Delhi

New Delhi

CC/114/2015

Rohit Gupta - Complainant(s)

Versus

M/S. Apollo Munich Health Insurance Company Ltd. - Opp.Party(s)

16 Aug 2019

ORDER

 

 

 

                               CONSUMER DISPUTES REDRESSAL FORUM-VI

                                   (DISTT. NEW DELHI),

                        ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                  NEW DELHI-110001

 

Case No.C.C./114/2015                                        Dated:

In the matter of:

          Sh. Rohit  Gupta,

          S/o Sh. Sajjan Kumar Gupta,

          C-1/28, Mianwali Nagar,

          Sundar Vihar,

         Delhi-87.

                …… Complainant

 

Versus

1. Apollo Munich Health Insurance Co. Ltd.,

            1^st Floor, Peerless Building 

          6 & 7 B.K. Roy Court,

          Asaf Ali Road,

          Darya Ganj,

          New Delhi-10002.

 

Also at:

Apollo Munich Health Insurance Co. Ltd.,

103, UGF, Twin Towers, Netaji Subhash Place,

                         Peetampura,

New Delhi.

 

2. Apollo Munich Health Insurance Co. Ltd., 

         10^th Floor, Building No.10,

         Tower B, DLF Cyber city, Ph.2,

         Gurgaon-122002

           Through authorized signatory.

 

                ……. Opposite parties

 

 

 

 

NIPUR CHANDNA, MEMBER

ORDER

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The gist of the complaint is that the complainant is the medi- claim policy holder viz “Easy Health Insurance Policy  of OP vide its policy bearing no. 900001/11051/100402368-01 for a period of 11.07.2014 to 10.07.2015 for a sum insured of Rs.5,00,000/-. The said policy was a cashless floater composite family policy viz any member of the policy can avail, as per medical needs, the entire benefit of Rs.5,00,000/- of the sum insured.   The wife(Mrs. Pooja Gupta)  of the complainant, was one of insured person in the policy in question, who had developed a tendency of excessive weight. Therefore, as per medical advice on 30.9.2014, she was admitted in the Institute of Minimal Access, Metabolic & Bariatric Surgery of Sir, Ganga Ram Hospital, New Delhi, where she was operated on 1.10.2014  and was discharged on 3.10.2014 from the hospital.

2.     Intimation of the hospitalization was given immediately to OP but OP denied cashless facility, having no other option complainant paid a total sum of Rs. 3,56,513/-  for the treatment of his wife. On 14.10.2014, the complainant submitted claim form with the OP at its office at New Delhi for reimbursement.  Vide letter dt.21.10.2014, his claimed was repudiated on the ground of exclusion clause by the OP.  On 29.10.2014, the complainant sent an  e-mail  to the OP  for re-consideration of his claim, but all in vain. Complainant therefore approached this Forum for the redressal of his grievance.

3.     The complaint has been contested by the OP. In its written statement OP has not disputed the policy in question. It is stated that the aforesaid policy was issued subject to various terms and conditions and the complainant and his other insured had consented to abide by the terms and conditions of the policy.  It is further stated that the claim of the complainant was thoroughly processed and after scrutiny of all the documents it was noted that Mrs. Pooja Gupta was treated for Morbid obesity and as per  Exclusion Clause i.e. Clause VI) C) V) of the policy terms and conditions, Morbid Obesity was excluded in the policy, therefore, the claim of the complainant was rightly repudiated.  Prayed for dismissal of present  complaint.

4.     Both the parties have filed their evidences by way of affidavits.

5.     We have heard argument advance at the Bar and have perused the

Record.

 

6.     It is  argued on behalf of OP that the Health Insurance is a contract like any other contract and operates subject to terms and condition of the policy, and as per exclusion Clause VI) C) V) of the policy, the claim of the complainant is rightly repudiated.

7.     Counsel for the complainant on the other hand has argued that the complainant had purchased the above policy and paid the premium for reimbursement of medical expenses in question.  The above treatment was taken by the wife of the  complainant only on the advice of the treating doctor as the operation was done as Life Saving Surgery for life threatening disease, hence, the repudiation is arbitrary and unjustified and further  prayed that the relief claim be granted..

8.     Some facts are not denied by the parties such as the policy documents and the treatment taken.  The only question for our consideration is whether the repudiation of claim on the ground of exclusion Clause VI) C) V) of the policy is justified or not.

9.     Admittedly,  Health Insurance is a contract like any other contract and operates subject to terms and condition of the policy. Perusal of the policy terms and conditions makes it clear that as per Medical Exclusion Clause V) a) which reads as under:

V. Cosmetic, aesthetic and reshaping treatment and surgery.

a. Treatment of  obesity and any weight control program me.

are excluded.  In the present complaint, the complainant has taken the treatment for morbid obesity,  which fall under the exclusion clause, hence, repudiated.

10.    Insurance is a contract between the insured and insurer and both the parties are bound by the terms contained therein. The Hon’ble NCDRC in the matter of National Insurance Co. Ltd. vs. Vinod Puri as reported in I [2014] CPJ 341 (NC) is pleased to hold as under:

Insurance contract has to be construed like any other contract on basis of its terms and conditions and outside aid for construction of insurance policy is impermissible.

 11.   The Hon’ble Apex Court in the case of Oriental Insurance Co. Ltd. versus Sony Cheryan reported in (1999) 6 SCC 451 is pleased to hold as under:

The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy.

 12.   Similarly in the case of General Assurance Society Ltd. vs. Chandumull Jain and Anr., reported in (1996) 3 SCR, 500, the Constitution Bench has observed that the policy document being a contract and it has to be read strictly. It was observed:

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. Looking at the proposal, the letter of acceptance and the cover notes, it is clear that a contract of insurance under the standard policy for fire and extended to cover floor, cyclone etc. had come into being.

 

13.    The Hon’ble NCDRC in the matter of Ind Swift Ltd. versus New India Assurance Co. Ltd. reported in IV[2012] CPJ 148 (NC) is pleased to rule as under:

Construction of the policy is to be construed strictly as per the terms and conditions of the policy document which is binding contract between the parties and nothing can be added or subtracted by different meaning.

 

14.    Similarly in LIC versus Banwarilal Yadav reported in IV[2013] CPJ 38 (NC) the Hon’ble NCDRC observed as under:

“Forum has no jurisdiction to go beyond terms and conditions of the Policy.”

 15.   The NCDRC in yet another matter in the matter of Morien Chemicals Ltd. versus UCO Bank reported in III [2013] CPJ 261 (NC) is pleased to hold as under:

“Insurance Company is not liable to pay damages which are not covered under the policy.”

 

 16.   Having regard to the facts and circumstances of the case and  discussion heard, we are of the considered view that there exists no infirmity in the decision of the Insurance Company repudiating the claim since the same falls under Medical Exclusion Clause V(a) and not payable  under the terms and conditions of the policy. Courts are not meant to add or delete the terms of contract.  The above cited judgments are squarely applicable in the present case. 

17.    In view of the above discussion, we are inclined to hold that the repudiation of the claim of the complainant was justified.  We find no merits in the present complaint, same is hereby dismissed.

       

A copy of this order each be sent to both parties free of cost by post.  This final order be sent to server (www.confonet.nic.in ). File be consigned to Record Room.

Announced in open Forum on 16/08/2019.

 

 

 

(ARUN KUMAR ARYA)

      PRESIDENT

           (NIPUR CHANDNA)                                                  (H M VYAS)

                  MEMBER                                                               MEMBER