Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-86/2018
Deepak Soota r/o S-279, GF,
GK-II, New Delhi ...Complainant
Versus
OP1: National Insurance Co. Ltd.
(through Ms. Divya Bhardwaj, Dy. Manager),
CRM Deptt. Jeevan Bharti Tower II, Level IV
Cannaught Circus, New Delhi-110001
OP2: National Insurance Co. Ltd.
(through Mr. Sandeep Goyal, Divisional Manager),
Do II, Jhandewalan, 2,3, floor, 7E, Deen Dayal
Upadhya Bhawan, Jhandewalan Extension
Delhi-55
OP3: National Insurance Co. Ltd.
(through its CMD), 3, Middle Ton
Street, Kolkata, West Bengal-700071 ...Opposite Party
Date of filing: 19.04.2018
Date of Order: 09.08.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1. The present complaint has been filed by Sh. Deepak Soota (in short complainant) against Insurer viz. (1) National Insurance Co. Ltd. through Ms. Divya Bhardwaj, Deputy Manager, CRM (in short OP1), (2) National Insurance Co. Ltd. through Sh. Sandeep Goel, Divisional Manager, (in short OP2) and (3) National Insurance Co. Ltd. through its CMD (in short OP3) u/s 12 of the Consumer Protection Act, 1986.
1.2. Complainant had taken an insurance policy namely “National Pariwar Medi-claim” vide policy no. 350201501610000029, issued by office of OPs at Jhandewalan, New Delhi; effective from 15.04.2016 to 14.04.2017 for a basic sum assured of Rs. 6,00,000/- (insurance policy is at page no. 30-31 of the complainant’s paper-book). The said policy is in continuation to the policies which the complainant took from OPs since 2008.
1.3. Through the said policy, Insurer undertook to pay/ reimburse the expenses incurred for the treatment of various ailment to be suffered by the complainant and his wife. The complainant paid premium of Rs. 44,397/-. Complainant developed the symptoms of Parkinson’s disease during term of the said policy and treatment was needed for the same. The complainant chose to undergo the Ayurveda treatment of the said disease as there is no known cure in Allopath for the said disease, the complainant had undergone an Ayurvedic Ayush treatment at Tharvad Ayurveda Retreat Vellanchry, Kuttppuram, Malappuram, Kerala for treatment of the disease; the first part of the treatment started on 17.08.2016 and complainant was discharged on 07.09.2016 (copy of the medical certificate is annexed as C-5 and receipts for payment made to the said hospital are also annexed as C-6 collectively).
1.4. For the reimbursement of above expenses, complainant filed a claim of Rs. 89,620/- dated 22.09.2016; the said claim of the complainant was passed for Rs. 77,920/-, which was paid by OPs on 09.11.2016 (claim paper with medical documents, certificate of doctor are annexures C-7 collectively).
1.5. As per the doctors advise, the treatment was to be continued as internal patient for two more sessions and as advised, the complainant again got admitted to the above hospital for second part of treatment on 25.11.2016; second part of treatment continued till 10.12.2016 (copy of medical certificate is annexed C-8 and receipt for the payment to hospital for second part of treatment is annexure C-9)
1.6. For the reimbursement of above stated expenses, complainant filed a claim of Rs. 70,697/- on 16.12.2016 (claim with medical documents are at Annexure C-10). The above claim was sanction for Rs. 66,677/-, however, this amount was never paid; despite waiting for more than one month. The complainant approached TPA on 27.01.2017 and inquired the status of claim; the OP asked for Registration Certificate of the hospital through email dated 30.01.2017; complainant submitted the Registration Certificate of hospital with OP (Registration Certificate and its English translation are annexed Annexure C-11).
1.7. As per advice of doctor, the complainant again got admitted in the said hospital for third part treatment on 12.02.2017 and continued till 02.03.2017 ( copy of medical certificate is Annexure C-12). The complainant submitted claim of Rs. 70,135/- for third part treatment and the claim for the third part treatment was passed for Rs. 66,335/-, however, this amount was never paid.
1.8. When complainant did not receive any response from OPs for the second claim; then he sent email dated 22.03.2017 and OP replied vide email dated 22.03.2017 by referring Exclusion clause no. 4.15 which is reproduced as under:-
“Massages, Spa, Steam Bath, shirodhara, udhwarthanam, abhyangam, kayasekham and similar treatment.
Expenses for naturopathy, experimental medicine/ treatment, unproven procedure/ treatment, alternative treatments (other than Ayurveda and homeopathy), acupuncture, acupressure, magneto-therapy and similar treatment”.
1.9. On 23.03.2017, complainant sent email and clarified that the Exclusion clause no. 4.15 does not apply to the case of complainant; a plain reading of the said clause clearly states that all these methods are excluded (other than Ayurveda and homeopathy); even as per email of OPs it allows the Ayurveda treatment as per exclusion clause.
1.10. On 02.04.2017, the complainant again sent an email to OP3 with copy to the officials of OsP seeking early release of money for second claim; CMD of OP forwarded the email to the concerned officials of OP. The complainant also sent email to PMO in this regard. OP3 was sent email repeatedly but of no consequence.
1.11. Subsequent thereto, OP sent email to complainant stating that complainant’s claim does not fulfill the criteria of policy clause 2.1.6 pertaining to Ayurveda and homeopathy treatment mentioned in the said clause. In repudiation letter dated 09.05.2017, it is mentioned that “the company shall pay to the hospital the medical expenses or reimburse the insured the medical expenses pre-hospitalisation and post hospitalization expenses, incurred for Ayurveda and homeopathy treatment up to the sum insured provided the treatment is undergone in a government hospital or in an institute recognized by the government and/ or accredited by Quality Council of India/ National Accreditation Board of Health”. It was further mentioned in the said email that the said treatment centre/ hospital/ Ayurveda Retreat does not fulfill the criteria of hospital laid down in the policy, hence claim cannot be reimbursed for expenses incurred for Ayush treatment.
1.12. The complainant, thereafter, clarified that the concerned treating Institute was very much covered in the said clause. The clause number 2.1.6. was wrongly mentioned in the email but it was clause no. 1.2.6. The treating institute is recognized by the government; The Registration Certificate of the said hospital proved was also provided to the OPs and on that basis the first claim of the complainant was passed and money was paid. It was also in the email of the complainant that 73rd amendment of the Constitution and under Article 243 read with 11th Schedule, the Gram Panchayat is Government (i.e. local Govt.) and is empowered to register & recognize to hospital within its territorial jurisdiction.
1.13. The second claim was filed on 21.12.2016 and till 09.05.2017 the issue of hospital recognized by the Government was not raised by OPs.
1.14. The complainant served a legal notice dated 11.07.2017 explaining the entire situation and asking the claim amount with damages. The OP replied the notice on 25.07.2017 and took objections of non-recognition/ recognition of hospital.
1.15. Complainant requests to direct OP to pay a sum of Rs. 1,47,243/- to the complainant (second claim of Rs. 70,097/-, third claim of Rs. 70,135/- and interest of Rs. 7,011/-) with interest at the rate of 12% pa. The complainant also claimed from OP Rs. 10,00,000/- as compensation/ damages for mental harassment, pain and agony, apart from Rs. 1,00,000/- on account of litigation cost.
2.1. OP has filed reply under the signature of Sh. Raghunath Pawar, Administrative Officer (legal). The complaint is liable to be dismissed under clause 1.2.6. of the mediclaim policy. It is stipulated that insurance company shall reimburse the medical expenses of pre-hospitalisation and post hospitalization (up to the sum insured) incurred for Ayurveda and homeopathic treatment, provided that the treatment is undergone in a Government hospital or in an institute recognized by the Government/ or accredited by Quality Council of India/ National Accreditation Board of Health. However, due to inadvertence of TPA, first claim amount of Rs. 77,920/- of the complainant was wrongly settled; on discovering the mistake the OPs have started process to recover the same from TPA; thus, the said claim has been wrongly paid to the complainant by TPA and OPs reserve its right to recover the same.
2.2. Complainant took Ayurveda treatment from Tharavadu Ayurveda Retreat, Kerala, which does not fall in the category of Hospital approved by OPs. Thus, the claim of the complainant was not as per the terms and conditions of the policy. There is no cause of action against OPs. Insurance policy containing the terms and conditions is a contract between the complainant and OPs the terms and conditions have to be followed strictly by the parties. Complainant has not come to the court with clean hands and has suppressed the material facts, there is no deficiency of service on the part of OP, claim has rightly been rejected because of violation of terms and conditions of insurance policy.
3. Complainant in his rejoinder has denied that the treating institute does not fall within the category of hospital approved by the OPs. The hospital is approved by the OPs but by the Government and the said hospital is recognized. OPs failed to explain how the treating hospital does not fall within approved list of the Government, rest of the contents of the rejoinder are the repetition of the complaint.
4. Complainant has led evidence by way of filing affidavit which is on the line of complaint. OPs have also filed affidavit of evidence (under the signature) of Sh. Raghunath Pawar, Administrative Officer (legal) it is on the line of facts given in the reply.
5. Written arguments filed by the complainant is repetition/ narration of the pleadings & evidence. OPs have also filed the written arguments, which is also on the line of its reply & evidence.
6.1. (Findings)- Complainant took National Parivar Medi-claim Policy from OPs for Rs. 6,00,000/- (sum insured) by paying premium of Rs. 44,397/-. The policy was effective from 15.04.2016 to 14.04.2017. Complainant himself and his wife were insured person 8 in the policy. The said policy was in continuation to the insurance policy taken by the complainant from OPs. Complainant developed the symptoms of Parkinson’s disease it was during the validity period of the policy. He chose to undergo Ayurveda treatment as there was no known cure in allopathic. He got ayurvedic Ayush treatment at Insitute/ Retreat Centre in Mallapuram District of Kerala. For first part of the treatment within the validity period of policy, claim was submitted to OPs for Rs. 89,620/- which was approved and passed by OPs for Rs. 77,920/- on 09.11.2016 [bill voucher is at page 40-41/ CW-6 (colly)]. The complainant was diagnosed for parkinson’s disease the medical papers are at page no. 32 of the complainant’s paper book.
6.2. Thereafter, on the advice of the doctors, the complainant was treated as internal patient for two more sessions and he was admitted on 25.11.2016 and treatment continued till 10.12.2016 for the second stage and claim amount of Rs. 70,697/- for the second stage was passed for Rs. 66,677/- but it was not paid despite submissions of Registration Certificate of the hospital to OP (Registration Certificate and its English translation are at page no. 79-80/ CW-11). Perusal of the translated version of the Registration Certificate shows that the hospital is registered with the Government of Kerala. The complainant was treated as an internal patient for the third stage/ part and he filed the claim of Rs. 70,135/- but claim was not reimbursed despite number of emails sent by complainant to OPs (bill vouchers for Rs. 73,657/- dated 17.09.2016 and for Rs. 64,624/- dated 09.12.2016 are at page 34 -71 of the paper book of the complainant). OPs vide its email dated 22.03.2017 communicated to the complainant that the treatment taken by the complainant under the system falls under the exclusion clause 4.15 (exclusion clause 4.15 is already reproduced in para 1.8. above).
6.3. The complainant in its returned email dated 22.03.2017 intimated that he is a senior citizen suffering from Parkinson’s disease, for which there is no cure in allopathic medicine & the ayurvedic treatment taken by him was from a Government approved hospital. Ayurvedic treatment is covered under mediclaim and complainant fails to understand for delay in processing his claim. In another email dated 23.03.2017, sent by complainant to officer of Ops that by treating Consultant Doctor (Dr. C.U. Narmalajohn, Rtd., Senior Medical Officer, Government of Kerala), had clarified that Ayurveda and Homeopathy are included in the claim/ discipline (copy of exchanged mails are at page no. 91-92 of the complainant’s paper-book). In one of the emails dated 02.04.2017 (page no. 93 of the paper-book of complainant), the complainant has, inter alia, mentioned that the excuse given by Mr. Sandeep Goel, officer of OP contradicted itself as the exclusion does not apply to the Ayurveda and homeopathy. Clarification to exclusion clause to this effect was also sent on 23.03.2017 by the complainant to OP. The email sent by the complainant to CMD of the OP were simply forwarded to the concerned office of OP to provide status report to the insured.
6.4. It is relevant to refer email dated 09.05.2017 by, Deputy Manager, C.R.M., Department of OPs, which reads as:
Our health department has reviewed your file in detail and found that your claim does not fulfill the criteria of policy clause 2.1.6. pertaining to Ayurveda and homeopathic treatment. As per policy clause 2.1.6. “the company shall pay to the hospital the medical expenses or in an institute recognized by the Government and/ or accredited by Quality Council of Institute/ National Accreditation Board for Health”. The said treatment centre/hospital/ retreat does not fulfill the above criteria of hospital laid down in the policy and hence cannot be considered for reimbursement of expenses incurred for Ayush treatment (email dated 09.05.2017 is at page no. 102 of the complainant’s paper-book).
However, it is apparent that treatment was taken by the complainant from the recognized Government Hospital which has been discussed in detail in para 6.6 of this order. It is settled law that OP cannot take travel beyond the plea taken in repudiation letter dated 09.05.2017 and it was never taken by Ops in repudiation letter that first claim was settled wrongfully.
6.5. The contents of repudiation letter dated 09.05.2017 is at page 110 of complainant’s paper-book it contents has been mentioned in para 1.1 of this order. Main ground of rejection of claim by OPs is treatment should have been in a government hospital or institute recognized by the government and/ or accredited by Quality Council of India/ National Accreditation Board for Health. The said treatment centre/ hospital/ Retreat where complainant was treated does not fulfill the above criteria of hospital laid down in the policy, hence, can not be reimbursed for expenses incurred for ayush treatment. However, clause number 2.1.6. and exclusion clause 1.2.6. in policy terms and conditions has been reflected in para 1.12 of this order. However, the Ayush treatment taken by the complainant which falls within ayurveda medicine system has been taken from the Ayurveda Retreat Centre duly recognized by the Government, though, exclusion clause does not apply. Officers opinion in Para no. 6.4 also supports the case of the complainant.
6.6. The complainant through his email dated 14.05.2017 clarified that treatment taken from the institute was a government recognized hospital, as the same was recognized and registered by government through the Gram Panchayat as per 73rd Amendment of Constitution and Article 243 read with 11th Schedule; the Gram Panchayat is Local Government and is empowered to issue registration and recognition to hospital with in its territorial jurisdiction. As per Article 243 G.A. Gram Panchayat has to implement the schemes of economic development and social justice including those in relation to the matters listed in eleventh Schedule. At point no. 23 of Eleventh Schedule of Constitution “Health and sanitation including hospitals, primary health centres and dispensaries” is mentioned, therefore, complainant has taken treatment from a registered government hospital. In support of his stand, complainant has submitted copy of the Constitution (73rd amendment) Act, 1992 where in para 3 under the head ‘Statement of Objects and Reasons’, Article 243 G- empowers, authority and responsibilities of panchayats, point no. 23 of ‘ Eleventh Schedule are specifically referred by the complainant [copy of the constitution (73rd amendment) Act 1992 are at page no. 170 to 184 of complainant’s paper-book]. From the discussion, it is proved that as per the amendment of the Constitution, treatment taken from the institute/ Retreat was recognized and registered by the Government through the Gram Panchayat and the Gram Panchayat is Local Government empowered to issue registration and recognition to the hospital, therefore, the plea of the Ops that complainant did not take treatment from the Government approved hospital/ Retreat does not come to their rescue.
6.7. In OP’s mail dated 22.03.2017 (page 185) it is stated that ‘we have received the claim file from Medi Assist TPA. On perusal of claim file we observed that the treatment taken by complainant falls under exclusion clause 4.15 which has been discussed in para 1.8 of this order.
We have forwarded claim file to health department, DRO-I to sought their advice regarding our observation. If that is so, above exclusion clause (other than Ayurveda and homeopathy) supports the case of complainant as he got ayush treatment in the hospital which is covered in Ayurveda stream. Therefore, exclusion clause has relied upon by the OPs do not apply in case of the complainant.
7. From the aforesaid discussion/ deliberations and careful analysis, it came to the conclusions that complainant has established his case and since after the medical expenses and discharge from the hospital his claim of Rs. 1,40,232/- (complainant claims expenses Rs. 1,47,243/- including Rs. 7,011/- as interest on the claim) which was not reimbursed by OPs.
In facts and circumstances of the case; it is crystal clear that complainant was treated from the Government recognized hospital and medicine system for which the complainant was treated as internal patient in the Retreat for which exclusion clause does not apply, OPs made the payment for the first stage treatment to the complainant and denied to reimburse money spent by complainant for the second and third stage treatment; complainant suffered a lot due to non-refund of his money for treatment and he was to run from pillar to post by sending different mails at different occasions to refund the money spent on his treatment but in vain, therefore, complainant has proved deficiency on the part of OPs, which caused mental tension and agony to the complainant, therefore complainant is held entitled for compensation of Rs. 15,000/- against OPs and in favour of complainant. The complainant has been litigating since years together; we quantify and allow Rs. 10,000/- in favour of complainant as litigation expenses. Since complainant’s treatment amount has not been paid since 2017 and he was constrained to pay treatment bills/expenses of his own during validity period of insurance contract, the insured was deprived of his money to use the same, therefore, we deem fit to allow interest at the rate of 7% pa on the amount of Rs. 1,40,232/- from the date of fiing of complaint till its realization.
8. Since OPs is insurer. The contract of insurance policy is between OPs/ insurer and the complainant/ insured.
9. We direct OP to pay Rs. 1,40,232/- the expenses spent by the complainant on treatment under the mediclaim policy to the complaint along with interest at the rate of 7% pa from the date of filing of this complaint till its realization, Rs. 15,000/- as compensation for mental agony and harassment, apart from Rs. 10,000/- as litigation expenses within 30 days from the date of receipt of this order.
However, if the aforesaid amount is not paid to the complainant by OP1 within 30 days from the receipt of this order; medi-claim amount of Rs. 1,40,232/- shall carry interest at the rate of 8% pa instead of 7 % pa on this amount.
10. Announced on this 9th August 2023. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
