Delhi

North East

CC/444/2014

S.S. Pandey - Complainant(s)

Versus

M/s. United India Ins. Co. Ltd. - Opp.Party(s)

17 Nov 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No. 444/14

 

In the matter of:

 

		Shri S.S. Pandey R/o Plot No. 727 Flat No. S-1, Shalimar Garden Extn.1, Sahibabad, Ghaziabad (U.P.)		Complainant
		Versus
	1.       2.	M/s Vipul Medcorp TPA Pvt. Ltd Head Office:- 515, Udyog Vihar, Phase-V Gurgaon-122016.   M/s United India Insurance Co.Ltd D-24, E-25, 2nd Floor, Himalaya House,          23 K.G.Marg, New Delhi-110001.		Opposite Parties
			DATE OF INSTITUTION:		07.11.2014
			JUDGEMENT RESERVED ON :		15.11.2017
			DATE OF DECISION      :		17.11.2017

 

 

N.K.Sharma, President:-

Ms. Sonica Mehrotra, Member:-

 

Order by Ms. Sonica Mehrotra, Member:-

 

ORDER

1. Briefly stated the case of the complainant is that OP1 had granted Mediclaim Insurance Policy bearing no. 500300/481/441/00000002 to M/s. Central Warehousing Corpn. granting Group Mediclaim Insurance Cover   to their retired employees which included complainant and his wife. Period of insurance was effective 01.4.14 to 31.03.2015. The said policy was cashless one.  The OP1 was the TPA of OP2 and as such was directly looking after all Mediclaim cases and issuing / renewing ID cards etc for taking cashless facilities from their designated hospitals all over India as listed. The complainant further states that on 23.06.2014, his wife aged about 65 years suffered severe chest pain in her left side and the complainant fearing it to be a heart attack, rushed her to Max Healthcare Super Speciality Hospital Patparganj which was the designated hospital of OPs. His wife was admitted in emergency and was kept for further examination observation for about more than 9 hours. The complainant had requested the hospital for cashless treatment but was refused and OP1 advised the complainant to deposit the cash. Therefore, on advised of OP1, complainant deposited               Rs. 3,000/- on admission and Rs. 12,380/- on discharged (i.e. total sum of Rs. 15,380/- approx) with the hospital and purchased medicines worth           Rs. 1600/- . That on guidance of OP1, the complainant downloaded the claim form from its web site and the complainant submitted bill of                    Rs. 17000/- approx inclusive of medicines with the OP1 office on 26.06.2014 for approval of his claim. In this context complainant received message on 7.7.2014 on his mobile from OP1 stating that his claim file            no. 15 RBOIUIJ 0371 under his aforementioned policy of his claim was in query for necessary requirement of information / documents to process the claim. Thereafter, there was no development till July 2014 and no response to letters dated 01.08.2014 & 21.10.2014 written by complainant to OP1. The complainant has lastly stated that on 21.10.2014 the complainant received letter dated 20.10.2014 from OP2 stating as “As per the available documents hospitalization is for less than 24 hours. Hence claim is not justified and claim merits repudiation. As per policy terms and conditions, claim is not payable. We regret out inability to entertain your claim” thereby repudiating the claim of the complainant as being unjustified and expressed its regret for inability to entertain the same as it not being payable. The complainant had vide reply dated 24.10.2014 to the repudiation letter of OP2, agitated the wrongful repudiation stating that as per the Mediclaim Policy Guide Book provided to complainant by OP1, it was nowhere mentioned that 24 hrs hospitalization is necessary for payment of medical claim and further the self proclaimed competent officer of OP1 Mr. Bahl had also assured the complainant for releasing the payment and guided him all along since July 2014 till October 2914 to submit an affidavit stating that the claim has not been submitted to any other Mediclaim agency and had assured to complainant  of early reimbursement. However, seeing no response or relief from the OPs the complainant was constrained to file the present complaint before this Forum alleging harassment, mental agony, torture and wilful retention of his money and prayed for reimbursement of expenses of Rs. 17,000/- approx incurred on medical bills and interest thereupon @18%, Rs. 4,000/- for harassment and mental agony and undue retention of his money and litigation charges of Rs. 5,000/-.
2. Notice was issued to OPs. Written statement were filed by both the OPs wherein the existence of Group Mediclaim Insurance Claim extended to the complainant was admitted by the OP. However, OPs took the plea that the claim of the complainant was rightfully repudiated as per clause 2.10 DAY CARE TREATMENT which refers to medical treatment and surgical procedure which is (1) undertaken under general or local anaesthesia in a hospital/ day care centre in less than 24 hours because of technological advancement, and (ii) which would have otherwise required a hospitalisation of more than 24 hours read with clause 2.14  Hospitalization. As per the terms & conditions of the Health Insurance Policy – Group which very categorically stated that Hospitalization means admission in a Hospital/ Nursing Home for a minimum period 24 consecutive hours of inpatient care except for specified procedures/ treatments (as specified in clause 3.1 of the policy), where such admission could be for a period of less than 24 consecutive hours. The OP stated that in view of the aforementioned policy terms & condition, the complainant is not entitled to the Mediclaim reimbursement and his claim has been rightfully repudiated vide repudiation letter dated 20.10.2014. The OP further took the legal plea relying on the judgment of Hon’ble NCRDC in Revision Petition No. 211 of 2009 which clearly relied on the Hon’ble Apex Court’s ruling in General Assurance Society Limited V/s Chandumull Jain & Anr where the Hon’ble Apex Court held that “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.”
3. Evidence by way of affidavit were filed by both the parties exhibiting documents relevant to their respective stands in support thereof. Written arguments were filed too. In the written arguments filed by complainant, a very pertinent and relevant material argument was put forth by the complainant to the effect that at the time of issuance of policy, the OP had only supplied the guidelines framed by OP1 to whom OP2 had assigned TPA services and that the Terms & Conditions were never supplied to the complainant  and the complainant reiterated that he had clarified the same in his submission dated 3.6.2015  before this Forum endorsing the same. The complainant further argued that the OP was since all along aware that the hospitalization of his wife was for 9 hours only but it was a case of acute emergency (as per clause 2.2 of the policy term and condition), keeping in view severity of pain suffered by his wife in left side chest, the hospital had immediately admitted her in emergency ward and the act of OP of repudiation of his genuine claim was therefore total deficiency in service. Moreover, the repudiation of complainant’s claim by OP after a lapse of four months for denial of the Mediclaim could not be appreciated. OP on the other hand in its written submission reemphasised   clause 2.10 (day care treatment) and 2.14 (Hospitalization for minimum period of 24 consecutive hours) for rightful repudiation of the claim.
4. We have carefully perused the case file and the documents having evidentiary value placed on record by both the parties and arguments address there upon. Though, the terms & conditions of the policy are very categorical and specific with respect to the nature of treatment and duration thereof and according to which, the complainant’s claim could be construed to be rightfully repudiated, however, there are two aspects which are not in favour of OPs stand of repudiation. Firstly, the OP could not establish beyond reasonable doubt and satisfy us when specifically put to question whether the terms & conditions of the policy was supplied by them to the complainant and were rather evasive about the answering of this query which is indicative of the fact that the terms & conditions were not supplied or made aware to the complainant by the OP. Secondly, the OP was well aware from the time of hospitalization of complainant’s wife in June 2014 that it was cashless facility given to complainant under the policy and the hospitalization was only for a period of nine hours after which she was discharged on same day. Still, the OP1 asked the complainant to deposit the entire hospital bill of Rs. 15000/- approx. and asked the complainant to fill up the claim form and submit the same alongwith all medical records of his wife admissible as per Mediclaim Insurance Policy Guide Book with the OP1 office. The complainant kept pursuing his claim case from June till October 2014 and the OP was dilly-dallying the complainant on some pretext or other till finally rejecting his claim as unjustified.
5. In the catena of judgment passed by Hon’ble Supreme Court and National Commission it is a settled legal proposition that while construing the terms of contract of insurance, the words used therein must be given paramount importance without any addition, deletion or substitution of words. It is also well settled that on issuance of insurance policy, the insurer is only to indemnify the laws suffered by insured strictly in accordance with the terms & conditions laid therein for determination of extent of liability and the insured cannot claim anything more than what is covered in the insurance policy. However, in this present case, the OP had kept the complainant in dark about the terms & conditions of the policy related to Day Care Treatment and scheme of Hospitalization, as the same was never provided by the OP to complainant. The OP relied upon recent judgement passed by Hon’ble NCDRC in the case of LIC V/s Ramphal, in which the Hon’ble National Commission upheld the repudiation by the insurance company on grounds of hospitalization for less than 24 hours. However in that case the terms & conditions attached to the policy were duly provided to complainant which is not seen in the present case and therefore, the reliance on this judgement does not support the stand of OP in the present case to justify repudiation of claim of the complainant. The Hon’ble National Commission in recent judgement of SBI Life Insurance Co. Ltd vs. Kamaljeet Kaur I (2016) CPJ 347 (NC) had observed that such exclusion clauses are not consumer friendly and sometimes against their interest and as such this act of repudiation by OP is malafide, against principle of natural justice and amounting to deficiency in service despite knowledge of nine hours hospitalization and not handing over / apprising the complainant of the terms & conditions of policy for him to act and govern himself and his wife accordingly.

We, therefore, hold OP guilty of deficiency in service and direct the OP to pay to the complainant a sum of Rs. 17,000/- alongwith interest @ 9% per annum from the date of filing of complaint till realization. We also, award a sum of Rs. 4,000/- for harassment and mental agony and Rs. 3,000/- towards litigation charges to the complainant payable by the OP.

6. The order shall be complied within 30 days from the date of copy of receipt of this order.
7. Let a copy of this order be sent to each party free of cost as per regulation 21 of the Consumer Protection Regulations, 2005.
8. File be consigned to record room.

(Announced on 17.11.2017)          

(N.K. Sharma) President

(Sonica Mehrotra)            Member