action to file the complaint. Moreover this Forum alleged to be having no territorial jurisdiction because the policy in question was issued by the Ops  at Mumbai and payment for the said policy was received beyond territorial jurisdiction of this Forum.  Complaint also alleged to be barred by limitation, being filed beyond period of two years of occurrence of cause of action. Earlier complaint No.526/2014 on the same subject was filed and as such, this second complaint alleged to be not maintainable, particularly when the reasons for withdrawal of earlier complaint not disclosed. Besides it is claimed that complainant is not consumer within meaning of Consumer Protection Act (hereinafter referred as Act). It is also claimed that the complaint has been filed by suppressing and twisting true facts and without adhering to the terms and conditions of the policy. Motive for filing complaint alleged to be to extort money. It is also claimed that in view of complicated questions of law and facts involved in the case, the matter deserves to be decided by Civil Court of competent jurisdiction only. Each and every other averment of the complaint denied by claiming that Ops are under no obligation to pay Rs.2,30,000/- or the interest or litigation costs etc.

6.                Complainant to prove his case tendered in evidence, his affidavit Ex. CA along with documents Ex. C1 to Ex. C83 (except C41) and then his counsel closed evidence.

7.                On the other hand, counsel for Ops tendered in evidence affidavits Ex. RA of Sh. Pankaj Kumar, Manager Legal; Ex. RB of Dr. Nilotpal Bora along with documents Ex. R1 to Ex. R3 and then closed evidence.

8.                Written arguments submitted by complainant, but not by Ops. Oral arguments of counsel for parties also heard and record gone through minutely.

9.                Undisputedly complainant purchased Health Suraksha Policy for period from 26.02.2013 to 25.02.2014. Before that this policy was purchased for period from 26.02.2012 to 25.02.2013 (as revealed by contents of Ex. C1 and Ex. C2). The premium for Sarv Suraksha Policy and Health Suraksha Policy (Silver plan) was paid on 26.02.2013 by complainant is a fact borne from contents of receipt Ex. C3 and Ex. C4 and that is why the certificate was issued by Ops on 17.02.2013 qua receipt of premium amount of Rs.9,006/- towards health Suraksha insurance policy No.50620892 for period from 26.02.2013 to 25.02.2014. In this case before us refund of amount of Rs.2,30,000/-, the amount spent on treatment for the year 2013-2014 sought through para no.14 of the complaint for in-patient treatment and on account of hospital daily cash. These amounts are payable under Health Suraksha Policy is a fact borne from contents of Ex. C2 and Ex. C3 each.  Ex. C3 is Sarv Suraksha Policy document showing that the complainant insured for a sum of Rs.10,00,000/-  for covering risk of accidental death, permanent total disability and permanent partial disability. Claim for insurance put forth in this case regarding in-patient treatment as well as pre-hospitalization and post-hospitalization expenses or for day care procedures or domiciliary treatment, which is covered by the Health Suraksha Policy (Silver Plan) as disclosed by contents of Ex. C4. So certainly submissions advanced by counsel for Ops has force that claim for 2013-2014 were put forth under Health Suraksha Policy (Silver Plan) only.

10.              Ex. C5, Ex. C6, Ex. C8 and Ex. C9 are the documents produced to show that complainant got treatment of Chemotherapy in the first cycle from Sir Ganga Ram Hospital during period from 30.07.2012 to 20.08.2012. Whereas Ex. C7 is the document showing as if complainant got treatment from Sir Ganga Ram Hospital during period from 25.08.2012 to 28.08.2012. Ex.C10 is the document showing as if complainant got treatment from Haematology Department of Christian Medical College & Hospital, Ludhiana during period from 14.09.2012 to 31.10.2012. Ex. C11 is the discharge summary of treatment of complainant during period from 31.12.2012 to 22.03.2013 from Department of Haematology Christian Medical College, Vellore. Ex. C12 is the discharge summary of treatment of complainant from Christian Medical College, Vellore for period from 04.03.2013 to 07.03.2013, but Ex. C13 is the discharge summary of treatment of complainant form 04.03.2013 to 07.03.2013 from Christian Medical College, Vellore. Ex. C14 to Ex. C69 are copies of the bills of expenses borne on treatment or purchase of medicines during period from February 2013 onwards. It is vehemently contended by counsel for complainant that complainant suffered from cancerous disease due to which he got treatment continuously from 09.07.2012 onwards and as such, treatment of chemotherapy and of stem cell transplantation was in furtherance of the same treatment. It is vehemently contended that complainant was suffering from disease, which was a type of cancer and there was procedure of treatment to cure the same. That procedure of treatment may vary in the opinion of experts. The bone marrow and many other tests also were part of that treatment and finally stem cell transplantation treatment was provided on 23.01.2013 for curing the said disease to the end and as such, repudiation of the claim through letter Ex. C76 = Ex. R3 is unjustified. However, these submissions of counsel for complainant opposed by contending that in view of exclusionary clause 4 (e)(vi) of Ex. R1, repudiation of the claim is justified.

11.              Clause 4 (e) (vi) of Ex. R1 as well as clause 6 (e) (vii) of Ex. C75 are almost similarly worded. After going through these clauses, it is made out that insurer (ops) will not make any payment for any claim in respect of any insured person directly or indirectly for any disease caused by, arising from or in any way attributable to the stem cell implantation or surgery or growth hormone therapy etc. So virtually clause 4 (e) (vi) of Ex. R1 does not caste any obligation on insurance company for the treatment of stem cell implantation, Whatever may be cause of that stem cell implantation. So it has to be found as to whether stem cell implantation was in furtherance of earlier treatment of chemotherapy or it was necessitated for any other cause, may be due to consuming certain medicines. 

12.              When first cycle of chemotherapy treatment was provided to complainant during his treatment from 30.07.2012 to 20.08.2012, then complainant was diagnosed for, “ANGIOIMMUNOBLASTIC T-CELL LYMPHOMA (AITL) WITH BM INVOLVEMENT”. It is borne from contents of discharge summary Ex. C5 of Sir Ganga Ram Hospital. On discharge of complainant from hospital, his condition was stable. That discharge summary Ex. C5 further discloses that the complainant tolerated chemotherapy well and that is why he was discharged in stable condition with advise for further follow up treatment with Dr. Shyam Aggarwal. Contents of the discharge summary Ex. C6 of same period of 30.07.2012 to 20.08.2012 establishes that complainant was admitted due to complain of high grade intermittent fever up to 104 degree F since for the last 5 days associated with chills and rigor, aggravation of cough etc. Clinical summary mentioned in Ex. C6 discloses that  complainant was started on CHOP chemotherapy.  Complainant was managed conservatively as per contents of Ex. C6. However, during treatment for period from 25.08.2012 to 28.08.2012, complainant was treated with second cycle of chemotherapy along with IV antibiotics and IV fluids is a fact borne from Ex. C7. As complainant improved with this line of treatment and that is why he was discharged in stable condition is a fact borne from contents of discharge summary Ex. C7 of Sir Ganga Ram Hospital. During this period of treatment bone marrow report Ex. C8 of the complainant obtained and same did show impression of cellular bone marrow showing reactive changes with the presence of 3-5% atypical lymphoid cells. This report of bone marrow Ex. C8 is of dated 03.08.2012 and even report dated 03.08.2012 Ex. C9 of  Hematology Department of Sir Ganga Ram Hospital shows that possibility of an involvement of the bone marrow by a Hodgkin’s lymphoma may be there. Panel suggested  was CD15, CD30, CD3, CD5, CD10 and CD20 is a fact borne from contents of Ex.C9. Further complainant remained admitted in CMC, Ludhiana during period from 14.09.2012 to 31.10.2012 is a fact borne from the contents of medical report Ex. C10. Final diagnosis in stage IV in complete remission for ANGIOIMMINUBLATIC T CELL LYMPHOMA was noticed through report Ex. C10. This report Ex. C10 further mentions that complainant underwent bone marrow biopsy and lymph node biopsy. As per this report Ex. C10, complainant started receiving first dose of chemotherapy of CHOP-70% on 08.08.2012, but he got second cycle of CHOP on 26.08.2012. Despite these two cycles of CHOP dose, complainant continued to have intermittent fever and disease progression. So recommendation for repeated CECT chest and HRCT chest on 13.09.2012 was made and complainant was admitted for further management is a fact borne from contents of Ex. C10. So chemotherapy treatment continued to be provided to complainant during 2012 and claim of this treatment was not repudiated at all. Rather contents of para No.7 of the amended complaint shows that part of the claim amount for the year 2012-2013 of policy in name of complainant was released by Ops, but the full claim amount for the year 2013-2014 of the policy has not been released till date. So virtually claim for chemotherapy treatment of complainant during year 2012 has been released.  

13.              Ex. C11 is the discharge summary of treatment of complainant of Department of Haematology Christian Medical College, Vellore for period from 31.12.2012 to 22.02.2013. After going through brief history contained in Ex. C11, it is made out that after two cycles of chemotherapy treatment provided to complainant, until August 2012, the chemotherapy regimen was changed of CHOEP in view of disease progression. That change in first cycle took place in September 2012 as per contents of Ex. C11. So initially treatment of CHOP chemotherapy cycle was provided, but later on same was changed to CHOEP with effect from September 2012.

14.              Discharge summary Ex. C12 of Christian Medical College, Vellore for period of treatment of complainant from 04.03.2013 to 07.03.2013 discloses that complainant was diagnosed for treatment of T CELL ANGIO IMMUNOBLATIC LYMPHOMA, POSTALOGENIC HEMATOPOIETIC STEM CELL TRANSPLANTATION CHRONIC DUODENITIS. So after having look at all these discharge summaries, it is made out that though in year 2012 complainant was treated for AITL by providing chemotherapy cycle from CHOP to CHOEP cycle, but later on with effect from March 2013, complainant was also treated for stem cell transplantation, being chronic duodenitis. However, the disease of chronic duodenitis developed qua which mention made at page No.3 of discharge summary Ex. C12.

15.              After going through head, “Discussion” at page 3 of Ex. C12, it is made out that the conducted biopsy showed complainant as chronic duodenitis with fibrosis and eosinophilia from D2 mucosal biopsy. Biopsy findings were attributed non specific duodenitis and gastritis most probably drug induced. Further it is mentioned in Ex. C12 itself that blood investigation on day of admission showed increased creatinine level associated with hyponatremia. As per Ex. C12, investigations were suggestive of acute kidney injury probably due to cyclosporine. Dose of cyclosporine was reduced and mycofenolate was added for immunosuppression. So from this discharge summary Ex. C12, it is made out that kidney injury of complainant was found caused due to dose of cyclosporine and that is why reduction of the same recommended. Increase of creatinine level even was found through discharge summary Ex. C12 and as such, it is obvious that complainant was diagnosed as chronic Duodenitis due to which stem cell transplant treatment was recommended and provided. That stem cell treatment was due to disease of duodenitis caused on account of creatinine level increase and due to dose of cyclosporine. Same were the findings recorded in discharge summary Ex. C13 also for period from 04.03.2013 to 07.03.2013 as well as in Ex. R2.

16.              Duodenitis is inflammation occurring in the duodenum, the beginning of the small intestine. Severe illness and prolonged use of medications such as nonsteroidal anti-inflammatory drugs ((NSAIDs), alcohol or tobacco may also lead to duodenitis. As acute kidney injury found  through Ex. C12 and Ex. C13 probably due to dose of cyclosporine and as such, the development of duodenitis attributable to the severe illness and prolonged use of medications by complainant. So the treatment provided during policy year of 2013-2014 was not for cancerous disease alone, but for inflammation occurring in the duodenitis i.e. beginning of small intestine.

17.              A blood and marrow stem cell transplant is the treatment of duodenitis as per Google search at internet. Stem cell replaces a person’s abnormal stem cells with healthy ones from another person (a donor). This procedure allows the recipient to get new stem cells that work properly. Stem cells are found in bone marrow, a sponge-like tissue inside the bones. Stem cells develop into the three types of blood cells that the body needs.

18.              It is the case of complainant put forth in para No.6 of the complaint that stem cell transplant treatment was performed on 23.01.2013. Even contents of Ex. C11, the discharge summary treatment of complainant for period from 31.12.2012 to 22.03.2013 provides that peripheral blood stem cell transplantation was performed on 23.01.2013. The donor for such stem cell transplantation was Ms. Sudha Narad is a fact borne from perusal of page 2 of Ex. C11. So from this Ex. C11 and the record of other discharge summaries discussed in detail above, it is made out that the complainant continued to have chemotherapic treatment first and then CHOEP treatment, but the stem cell transplantation provided for curing duodenitis disease that occurred due to prolonged illness of complainant and providing of dose of cyclosporine. So the stem cell treatment attributable due to the dose of cyclosporine as well as due to prolonged illness. That stem cell treatment claim not entertain-able in view of clause 4 (e) (vi) of Ex. R1 and as such, repudiation of claim is justified, particularly when the stem cell transplantation treatment was not  for curing blood cancer, but for curing inflammation occurring in duodenal, beginning of small intestine.

19.              Angio Immunoblastic T-Cell Lymphoma (AITL) is a disease curable with chemotherapy. Lymphoma is the most common blood cancer. The two main forms of lymphoma are Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Lymphoma occurs when cells of the immune system called lymphocytes, a type of white blood cell, grow and multiply uncontrollably. Cure for AITL i.e. Angio Immunoblastic T Cell Lymphoma for the first instance through chemotherapy cycles was provided in 2012 to complainant and thereafter, finding the disease progression, CHOEP cycle was provided in September 2012, but thereafter, due to prolonged ailment and medication, treatment of stem cell transplantation w.e.f. 23.01.2013 was provided for curing duodenitis and as such, virtually the treatment provided during policy year of 2013-2014 was for stem cell transplant. As stem cell implantation treatment occurring for any reason not payable by the insurer and as such, repudiation of the claim is justified, particularly when the stem cell implantation treatment is for different disease than that of blood cancer i.e. lymphoma. Lymph nodes are found both above and below of diaphragm, but duodenitis affects duodenum, the beginning of small intestine. So the chemotherapic treatment for AITL stood on different footing than that of the stem cell implant treatment meant for curing duodenitis. Being so, stem cell treatment could not be considered as a treatment in furtherance of the earlier chemotherapic treatment for AITL diagnosis.

20.              It is vehemently contended by counsel for complainant that terms and conditions of insurance policy were not duly communicated or explained or sent to the complainant/insured and as such, benefit of exclusionary clauses not available to insurer i.e. Ops. Such plea of non communication of the terms and conditions of insurance policy in question Ex. C75 or Ex. R1 not taken in the complaint and nor raised in course of evidence. Rather complainant himself pleaded in para No.8 in detail as to what benefits to accrue under the policy and as such, in view of placement on record the copy of policy Ex. C75, it is obvious that the complainant must have gone through exclusionary Section 6 (e) (vii) of Ex. C75 itself while getting the policy in question, particularly when he is continuing with the policy since from 26.02.2012, as per plea taken in para No.2 of the complaint itself. A person purchasing some policy earlier will purchase that policy in the following year only, if he is well aware of the terms and conditions of the policy. In view of these circumstances, it cannot be held that complainant was not made aware of the entire terms and conditions of the policy in question.  Being so benefit from ratio of case titled as National Insurance Company Ltd. Vs Mona Ohri and another 2011(2) C.P.J. 383 (State Consumer Disputes Redressal Commission, Punjab) cannot be availed by complainant. After going through para No.17 of this cited case, it is made out that it is no where mentioned in the policy that the terms and conditions of the insurance were also communicated by the insured and that is why it is held that these terms and conditions were not explained to complainant. However, after going through Ex. C1 and Ex. C2 each, it is made out that the complainant was informed that the insurance policy enclosed is a written agreement providing confirmation of the terms of the cover(s) agreed telephonically. As the insurance policy sent along with letters Ex. C1 and Ex. C2 represented a written agreement confirming the terms of the cover and as such, it is obvious that this wording of Ex. C1 and Ex. C2 enough to held that written agreement qua the policy terms was sent to complainant through Ex. C1 and Ex. C2. So facts of cited case are quite distinct than those of the reported case.

21.              In case title as United India Insurance Co. Ltd. Vs Kusum Gupta 2007(2) C.P.J. 320 (Delhi State Consumer Disputes Redressal Commission, New Delhi), complainant was illiterate and was not explained that the treatment for particular disease was not covered, but that is not the position in the case before us because here the complainant is not shown to be illiterate. Rather the complainant has put his signatures on complaint and other documents in English reflecting as if complainant is literate, to whom the terms and conditions of the policy in the shape of the written agreement was sent through letter Ex. C1 and Ex. C2. As the written agreement containing exclusionary clause referred above (mentioned in Ex. C75 or Ex. R1) is a part of the contract agreement and as such, the benefit from ratio of the case M/s. Modern Insulators Ltd. Vs Oriental Insurance Co. Ltd. 2000 (2) SCC 734 (SC), not available to complainant. In case of ICICI Prudential Life Insurance Company Limited Vs Anil Kumar Jain 2010 (2) CPR 480 (Delhi State Consumer Disputes Redressal Commission, New Delhi), it was found that condition qua certain symptoms of disease being not covered by the insurance cover was an unreasonable condition, but that is not the position in the case before us because from the specific clause qua the insurer not liable to pay for stem cell implantation is included in Ex. R1 and Ex. C75. Same is the position with respect to non applicability of ratio of case titled as United India Insurance Co. Ltd. Vs Sudesh Kumar Garg  2004(4) C.P.J. 357 (Uttarakhand State Consumer Disputes Redressal Commission, Dehradun) as well as of case Sahara India and another Vs Rekha Dey 2012 (2) C.P.J. (N.C.) 571. Terms of the policy in question conveyed through Ex. C1 and Ex. C2 to complainant as held above and as such, benefit of ratio of the case National Insurance Company Ltd. Vs Raj Narain 2008 (1) C.P.J. (N.C.) 501, cannot be  availed by complainant. As the repudiation of the claim as per exclusionary clause of the terms and conditions of the policy took place and contract of insurance is binding on the parties and this Forum cannot add or subtract to the terms and conditions of the policy and as such, we have no hesitation in holding that there is no deficiency in service on the part of Ops in respect of repudiation of the claim in question, particularly when admissible claim for earlier year has been released is a fact admitted by complainant.

22.              As a sequel of above discussion, complaint dismissed with no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

                                      (Karnail Singh)                            (G.K.Dhir)

                                Member                                      President

Announced in Open Forum

Dated:05.09.2016     

Gobind Sharma.