Delhi

New Delhi

CC/918/2010

Prem Bhalla - Complainant(s)

Versus

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

13 Nov 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./918/2010                                                    Dated:

In the matter of:

Dr. Prem Bhalla,

Bhalla Nursing Home,

B-47-48, Ramesh Nagar,

New Delhi- 110018.

                    …… Complainant

Versus

1. United India Insurance Co. Ltd.

Through its Branch Manager,

H-61, First Floor, Govind Mansion,

Indira Place, Behind Plaza Cinema,

Connaught Place, New Delhi- 110001.

 

2. United India Insurance Co. Ltd.

Through its Sr. Division Manager,

DO0-17, New Delhi- 110002.

3. The Chairman,

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 OP under section 12 of Consumer Protection Act, 1986.  The brief facts as alleged in the complaint are that the complainant is a qualified doctor, running her nursing home under the name and style “Bhalla Nursing Home”. The complainant was covered under the professional indemnity insurance policy for a period from 22/09/1994 to 21/09/1995 for a sum insured of Rs. 02,50,000/- for any one claim and Rs. 03,25,000/- for series of claim arising out of any one event. One patient Sh. Poonam Sharma filed a case bearing no. 207/1995 before Hon’ble State Commission, Delhi against the complainant alleging deficiency in services as well as medical negligence against the complainant. After the prolonged procedure the said complaint was finally decided by Hon’ble State Commission, Delhi vide its order dated 11/12/2006 wherein a compensation of Rs. 2.5 lacs was awarded in favour of the complainant Smt. Poonam Sharma and against the complainant.

The intimation regarding the order of Hon’ble State Commission was given to OP insurance co. on 09/01/2007. The order passed by Hon’ble State Commission  was challenged by the complainant by filing an appeal bearing no. FA-26/07 before Hon’ble National Commission after depositing Rs. 1.25 lacs as directed by Hon’ble National Commission vide pay order no. 404268 dated 29/03/2007. The complainant vide letter dated 01/05/2007 requested the OP co. to reimburse the same but no payment was made by OP insurance co. despite several letters and visits.

During the proceed the Hon’ble National Commission suggested the complainant to settle the issue outside the Commission.  Accordingly, the matter was settled between Poonam Sharma and the complainant  for a sum of Rs. 2.5 lacs and the Hon’ble National Commission vide its order dated 13/11/2009 dismissed the complaint against the complainant and other treating doctors. The complainant wrote a letter to the insurance co. to reimburse the entire amount of Rs. 2.5 lacs. However, the OP insurance Co. instead of honoring the claim, rejected the same vide letter dated 01/12/2009 on false and frivolous ground, hence this complaint.

 

            Complaint has been contested by OP.  OP has filed its written statement wherein it denied any deficiency in service on its part and stated that the complainant has not completed all the formalities as required by the OP. It is further submitted that the parties settled their matter out of the court, without impleading OP, which was the necessary party to the case, hence, OP is not liable to reimburse the claim of the complainant.  It is further submitted that the repudiation of the claim is justified, and the present complaint be dismissed.

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

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

            Some facts are not disputed by the parties such as the Insurance policy and the orders passed by Hon’ble State Commission and Hon’ble National Commission.  We have gone through the policy documents attached with the complaint as well as the repudiation letter dated 01/12/2009 vide which the claim of the complainant was repudiated. It is stated in the repudiation letter that the complainant had violated the condition no. 1 & 6 of the policy in question, hence, the company is absolved from any liability.  The condition no. 1 & 6 of the Policy was attached with the policy document placed on record by the complainant, the contents of the same is reproduced as under:-

“1) Notice- Every notice or communication to be given or made under this policy shall be delivered in writing to the office of the Company through which this insurance is effected.

6) Claim Procedure- The insured shall upon the occurrence of any event given rise or likely to give rise to a claim under this policy, shall give immediate notice to the company and shall forward to the company forthwith after receipt thereof every written notice or information of any verbal notice of claim. The insured shall give all necessary information and assistance and forward all documents to enable the company to investigate, settle or resist any claim as the company may deem fit.

The insured shall not incur any expense, litigation or otherwise, or make any payment, settlement, arrangement or admission of liability in respect of any event for which the company may be liable under this policy without the written authority of the company. The company shall in respect of anything insured under this policy be entitled to use the insured for bringing, defending, enforcing or settling of legal proceedings for the benefit of the company. The company may prior to or at any stage of such proceedings pay to the insured the full amount payable under this policy in respect of any claim and shall thereupon be relieved from all further liability in respect of the claim in question and shall not be responsible for any lose alleged to have been sustained by the insured in consequences of any action of omission of the company in connection with such claim or proceedings.”

 Perusal of the above conditions make its clear that the complainant ought to have informed the insurance company all necessary information and assistance and forward all documents to enable the company to investigate, settle or resist any claim as the company may deem fit. The insured shall not incur any expense, litigation or otherwise, or make any payment, settlement, arrangement or admission of liability in respect of any event for which the company may be liable under this policy without the written authority of the company. The company shall in respect of anything insured under this policy be entitled to use the insured for bringing, defending, enforcing or settling of legal proceedings for the benefit of the company.

 The complainant in the present complaint had failed to implead the insurance company as a party in the case filed before Hon’ble State Commission, even the complainant failed to informed the OP company about the appeal filed by her against the order of Hon’ble State Commission and suo moto settled the matter with Smt. Poonam Sharma for a sum of Rs. 2.5 lacs, resulting in the violation of condition no. 1 & 6 of the policy in question.

 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.”

            Having regard to the facts and circumstances of the case, we are of the considered view that since the complainant had  suo moto settled the matter with Smt. Poonam Sharma for a sum of Rs. 2.5 lacs, resulting in the violation of condition no. 1 & 6 of the policy in question, 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 13/11/2019

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                                         (H M VYAS)

       MEMBER                                                                                       MEMBER