Delhi

New Delhi

CC/99/2011

Mukesh Gupta - Complainant(s)

Versus

M/S. United India Insurance Company Ltd. - Opp.Party(s)

13 Mar 2020

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./99/2011                                          Dated:

      In the matter of:

      Mukesh Gupta,

      100,  Chitra Vihar,

       Delhi-110092.

                …… Complainant

Versus

1. Thr Branch Manager,

United India Insurance Co. Ltd.

City Branch Office

307, Akashdeep Building,

26-A, Barakhamba Road,

New Delhi- 110001.

 

2. United India Insurance Co. Ltd.

24, White Road,

Chennai- 600014.

 

……. 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 during the month of September 2004, the complainant purchased a mediclaim insurance policy bearing No.040801/48/04/00323 for himself and his family members from OP-1.  The said policy was effective for 1 year i.e. from 24.9.2004 to 23.9.2005 and the complainant renewed the above policy from time to time.   As per the policy in question, the complainant and his family were insured upto an amount of Rs.2,25,000/-  against medical expenses incurred for any disease.  In the month of March, 2009, the complainant purchased a CPAP machine with 7 cm H20 pressure, as per prescription of  doctor Sh. S.K. Sharma  as he was suffering  from sleep related breathing disorders i.e. excessive loud snoring while sleeping, excessive day time sleeping and excessive fatigue.

2.     Thereafter, the complainant lodged the claim for reimbursement of Rs.70,000/-  i.e. cost of aforesaid machine with OP-2.   Despite  receiving the claim amount,  OP-2 vide letter dt. 21.9.2010  refused the claim of the complainant by stating that as per clause 4.13 External and durable medical /Non-medical equipment of any  kind used for diagnosis and or treatment   and also any medical equipment which subsequently used at home etc. , the cost of the such equipment purchased by the complainant cannot be paid and  the claim of the complainant was denied.  The complainant personally approached OP-2 several times and requested it to re-consider  his claim as he was not suffering with the disease by birth and any person having such disease cannot survive without this equipment.  But OP-2 categorically refused to entertain the complainant.  Complainant, therefore, approached this Forum for redressal of his grievance.

3.     Complaint has been contested by OP.  In its written statement,  OP has stated  that the complainant had made some material mis-statements in the Claim Form.  It is submitted that the present claim is heavily barred under condition no.4.13 of the Individual Health Insurance Policy , hence the claim was rightly repudiated.  It is further submitted that the present complaint involves the complicated question of law and facts, which requires elaborate oral and documentary evidence and as such is not entertained by this Forum.  It is stated that the complainant under the grabs of the present complaint is trying to gulp the public funds of which the OP Co. is the Trustee and the OP Co. is duty bound to take all precautions  in distributing the public funds judicially and strictly according to terms and conditions and clauses of the contract of Insurance while entertaining claims. It is further stated that the complainant is trying to take the benefit of its own wrong which is not permissible under any law, further, prayed for dismissal of complaint.

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

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

6.     It is argued on behalf of complainant that he is policy holder of OP Co. since 2004. He further stated that on the recommendation of treating doctor he purchased the CPAP machine for a sum of Rs.70,000/- as he was the policy holder of the OP Co., therefore, OP is liable to indemnify the cost of the machine in question. But the OP Co. arbitrarily repudiated the claim which amounts to deficiency in services on its part, hence, he is entitled for the relief claim.

7.     No arguments is addressed on behalf of OP, despite several opportunities given.

8.     File perused, The complainant himself has placed on record, the copy of policy documents along with its terms and conditions for the year 2009-2010.  The perusal of clause No.4.14 makes it clear that External and durable medical /Non-medical equipment of any  kind used for diagnosis and or treatment   and also any medical equipment which subsequently used at home etc.

9.     The complainant in the present complaint has claimed the cost of CPAP machine but it covered under clause 4.14 of the policy terms and condition, hence not payable.

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, we are of the considered view that since the claim of the complainant duly covered under clause 4.14 of the policy terms and conditions, the claim was rightly repudiated by OP Insurance Co.,  hence, the repudiation is 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 13/03/2020.

 

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                        (H M VYAS)

       MEMBER                                                                MEMBER