DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No. 536/13
- Smt. Rosy Aggarwal W/o Sh. Rajeev Aggarwal
- Sh. Rajeev Aggarwal S/o Sh. R.B. Aggarwal
Both R/o – F 133, Karam Pura,
New Delhi – 110015 -Complainants
Vs
1. Medi Assist India (P) Ltd
F-2 Kailash Plaza, 2nd Floor,
Sant Nagar, East of Kailash.
Near Escon Temple, New Delhi-110065
2. Reliance Life Insurance Co. Ltd.
(Regd. No. 121) Regd. Office H Block,
First Floor, Dhirubhai Ambani Knowledge City
Navi Mumbai, Maharashtra – 400710
3. Medi Assist India TPA Pvt. Ltd.
Team Reliance Health and Wealth,
Shilpa Vidya, 3rd Floor, No. 49, 3rd Stage
J.P. Nagar, Bangalore – 560078. -Opposite Parties
Date of Institution: 28.10.2013 Date of Order: 17.08.2016
Coram:
N.K. Goel, President
Naina Bakshi, Member
S.S. Fonia, Member
O R D E R
The case of the complainants, in brief, is that the complainant-1 (Wife) as principal and complainant-2 (Husband) and their daughter as beneficiaries took policy No. 1551903 (Customer ID No. 72113863) for the period from 21.10.2009 to 31.10.2019 from OP-2; that complainant-2, the beneficiary of the mediclaim insurance policy issued by the OP-2, suffered acute CDA-AWMI and was got admitted to Agrasen Hospital, Punjabi Bagh, New Delhi on 28.10.2011 where he remained admitted till 30.10.2011 regarding which intimation was sent to the OPs online at No. RL1C/4557. The complainants incurred a sum of Rs. 1,61,917/- on the medical treatment of complainant-2. Claim was lodged with the OPs vide claim No. RL1C/4557. The same was rejected on the following grounds:
“The Hospital cash benefit will be paid for each complete day of Hospitalization (i.e. 24 hours) after the first 48 hours. There will not be any payment for the part of the ay i.e. before completion of 24 hours. No retrospective payments day one are to be made.
As per the Hospital bill, the admission has been on 28.10.2011 and the discharge has been on 30.10.2011. Hence the hospitalization duration if for 2 days. After deducting the waiting period of the first 48 hours (2 days) the balance period hospitalization does not meet the required period of ‘complete day’ – 24 hours, and ‘There will not be any payment for the part of the day i.e. before completion of 24 hours.”
The complainants sent numerous letters to the OPs for reconsideration inter-alia pleading as under:
“I, Rajeev Aggarwal, was admitted in emergency due to acute CDA-AWMI, single vessel disease, which could not have been waited for treatment for the next 48 hours and the discharge was done on the expert medical advice of Doctors and not by the patient himself.”
It is claimed that the claim of the complainants has been rejected only because his treatment started immediately on his admission in the Hospital and not after 48 hours of his admission in the Hospital. It is pleaded that it is next to impossible for a patient suffering from acute CDA-AWMI to wait for his medical treatment for 48 hours after his admission in the Hospital for want of his mediclaim even at the risk of his life. It is stated as under:
“The complainants were unaware about ‘page No. 8, Benefits: DHCB for the Principle Insured-Column-How & When payable: Para 2 of the said policy at the time of issuance of said policy to the complainants by agent of opposite party No. 2. The complainants were not provided the copy of the insurance policy before providing them the said mediclaim policy and at the time of receiving premium of said mediclaim policy from the complainant No. 1, by the opposite party No. 2, through its agent. Under the circumstances, there was no occasion for the complainants to understand the terms and conditions, specifically ‘page No. 8, Benefits: DHCB for the Principle Insured-Column-How & When payable: Para 2 of their aforesaid mediclaim policy.”
Hence pleading deficiency in service on the part of the OPs, complainants have filed the present complaint for issuing directions to the OPs to pay Rs. 1,61,917/- with all other benefits against the policy in question and a sum of Rs. 5 lacs as damages for pains, sufferings, mental shock, agonies, hardship, humiliation etc. on account of intentional and willful negligence and apparent deficiency in service on the part of the OPs.
OP-1 has been proceeded exparte.
In its written statement, OP-2 has inter-alia pleaded that as per clause 6 (2) of the Insurance Regulatory and Development Authority (Protection of Policyholder’s Interests) Regulations, 2002, the complainants have a period of 15 days from the date of receipt of the policy documents to review the terms and conditions of the policy and in case the insured disagrees to any of those terms or conditions, he has the option to return the policy stating the reason for his objection when he shall be entitled to a refund of the premium paid, subject only to a deduction of a proportionate risk premium for the period of cover and the expenses incurred by the insurer on medical examination of the proposer and stamp duty charges. However, the complainants did not avail the said free lock provision and kept mum for a long period of time and hence it was presumed that the contract of insurance in question had been legally concluded between the complainant and the OPs. It is pleaded that the complainants had obtained/procured the policy in question after making all the inquiry and satisfied themselves in all respects. It is pleaded that the matter involves complex questions of facts and law which cannot be determined by this Forum and hence complainants should seek redressal of their grievances in a civil court, if so advised. The other averments made in the complaint have not been denied. Thus the facts with regard to the treatment received by the complainant-2 from Agrasen Hospital, New Delhi for acute CDA-AWMI, making payment of Rs. 1,61917/- by the complainants to the Hospital, filing of claim No. RL1C/4557 by the complainants with the OPs for payment of the said amount and the rejection thereof by the OPs under the above stated provision have not been denied.
Complainants have filed a rejoinder to the written statement. It is inter-alia stated that “in Para No. 4 of the terms and conditions under the heading Benefit (Page 18 of Policy document) table of different types of benefits are given where exclusion of 48 hours are mentioned in column (How & When payable) but in the heading column Size of benefits the case of intensive care unit (ICU) are excluded. The present case of complainants are of ICU from (28/10/2011 to 30/10/2011)”.
Complainant-1 has filed her own affidavit in evidence. On the other hand, affidavit of Sh. Amal Srivastava, Territory Manager of OP-2 has been filed in evidence.
Written arguments have been filed on behalf of the parties.
We have heard the arguments of the complainant in person and the counsel for OP-2 and have also carefully gone through the record.
The dispute is with regard to the applicability of clause 4 “Benefit” of the policy in question in the present case. Therefore, the matter does not involve the complicated questions of law and facts and can be decided in a summary way. Therefore, we hold that this forum has the jurisdiction to entertain and decide the complaint on merits.
We presume that the copy of the policy in question containing the terms and conditions had been duly delivered to the complainants and the complainants were familiar and acquainted with terms and conditions contained therein. Clause 1.31 defines “Hospitalization” to mean the insured is required to stay as an impatient in a hospital within India for medically necessary treatment following and due to accidental bodily injury or sickness. The term “Hospitalization period” has been defined in clause 1.32 to mean the time in number of hours and minutes between the date and time in number of hours and minutes of admission into the hospital and the date and time in number of hours and minutes of discharge from the hospital. The term “Intensive Care Unit (ICU)” has been defined in clause 1.34 to mean a special ward in any hospital that is used for the sole purpose of treatment of patients with a critical or exigent condition, and where the patient is under 24 hours care and monitoring, by a physician and a nurse. It is undisputed case of the parties in the present case that the complainant had been got admitted in Agrasen Hospital and he had got the treatment in ICU i.e. Intensive Care Unit for a critical and exigent disease i.e. Cardiac Coronary Arteries disease. Clause 4 “Benefit” inter-alia reads as under:
“Daily Hospital Cash Benefit for the Insured Spouse (if any) | Lump sum payment if the insured person has to stay for more than 48 hours in hospital as a result of injury, sickness or disease provided the policy is in force. The Hospital Cash Benefit will be paid for each complete day of hospitalisation (i.e. 24 hours) after the first 48 hours. Thre will not be any payment for part of the day i.e. before completion of 24 hours. No retroactive payments from day one are to be made. There is a waiting period of 90 days from the date of adjustment of first Premium or date of revival/reinstatement of policy/whichever is later. No Hospital Cash Benefit claim will be entertained during the waiting period unless the hospitalisation has arisen on account of an accident. | If the insured spouse is admitted in a ward other than Intensive Care unit (ICU), the daily cash benefit amount mentioned in the policy schedule is payable. If the insured Spouse is admitted in an Intensive Care Unit (ICU) the daily cash benefit will be twice the amount payable in a ward other than ICU. The maximum number of days that can be spent in an ICU by the Insured Spouse are restricted to 7 in the first policy year and 30 days during any policy year thereafter. The maximum number of days (including days spent in an ICU) that can be spent in the hospital by the Insured Spouse are restricted to 18 days in the first policy year and 60 days during any policy year thereafter. During the entire policy term, the maximum number of days that can be spent in the hospital (including days spent in an ICU) by the Insured Spouse are restricted to 180 days.” |
(Italics ours)
Angiography and PTCA procedures can only be done after the hospitalisation of the patient in a hospital. Angiography as well as PTCA require invasive procedure. The patient has to be taken to the Cath Lab and is required to undergo some invasive surgery known as Angiography and /or PTCA. Both the procedures involve risk to life. Therefore, the stay in the hospital for the said procedure has to be determined by the attending doctors and not by the patient himself/herself. It is a matter of common knowledge that the medical science has been advancing day by day and the stay period of hospitalisation after invasive procedures is reducing day by day. The stay of 7 days or more has now been reduced and/or has come down to two days hospitalisation period. Therefore, in the present case, the complainant No. 2 had no control over the period of stay. Whether treatment provided to him by the doctors in Agrasen Hospital required 48 hours stay or for more than 48 hours stay, was to be decided only by the treating doctors and their final decision was not liable to be challenged by anyone including the OPs. Moreover, the hospitalisation period has been computed as about 46 hours i.e. 2 hours less than the period of 48 hours. We are of the considered opinion that while calculating the said stay period, the OPs, in fact, adopted a totally hypothetic view with a view to reject the claim of the complainants.
Secondly and most importantly, we are of the considered opinion that the clause by taking the shelter of which the claim in question has been rejected by the OPs is not applicable to the present case. Admittedly, it is the complainant-1 who was the principal insurer and complainant -2 was only a beneficiary spouse. Therefore, the case of the complainants fell within the ambit of the clause applicable to the “insured spouse”. The relevant portion of the said clause has already been reproduced hereinabove and italicised by us. A bare perusal of the italicised portion would go a long way to prove that there is no time restriction for admission in a hospital so far as the insured spouse is concerned.
Therefore, we hold that the OPs committed illegality while rejecting the claim in question of the complainants and the rejection of the claim of the complaints was an act of perversity and arbitrariness on the part of the OPs which, no doubt, also amounted to deficiency in service and unfair trade practice.
In view of the above discussion, we allow the complaint and direct OP-2 Insurance Company to pay Rs. 1,61,917/- towards the hospitalisation charges and also a sum of Rs. 1 Lakh for mental pain and agony to the Complainants within one month from the date of receipt of copy of this order failing which the OP-2 Insurance Company shall become liable to pay Rs. 1,61,917/- along with interest @ 7% p.a. from the date of this order till the date of realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(S.S. FONIA) (NAINA BAKSHI) (N. K. GOEL) MEMBER MEMBER PRESIDENT
Announced on 17.8.2016
Case No. 536/13
17.8.2016
Present – None.
Vide our separate order of even date pronounced, the complaint is allowed. OP-2 Insurance Company is directed to pay Rs. 1,61,917/- towards the hospitalization charges and also a sum of Rs. 1 Lakh for mental pain and agony to the Complainants within one month from the date of receipt of copy of this order failing which the OP-2 Insurance Company shall become liable to pay Rs. 1,61,917/- along with interest @ 7% p.a. from the date of this order till the date of realization. Let the file be consigned to record room.
(S.S. FONIA) (NAINA BAKSHI) (N. K. GOEL) MEMBER MEMBER PRESIDENT
