^{DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,}

^{U.T.CHANDIGARH}

^========

N.R.Chauhan s/o Late Sh.Jagan Nath resident of House No.5097/1, Modern Housing Complex, Manimajra,Chandigarh.

^{…..Complainant}

1.            Indian Overseas Bank having its Regional Office at SCO No.11, Sector 7, Madhya Marg, Chandigarh -160 007 through Chief Regional Manager, SCO No.11, Sector 7, Madhya Marg, Chandigarh.

2.            E-MEDITECH (TPA) Services Limited, SCO No.56, First Floor, Sector 30-C,Chandigarh.

3.            M/s Universal Sompo General Insurance Co. Ltd., SCO No.72, First Floor, Swastik Vihar, Sector 5, MDC, Panchkula.

^{……Opposite Parties}

QUORUM:                                                                   

For Complainant:Sh.V.S.Manhas, Advocate.

For OP No.1 :          

For OP No.3 :                

For OP No.2 :                 

^{PER P.L.AHUJA, PRESIDENT}

1.                       

Ø  Pre existing diseases will be covered.

Ø  Waiver of exclusion of waiting period of 30 days.

Ø  Waiver of exclusion of first year.

Ø  X x x x x x

Ø  X x x x x x

The complainant subscribed the said scheme and paid one time subscription fees amounting to Rs.15,750/- as per his entitlement. It has been contended that the complainant is a consumer as he availed the services of the OPs and obtained the medical insurance. On the basis of subscription by the complainant, OP No.3 issued identity card to him and his spouse valid from 1.10.2012, copy of which is Annexure C-2. It has been contended that Smt.Geeta Chauhan, wife of the complainant was having knee problem and she was admitted inFortisHospital, Mohali on 2.12.2012 for treatment. Since the doctor advised for knee replacement surgery, complainant deposited an amount of Rs.1,64,000/- as advance. Knee replacement was carried out by the doctors and she was discharged from the hospital on 9.12.2012. Copy of the discharge summary is Annexure C-3. The total package for the treatment was Rs.3,20,250/- and the complainant deposited his share of Rs.1,60,250/- and the balance was to be paid by TPA Company M/s E-Meditek (TPA) Services Limited as per the scheme. The details of the expenses are at Annexure C-4. The complainant has contended that to his utter surprise, the medical claim of his wife was rejected by OP No.2 vide its letter dated 20.12.2012 Annexure C-5 on the ground that the waiting period for the ailments of joint replacement due to degenerative conditions and the age related osteoarthritis and osteoporosis is 3 years under the policy. It has been contended that the rejection was wrong and unjustified because as per the circular, there was no such condition in the policy. The complainant was not informed these conditions and after reading the circular, he deposited the requisite fees to become the member of the Group Welfare Society of Indian Overseas Bank. Had these conditions been incorporated in the circular at that time then the complainant would not have opted for the medical insurance. It has been alleged that the OP has misled the complainant and cannot reject the claim on flimsy grounds. After receiving the letter of rejection of the claim from OP No.3, the complainant approached OP No.1 and pointed out the illegal rejection of his medical claim vide letter dated 11.1.2013 Annexure C-6. The complainant has alleged harassment and mental agony, due to misleading and giving lucerative offer by OPs.  

2.                       

3.                       

4.                        

5.                        

6.                       7.                       

8.                       

• Treatment in the hospitals/nursing homes inIndia
• Limit per family shall be Rs.1,50,000/- covering self and spouse on family floater basis.
• Members will be benefited out of cash less facility for their hospitalization claims subject to 20% of co-payment clause.

Add on benefits :

Ø  Pre existing diseases will be covered.

Ø  Waiver of exclusion of waiting period of 30 days.

Ø  Waiver of exclusion of first year.

Ø  Policy covers the age band of 50 – 90 years.

Ø  Coverage of death due to accident of retiree (not spouse) for Rs.2 lacs.”

As per the scheme, all eligible members were to pay one time entry subscription fee, as detailed in para No.3 of the circular and the members had to submit an application form for membership along with demand draft favouring Indian Overseas Bank Retired Employees Medical Assistance Scheme. OP No.1 has not denied this fact that the complainant paid the subscription fee (premium) of Rs.15,750/- to it by demand draft. After receipt of the subscription fee (premium), identity cards Annexure C-2 were issued in favour of the complainant and his wife showing policy No. 2816/52396325/00/000 effective from 1.10.2012. The averments in the complaint coupled with the discharge summary Annexure C-3 and the bill Annexure C-4 show that Mrs.Geeta Chauhan was admitted in Department of Orthopedic,FortisHospital, Mohali on 2.12.2012 and was discharged on 9.12.2012. As per detailed discharge summary Exhibit R-4 produced by OP No.3, Mrs.Geeta Chauhan, wife of the complainant was suffering from tenderness in both knees and feeling difficulty in walking and weight bearing. Both knee joint showed osteoarthritis. After necessary process total knee replacement was done. The evidence shows that the complainant deposited an amount of Rs.1,60,250/- as his share and an amount of Rs.1,60,000/- was to be paid as share of E-Meditech (TPA) Services Limited, OP No.2.

9.                       

“Pre-existing Condition : Any condition, ailment or injury or related condition(s) for which you had signs or symptoms and/or were diagnosed, and/or received medical advice/treatment, within 36 months prior to your first Policy with us.”

The definition of “Coverage” at page No.7 of the conditions shows that hospitalization expense incurred in the first year of operation of the insurance cover on treatment of the certain diseases including joint replacement unless required due to accident is excluded. The endorsement schedule of Group Health Insurance Policy Annexure R-2 also shows that the waiting period for the ailments of joint replacement due to degenerative conditions and age related osteoarthritis and osteoporosis is 3 years under the policy. It has been held by the Hon’ble Supreme Court in Vikram Greentech (I) Ltd. & Anr. Vs. New India Assurance Co. Ltd., II(2009) CPJ 34 (NC) and Deokar Exports Pvt. Ltd. Vs. New India Assurance Company Ltd., I(2009) CPJ 6 (SC), that insurance contract is a species of commercial transactions and it must be construed like any other contract. Its terms have to be strictly construed to determine the extent of liability of insurer. Endeavour of Court must always be to interpret words of contract. Court is not expected to venture into extra liberalism that may result in re-writing the contract/substituting terms not intended by parties. In the instant case, a perusal of the terms and conditions of the insurance policy covering the complainant and other subscribers Annexure R-2 clearly shows that the policy of the complainant incepted on 1.7.2012 and two years of continuous policy coverage had not been completed on the date of knee replacement of the wife of the complainant, therefore, as per exclusion in the policy, the knee replacement operation undergone by the wife of the complainant was not covered under the Group Health Insurance Policy obtained by Indian Overseas Bank in favour of 3994 insured persons and their dependents. Consequently, we feel that if OPs No.2 and 3 have rejected the claim of the complainant, there is no deficiency in service on their part.

10.                    

11.                    

i)                        

ii)                       

iii)                      

The complaint fails against OPs No.2 and 3.

12.                    

13.