Date of filing: 11.08.2011
Date of disposal: 06.08.2012
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ANANTAPUR.
PRESENT: - Sri T.Sundara Ramaiah, B.Com., B.L., President (FAC)
Smt. M.Sreelatha, B.A., B.L., Lady Member
Sri S.Niranjan Babu, B.A., B.L., Male Member
Monday, the 06th day of August, 2012
C.C.No.130/2011
Between:
Smt. S.Saraswathamma,
W/o S.Nagabushanam,
D.No.22/404, Reddy Street,
Old Town, Opp: I Town Police Station,
Anantapur. … Complainant
Vs.
1. Max New York Life Insurance Company Limited
Rep. by its Branch Manager,
Meda Complex, Near Corporation Bank,
Subash Road,
Anantapur.
2. Max New York Life Insurance Company Limited,
Rep. by its Managing Director,
Operation Centre, Plat No.90-A,
Sector 18, Udhyoug Vihar,
Gurgaon,
Hariyana-122 015, … Opposite Parties
This case coming on this day for final hearing before us in the presence of Sri N.P.Sreenivasulu and Sri K.Jagadeeswar Reddy, Advocates for the complainant and the 1stopposite party call absent and set exparte and Sri Amit Srivatsava and Sri N.U.Devanatha Reddy, Advocate for the 2nd Opposite Party and after perusing the material papers on record and after hearing the arguments of both sides, the Forum delivered the following:
O R D E R
Sri S.Niranjan Babu, Male Member: - This complaint has been filed by the complainant under section 12 of the Consumer Protection Act, 1986 against the opposite parties 1 & 2 to pay a sum of Rs.3,78,814/- towards medical expenses, Rs.17,180/- towards investigation bill amount, Rs.21,000/- towards physiotherapy bill amount, Rs.50,000/- towards mental agony, Rs.10,000/- towards costs of the complainant and Rs.20,000/- towards deficiency of service, totaling to a sum of Rs.4,96,994/- with future interest @ 18% p.a.,
2. The brief facts of the complaint are that: - The complainant is a permanent resident of Anantapur Town. The complainant has taken Health Insurance Policy “ Life Line Wellness Plus” non-linked insurance policy from the 1st opposite party under the policy bearing No.381706480 dt.13.02.2009 by paying a sum of Rs.12,631.15 as an yearly premium and the sum assured is Rs.4,00,000/- and the period of 15 years.
3. Subsequently the complainant was suffering with Knee pains of both legs and she approached the local doctor and the doctor advised the complainant undergo operation and referred to Sagar Hospital, Bangalore for treatment. Before going to Bangalore the complainant and her husband went to the 1st opposite party and explained their problem for applicability of the policy for the said complaint. Then the 1st opposite party explained about the health policy condition No.36 Major Organ transplant.
The receipt of a transplant of:
Human bone marrow using haematopoietic stem cells preceded by total bone
marrow.
One of the following human organs: heart, lung, liver, kidney, pancreas, that
resulted from irreversible end-stage failure of the relevant organ.
Other stem-cell transplants are however not covered.
and knee pains come under the relevant health policy is applicable. After the assurance given by the 1st opposite party that the medical charges and other expenses can be claimed under the policy. The complainant was admitted at Sagar Hospital, Bangalore on 08.09.2009 I.P.No.ID0078639. On 09.09.2009 she under went operation for her both knees. The complainant paid the operation charges and medical expenses to the hospital on 23.09.2009 before getting discharged. The complainant incurred a sum of Rs.17,180/-towards (blood test, urine test and X-rays), Rs.21,000/- towards the physiotherapy to Dr.Chandra at Anantapur.
4. Subsequently after discharge from the hospital the complainant produced all the original bills and claimed for reimbursement from the 1st opposite party and the same was sent to the 2nd opposite party for processing the claim. Later the opposite parties 1 & 2 repudiated the claim stating that the knee replacement does not cover under the said policy, hence the claim was repudiated. As the claim of the complainant was repudiated by the opposite parties 1 & 2 and the main object of taking the policy is to protect her health only she took the said policy by paying a sum of Rs.12,631.15 as premium for one year. Though the knee operation of the complainant was covered under the said policy and as the opposite parties 1 & 2 repudiated the claim on 13.10.2009 which is nothing but deficiency of service on the part of the opposite parties 1 & 2. In the above circumstances the complainant made a complaint claiming a sum of Rs.4,96,994/- against the opposite parties 1 & 2.
5. The 1st opposite party called absent and set exparte.
6. The 2nd opposite party filed counter stating that the 2nd opposite party denied all the averments and contentions made by the complainant. The 2nd opposite party submits that the instant complaint is a malicious complaint filed with a malafide intention in order to gain monetarily from this opposite party. The 2nd opposite party submits that the complaint is based on mere surmises and conjectures. The 2nd opposite party submits that on 13.02.2009 the complainant after understanding all the terms and conditions of the policy filled up in the proposal form bearing No.381706480 for a “Life Line Wellness Plus” policy for an assured amount of Rs.4,00,000/-. Basing on the declaration and the information provided in the said application a policy bearing No.381706480 was issued to the complainant on 18.02.2009 after receiving a premium of Rs.12,631/-.
7. The 2nd opposite party submits that the policy issued to the complainant contains the terms and conditions and as per condition No.36:-Major Organ transplant. The receipt of a transplant of:
Human bone marrow using haematopoietic stem cells preceded by total bone
marrow.
One of the following human organs: heart, lung, liver, kidney, pancreas, that
resulted from irreversible end-stage failure of the relevant organ.
Other stem-cell transplants are however not covered.
The complainant’s total knee replacement surgery will not be covered under the above policy. The 2nd opposite party sates that on 14.10.2009 they received a letter from the complainant requesting them to process the claim under the said policy. The 2nd opposite party further submits that the medical records provided by the complainant pertaining to her undergoing surgery for total knee replacement surgery will be covered under the policy. Hence, the same was communicated to the complainant vide letter dt.31.10.2009. Further the 2nd opposite party submitted that under the terms and conditions of the policy receipt, transplant of human organs, namely heart, lung, liver, kidney, pancreas, that resulted from irreversible end stage failure of relevant organ only is covered. However the total knee replacement does not fall under the above said terms and as the same can be clearly understood from plain reading of the said term and there is no scope for misunderstanding the term.
8. And the further allegation that the 1st opposite party has given assurance for payment to the total knee replacement and recommended the complainant to proceed for treatment is utter false. Further the 2nd opposite party submits that the terms of the contract have to be construed strictly without altering the nature of the contract as it may affect the interest of both parties adversely. Hence, the complaint is liable to dismissed as there is no deficiency of service on the part of the opposite parties in repudiating the claim made by the complainant.
9. Basing on the above pleadings, the following points that arise for consideration are:-
i) Whether there is any deficiency of service on the part of the opposite parties 1 & 2?
ii) To what relief?
10. In order to prove the case of the complainant, the complainant has filed his evidence on affidavit and marked Exs.A1 to A5 documents. On behalf of the 2ndopposite party, the 2nd opposite party filed evidence on affidavit and marked Ex.B1 to B6 documents.
11. Heard both sides
12. POINT NO 1:- It is an admitted fact that the complainant has taken a Health Insurance Policy bearing No.381706480 dt.13.02.2009 for a sum of Rs.4,00,000/- by paying a premium of Rs.12,631.15 as the first premium and it is a health insurance policy named “ Life Line Wellness Plus”. After taking the policy the complainant was suffering from Knee pains of both legs and approached the doctor for treatment. The doctor advised the complainant to under go operation for the Knee pains and referred to Sagar Hospital,Bangalore for treatment. The counsel for complainant argued that before going to Bangalore the complainant and her husband went to the 1st opposite party and explained their problem for applicability of the policy for the knee pains. The counsel for the complainant argued that on the advice of the 1st opposite party under the condition No.36 the complainant can claim for the insurance amount after getting operated for her both knees. Hence the complainant went to Sagar Hospital Bangalore and got operated to her both knees by spending a huge sum of Rs.3,78,814/- for operation and Rs.17,180/- (for blood test, urine test and x rays) and also spent Rs.21,000/- towards physiotherapy at Anantapur. Subsequently after getting discharged from the hospital on 23.09.2009 the complainant filed all the original bills claiming the medical expenditure incurred by her for reimbursement from the opposite parties. But the claim was repudiated by the opposite parties stating that the total knee replacement operation does not fall under the policy and hence the claim is repudiated. Though the opposite parties 1 & 2 ought to have paid the claim amount and as they have failed to pay the expenses incurred by her for operation shows their negligence in settling their claim. Hence there is deficiency of service on the part of the opposite parties 1 & 2 and hence they are liable to pay a sum of Rs.4,96,994/-.
13. The counsel for the 2nd opposite party argued that it is true that the complainant has taken a “Life Line Wellness Plus” for a sum of Rs.4,00,000/- and the preliminary liability of the opposite parties is limited a sum of Rs.4,00,000/- only. The counsel for the 2nd opposite party denies the allegation made by the complainant that the 1st opposite party has assured the complainant that the total knee replacement operation is covered under the policy and he also assured to reimburse the medical expenses and other expenses. The counsel for 2nd opposite party argued that the terms and conditions of the policy are clear and particularly with regard to term No.36 there is a clear mention of the organs which are covered under the policy and no other organs are covered under the policy. So the repudiation of the complainant’s claim will not fall under deficiency of service hence the complaint is liable to dismissed.
14. After hearing the arguments of both the counsels and perusing the documents the only point i.e., to be taken into consideration is that whether the total knee replacement operation falls under the said policy or not. After perusing the documents filed by the complainant which is marked Ex.A1 which is the policy document with terms and conditions and in the condition No.36. It is clearly mentioned that major organ transplant.
The receipt of a transplant of:
Human bone marrow using haematopoietic stem cells preceded by total bone
marrow.
One of the following human organs: heart, lung, liver, kidney, pancreas, that
resulted from irreversible end-stage failure of the relevant organ.
Other stem-cell transplants are however not covered.
The above condition clearly specifies the organs and their replacement which are covered under the policy and clearly mentioned with other stem transplants which are however not covered. It is the complainant of total knee replacement operation which is not an organ in the above said transplants and the coverage of insurance does not arise.
15. As the complainant total knee operation is not covered under the said policy the opposite parties’ repudiation cannot be taken as deficiency of service.
16. The Hon’ble Supreme Court of India, it has been held that duty of the court is to interpret the document of contract as was understood between the parties. In the case of General Assurance Society Limited Vs. Chandmull Jain (1966) 3 SCR 500, it was observed as under:
In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves.
Similarly in the case of Oriental Insurance Company Limited Vs Samayanallur Primary Agriculture Co-op. Bank AIR 2000 SC 10, it was observed as under:
The insurance policy has to be construed having reference only to the stipulations contained in it and no artificial farfetched meaning could be given to the words appearing in it.
In the case of polymath India Private Limited and Anr. Vs. National Insurance Company Limited and Ors. AIR 2005 SC 286, it was observed as under:
The terms of the contract have to be construed strictly without altering the nature of the contract as it may affect the interest of parties adversely.
17. In the above circumstances we are of the view that the repudiation of the claim by the opposite parties is not deficiency of service and the complaint made against the opposite parties 1 & 2 is dismissed without costs.
18. In the result the complaint is dismissed without costs.
Dictated to the Steno, transcribed by him, corrected and pronounced by us in open Forum, this the 06th day of August, 2012.
Sd/- Sd/- Sd/-
MALE MEMBER LADY MEMBER PRESIDENT (FAC)
DISTRICT CONSUMER FORUM DISTRICT CONSUMER FORUM DISTRICT CONSUMER FORUM
ANANTAPUR ANANTAPUR ANANTAPUR
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
ON BEHALF OF THE COMPLAINANT:
NIL
ON BEHALF OF THE OPPOISITE PARTIES 1& 2
-NIL-
EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT
Ex.A1 Health Insurance Policy document book let relating to the complainant issued
by the 2nd opposite party.
Ex.A2 Medical bill dt.23.09.2009 issued by Sagar Hospital, Bangalore in the name of
the complainant.
Ex.A3 Discharge summary relating to the complainant issued by the Sagar Hospital,
Bangalore.
Ex.A4 Cancelled Canara Bank cheque bearing No.784521 issued by complainant.
Ex.A5 Repudiation letter dt.31.10.2009 issued by the 2nd opposite party to the
complainant.
EXHIBITS MARKED ON BEHALF OF THE 2nd OPPOSITE PART
Ex.B1 Photo copy of proposal form submitted by the complainant to the opposite
parties.
Ex.B2 Photo copy of policy document relating to the complainant issued by the
opposite parties.
Ex.B3 Photo copy of claim application form submitted by the complainant to the
opposite parties.
Ex.B4 Photo copy of discharge summary relating to the complainant issued by the
Sagar Hospital, Bangalore.
Ex.B5 Repudiation letter dt.31.10.2009 issued by the 2nd opposite party to the
complainant.
Ex.B6 Photo copy of letter dt.29.01.2010 issued by Insurance ombudsmen
Hyderabad to the opposite parties.
Sd/- Sd/- Sd/-
MALE MEMBER LADY MEMBER PRESIDENT (FAC)
DISTRICT CONSUMER FORUM DISTRICT CONSUMER FORUM DISTRICT CONSUMER FORUM
ANANTAPUR ANANTAPUR ANANTAPUR
