Chandigarh

DF-II

CC/683/2020

Pal Singh - Complainant(s)

Versus

LIC of India - Opp.Party(s)

Adv. Neeraj Gupta

13 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	683 of 2020
Date  of  Institution	:	15.12.2020
Date   of   Decision	:	13.06.2023

 

 

 

 

 

Pal Singh, House No.503, GH-62, Sector 20, Panchkula, Haryana.

             …..Complainant

 

Versus

1]  LIC of India, Divisional Office, Jeevan Parkash Building, Sector 17-B, Chandigarh, through its Sr. Divisional Manager

2]  The New India Assurance Company Limited, having its Corporate Office at Mumbai, through its Regional Office in Chandigarh at SCO 36-37, Sector 17-A, Chandigarh through its Regional Manager.

3]  MD India Health Insurance TPA Pvt. Ltd., having its Head Office at S.No.46/1, E-Space, A2 Building 3^rd Floor, Pune Nagar Road, Vadgaonsheri, Pune 411014

   ….. Opposite Parties

 

 

BEFORE:  SMT.SURJEET KAUR     PRESIDING MEMBER 

                    SH.B.M.SHARMA              MEMBER

                               

Argued by  : Sh.Neeraj Gupta, Counsel of Complainant

Sh.Banni Thomas, Counsel of OP No.1

Sh.Vinod Choudhary, Counsel of OP NO.2.

OP No.3 exparte.

 

PER SURJEET KAUR, PRESIDING MEMBER

 

         The case of the complainant is that he is a retired employee of OP No.1. The complainant as well as his family members were duly covered by Medical Claim Policy taken by the OP NO.1 from OP NO.2 for the year 2019-2020 having coverage of sum assured of Rs.30 lacs (Ann.C-1). It is stated that during the coverage period of the said policy, the daughter of the complainant namely Ms.Rajni Devi was detected with lung Cancer.  She took treatment at different hospitals, medical institutes i.e. General Hospital, Sector 6, Panchkula, Fortis Hospital, Mohali, Denvax Cancer Cetre, Delhi etc. for the same and unfortunately died on 18.1.2020.  It is stated that the medical expenditure incurred by complainant on the cancer treatment of her insured daughter was settled by the OPs only to the tune of Rs.57,772/- and denied the balance amount of Rs.3,96,932/- on the ground that she had undergone Stem Cell Transplantation Procedure, which is not payable under the policy (Ann.C-6).  Hence, this complaint has been preferred alleging the said act of the OPs as deficiency in service.

         The OP No.1 has filed written version and while admitting the factual matrix of the case, stated that the complainant submitted a bill of Rs.1,84,772/- on 11.10.2019 out of which Rs.57,775/- has been settled and the unsettled/repudiated amount is Rs.1,27,000/-.  It is also stated that further a bill of Rs.2850/- was submitted out of which Rs.2500/- has been settled by the insurer on 9.1.2020.  It is submitted that after repudiation on 13.11.2019, the case was again reconsidered and on 18.12.2019, the case was finally repudiated by the TPA for the balance amount of Rs.1,27,000/-.  It is also submitted that this particular treatment has not been covered under the policy in question and hence the claim for balance amount was repudiated which was valid and was as per policy terms & conditions. Denying other allegations, the OP No.1 prayed for dismissal of the complaint. 

         The OP No.2 has also filed written version and while admitting the factual matrix of the case about insurance, treatment taken by insured and claim lodged, it is stated that the claim was filed for treatment taken for metastatic carcinoma of lungs during policy period and the complainant was informed that the remaining claim fell outside the scope & ambit of policy as Dendritic Cell Therapy being stem cell therapy was excluded in respect of cancer and there were sub-limit for different stem cells transplantation provided in the policy.  It is submitted that as per terms & conditions of the policy, the stem cell therapy was excluded from the reimbursement except in certain type of cancer i.e. bone marrow, blood cancer, myeloma etc.  It is stated that the claim was rejected after examining every aspect of the controversy and since the claim fell in the exclusive clause, the same was not entertained.  Pleading no deficiency in service and denying other allegations, the OP NO.2 has prayed for dismissal of the complaint.

         The OP NO.3 did not turn up despite service of notice sent through regd. post, hence the OP NO.3 was proceeded exparte vide order dated 17.11.2021.

 

3]       Parties led evidence in support of their contentions.

 

4]       We have heard the ld.Counsel for the contesting parties and have gone through the documents on record including written arguments.

 

5]       Admittedly, the complainant’s daughter namely Ms.Rajni Devi, duly insured with OPs vide mediclaim policy in question, was detected & treated for Lung Cancer during the policy period and unfortunately passed away on 18.1.2020.  

 

6]       The grouse of the complainant is that the claim lodged by him with the OPs for reimbursement of medical expenses incurred on the cancer treatment of his insured daughter has been settled only for Rs.57,772/- and the balance claim amount of Rs.3,96,932/- was illegally denied/repudiated by the OPs, whereas the stand of the OPs No.1 & 2 is that the claim for stem cell therapy/transplantation undertaken by the patient/insured being not covered and falling under exclusion of the policy has righty been repudiated.  

 

7]       We do not find any merit in the stand taken by the OPs.  The OPs have not disputed that the insured daughter of the complainant was detected & treated for lung cancer and the stem cell therapy/transplantation so taken & provided to the insured patient was in response & revival from cancer. It is also not disputed by the OPs that the treatment of cancer is covered under the policy. It is opined that any clause in the policy either exclusion or otherwise, cannot be read or introduced to the disadvantage of the policy holder and the insurance companies as in the present case cannot deny the claim on technical ground.  

 

8]       The Hon’ble Apex Court in its recent judgment passed in CIVIL APPEAL NO.8249 OF 2022 [Arising out of SLP (Civil) No. 25457 of 2019] titled as M/s Texco Marketing Pvt. Ltd. Versus TATA AIG General Insurance Company Ltd. & Ors., decided on 9.11.2022 has categorically held that

 

An exclusion clause has to be understood on the touch-stone of the doctrine of reading down in the light of the underlining object and intendment of the contract. It can never be understood to mean to be in conflict with the main purpose for which the contract is entered. A party, who relies upon it, shall not be the one who committed an act of fraud, coercion or mis-representation, particularly when the contract along with the exclusion clause is introduced by it. Such a clause has to be understood on the prism of the main contract. The main contract once signed would eclipse the offending exclusion clause when it would otherwise be impossible to execute it. A clause or a term is a limb, which has got no existence outside, as such, it exists and vanishes along with the contract, having no independent life of its own. It has got no ability to destroy its own creator, i.e. the main contract. When it is destructive to the main contract, right at its inception, it has to be severed, being a conscious exclusion, though brought either inadvertently or consciously by the party who introduced it.

 

 

9]       In view of above discussion, findings and law, we are of the opinion that the OPs No.1 to 3 have wrongly & illegally repudiated the genuine claim of the complainant, which clearly amounts to deficiency in service on their part causing loss, harassment and metal agony to the complainant. Therefore, the complaint stand allowed against the OPs No.1 to 3 with direction to pay the balance claim amount to the complainant i.e. Rs.3,82,469/- (Rs.4,40,241- Rs.57,772), the medical expenses incurred by him on the treatment of his insured daughter    (Ann.-A), along with interest @10% p.a. from the date of filing the present complaint – 15.12.2020 till its realization.  The OPs No.1 to 3 are also directed to pay a compensation amount of Rs.25,000/- to the complainant for causing harassment and mental agony on account of their deficient service, along with litigation cost of Rs.15,000/-.

         This order shall be complied with by the OP No.1 to 3 jointly & severally within a period of 45 days from the date of receipt of its copy, failing which they shall be liable to pay additional cost of Rs.20,000/- apart from the above relief.

        Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

13^th June, 2023                                                                               sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

(B.M.SHARMA)

MEMBER