Delhi

New Delhi

CC/255/2014

Jatin Arora - Complainant(s)

Versus

M/S. The Oriental Insurance Company - Opp.Party(s)

21 Dec 2018

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.255/2014                                                                           Dated:

              In the matter of:

Sh. Jatin Arora,

S/o Late Lekh Raj Arora,

R/o RZ K-88, New Roshan Pura,

Najafgarh, New Delhi-110043.

                 ……..COMPLAINANT

VERSUS

             The Oriental Insurance Co. Ltd.

             Through Divisional Manager,

              The Oriental Insurance Co. Ltd.,

              DO-21, K-37, 1^st Floor,

              Connaught Circus, New Delhi-01.

Opposite Party.

                

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 was the  mediclaim policy holder bearing No.272300/48/2013/3412 of OP for assured a sum of Rs.2,00,000/-  w.e.f. 4.02.2013. It is alleged that the complainant suddenly fell ill and started suffering from the disease namely  PILONIDAL CYST and  as such he was admitted in Artemis Hospital, Dwarka, New Delhi in emergency.   It is alleged that after approval for cashless facility from the OP,  he was operated by the hospital on 22.11.2013 and was discharged on 24.11.2013.  It was  alleged that  the OP Insurance Co. refused cashless treatment to complainant, but  assured him that  the amount would be re-imbursed to him on  submission of medical record and treatment bills.    

2.     It is submitted by the complainant that his claim was repudiated vide letter dated 10.12.2013 on false and frivolous ground. It is submitted that the complainant also sent a legal notice dated 23.12.2013 to the OP for re-considering his claim but till date no response has been received, hence this complaint.

3.     Complaint has been contested by OP.  In its written statement, OP denies any deficiency in service on its part.  It was stated on behalf of OP that as per the discharge summary of the hospital, the complainant was admitted with the complaint of swelling and pain over natal cleft since 2-3 months with history of pus discharge from the same and was diagnosed as Pilondal Sinus.  The policy inception date is 4.2.13 and as per the present policy terms and conditions, there is 2 years waiting period for the above said disease, hence, the claim was rightly repudiated.

4.     Both the parties have filed their evidence by way of affidavit.

5.     We have heard arguments advanced at bar,  perused the pleadings and evidence adduced on record.

6.     As per the policy in question the claim of the complainant is not covered  as the policy inception date is 4.2.13 and as per the present policy terms and conditions, there is 2 years waiting period for the above said disease.  We have gone though the terms and conditions of the policy attached with the written statement.  Perusal of the same shows that exclusion clause 4.3 xv of the policy Pilondal Sinus disease was covered after two years of the policy. 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.

 

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.

 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.

 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.

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.”

 

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.”

 

7.     Having regard to the facts and circumstances of the case and the discussion done  we are of  the considered view that there exists no infirmity in the decision of the Insurance Company repudiating the claim since not covered under the terms and conditions of the policy and courts are not meant to add or delete the terms of contract and having reached to this conclusion.  We are clearly of the opinion that the repudiation of the claim by the OP is justified, we find not merit in the present complaint, same is dismissed.

   Copy of the order may be forwarded to the parties to the case free of cost as statutorily required.  The orders be uploaded on www.confonet.nic.in. File be consigned to R.R

 

Announced in open Forum on 21/12/2018.

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER