Charanjit Singh, President
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainants have filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 14 against the opposite party on the allegations that the complainant No. 1 for the securing life of himself as well as of his family, purchased one Medical Insurance Policy with sum assured of Rs. 3,50,000/- each for himself as well as of his wife namely Smt. Purnima of the opposite parties No. 1 & 2, having policy No.404402/48/16/8500000360 for the period 30.05.2016 to 29.05.2017 against valuable consideration after paying premium. The complainant is regularly renewing his medical policy from opposite parties No.1 and 2 since 2017. In the month of September 2016, complainant No.2 suddenly fell ill and was admitted to Sukh Sagar Hospital, Amritsar for the period 13.09.2016 to 19.09.2016 for which intimation was duly given through e-mail to the opposite parties. Later on, she was again hospitalized from 21.09.2016 to 27.09.2016 in the Gupta Hospital and again information in this regard was given to opposite parties by e-mail. Further, complainants submitted all the requisite documents in the shape of bills and medical records alongwith duly filled prescribed claim from to opposite parties for the speedy disposal of medical claim. Even, the additional documents on request of opposite parties vide letter dated 26.12.2016 having reference No.NICCH1/27338 were given to them. The complainant remained in Sukh Sagar Hospital for the period 13.09.2016 to 19.09.2016 and again lateron in Gupta Hospital for the period 21.09.2016 to 27.09.2016 and had undergone various medical treatment and surgery and in total expenses to the tune of Rs. 1,07,863/- were spent on treatment, medicines, hospitalization and other medical treatments. Since complainant, No.2 fell ill during the period of the said insurance policy and for that complainant and his family was medically insured with opposite parties No.1 and 2 and as such, complainant No.1 submitted the medical claim of his wife i.e. complainant No.2 with the opposite parties alongwith all the requisite documents which were duly received by opposite parties. As per the existing medical policy the complainant No. 1 is legally entitled to the expenses which were incurred for treatment of complainant No.2. The opposite parties are legally bound to pay this medical claim to the complainant but instead of making the payment of this medical claim the opposite parties in a wrong and illegal way repudiated the claim of the complainant vide order dated 30.03.2017 stating that said claim falls under the exclusion clause of 4.7 of the said medical policy stating the reason that since complainant No.2 had history of Caesarean Section 16 years back and as such current medical condition has occurred due to that caesarean which has occurred to complainant No.2 sixteen years back, whereas no such problem has even occurred since past sixteen years i.e. since date of caesarean operation till Sept. 2016 and neither complainant was even hospitalized for the same, As such relating the current medical treatment of complainant, with the caesarean operation of complainant No.2 which occurred 16 years ago, just to defeat the claim of complainant is not justified in law. Since the buying of first medical policy in 2007 from the opposite parties till buying of current medical policy, no such terms and conditions were ever signed by the complainant. Even otherwise the claim of the complainant does not fall within any such exclusion clauses. The complainant many times requested the opposite parties that said medical treatment is duly covered under the medical insurance policy but opposite parties refused to accept the genuine request to the complainants. The complainants prayed the following reliefs:-
(a) To give direction to the opposite parties to pay the medical claim of Rs. 1,07,863/- to the complainant alongwith interest from date of entitlement till date of realization.
(b) To direct the opposite parties to pay compensation of Rs. 50,000/- to complainants for causing mental agony and harassment.
(c) To direct the opposite parties to pay litigation expenses of Rs. 15,000/- to complainant.
3 After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties No. 1 and 2 appeared through counsel and filed written version and contested the complaint by interalia pleadings the present complaint is not maintainable since in the light of terms and conditions of the mediclaim policy, it was found that the claim was not payable as per Exclusion Clause 4.7 of the insurance policy in question which reads as under :
Section 4. Exclusions- "Treatment arising from or traceable to pregnancy/childbirth including Caesarean section, miscarriage, surrogate or vicarious pregnancy, abortion or complications thereof including changes in chronic conditions arising out of pregnancy other than ectopic pregnancy which may be established by medical reports"
As per recommendation/opinion of DR A.K. Batra of the OP-3, the patient was hospitalized from 21-09-2016 to 27-09-2016 with diagnosis Stricture Terminal Ileum and she underwent Exploratory Laparotomy. The patient had history of Caesarean section 16 years back and it was further confirmed through the submitted certificate of Gupta Hospital Gupta Hospital dated 06-01-2017 that Terminal Ileum was narrow due to the presence of a Band which had developed during surgery. Since the Mediclaim Policy does not cover the expenses incurred on treatment arising from or traceable to pregnancy including Caesarean Section and its complications. Hence, the present claim was found inadmissible. Accordingly, the claim was considered as inadmissible by competent authority of opposite party. Therefore the opposite party No 1 and 2 repudiated the claim on merits in accordance with law and intimated the complainant regarding the same vide repudiation letter dated 30.03.2017. The complainant is estopped by his own act and conduct from filing the complaint. The complainant was duly provided the terms and conditions of the insurance policy in question. In fact the terms and conditions of each policy are part and parcel of the cover note/insurance policy and form the integral part of the contract of insurance. As such both the parties i.e. insured (being the 2nd party) and the insurer (being the 1" party) are bound by the same. Hence, the complainant is not entitled to any claim that is not covered under the insurance policy in question. The complainant has not approached this Commission with clean hands and has concealed the material facts. The parties to the complaint are strictly governed by the terms and conditions of the policy in question. The contract of insurance is based on utmost good faith and in this regard it is submitted that by concealing material facts it is apparent that the complainants have used fraudulent means for getting wrong claim. Hence, as per general conditions of the contract of Insurance as well as terms and conditions of mediclaim policy, it has been clearly held that the insurance Co. will not be liable to pay any claim if the claim is found to be in any respect fraudulent or any one act is done on his behalf to take benefit under the policy, all the benefits under the said policy shall be forfeited. In this regard it is further submitted that it has been held by various courts that public money cannot be thrown away by way of charity by the public sectors. The complaint filed by the complainant is otherwise bad for mis-joinder and non joinder of necessary parties and causes of action. As the claim already stands repudiated, and the complainant was duly intimated about the same vide letter dated 30/03/2017, therefore, no consumer dispute survives. Hence, the complainant has no cause of action to file the present complaint. Even otherwise as the claim already stands repudiated on merits and has been found not payable in the light of aforesaid findings, therefore, there is no deficiency or delay on the part of opposite party. Hence the relief towards interest and damages, etc. is not payable. As far as relevant policy in question is concerned, obtaining of the same is not disputed. It is however submitted that the liabilities under the said policy are strictly covered as per terms and conditions and exclusion clauses of the said policy. The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same.
4 Notice was issued to the opposite party No. 3 and it was duly served but it opted not to come forward to contest the complaint and consequently, the opposite party No. 3 was proceeded against ex-parte
5 To prove his case. Ld. counsel for the complainant has tendered in evidence affidavit of Poornima Seth Ex.CW1/A, copy of the insurance policy for the period from 30.5.2016 to 29.5.2017 E.C-1, copy of premium certificate Ex.C-2, copy of the insurance policy for the period from 30.5.2015 to 29.5.2016 Ex.C-3, copy of premium certificate of policy is Ex.C-4, copy of the insurance policy for the period from 30.5.2014 to 29.5.2015 Ex.C-5, copy of the insurance policy for the period from 30.5.2013 to 29.5.2014 Ex.C-6, copy of the insurance policy for the period from 30.5.2012 to 29.5.2013 Ex.C-7, copy of the cover note Ex.C-8, copy of the insurance policy for the period from 30.5.2011 to 29.5.2012 Ex.C-9, copy of cover note for the period from 30.5.2011 to 29.5.2012 Ex.C-10, copy of insurance policy Ex.C-11, copy of premium certificate of the policy Ex.C-12, copy of the insurance policy for the period from 30.5.2009 to 29.5.2010 Ex.C-13, copy of premium certificate Ex.C-14, copy of the insurance policy for the period from 30.5.2008 to 29.5.2009 Ex.C-15, copy of the insurance policy for the period from 30.5.2007 to 29.5.2008 Ex.C-16, copy of letter dated 28.4.2017 issued by Park Mediclaim opposite party No.3 to Branch Manager, National Ins.Co.Ex.C-17, copy of claim bill submitted Ex.C-18, Copy of the letter dated 7.11.2016 written by the complainant No.2 to Medical Supdt.Gupta Hospital Ex.C-19, copy of claim repudiation letter Ex.C-20, copy of the e-mails written regarding intimation of hospitalization Ex.C-21 and C-22, copy of the premium certificate issued on policy for the period from 30.5.2012 to 29.5.2013 Ex.C-23, copy of premium certificate for the policy period from 30.5.2011 to 29.5.2012 Ex.C-24, certificate dated 14.11.2017 issued by Gupta Hospital with regard to letter No. 32 dated 6.1.2017 Ex. C-25 and closed the evidence. Ld. counsel for the opposite parties No. 1, 2 tendered in evidence policy Ex. OP1,2/1 alongwith policy schedule Ex. OP1,2/2, affidavit of Gurkewal Singh Branch Manager Ex. OP1,2/3, certificate issued by Gupta Hospital Ex. OP1,2/4, recommendation from TPA Ex. OP1,2/5, copy of letter dated 14.2.2017 Ex. OP1,2/6 copy of letter dated 28.4.2017 Ex. OP1,2/7, copy of the letter dated 26.12.2016 Ex. OP1,2/8 and closed the evidence.
6 We have heard the Ld. counsel for the complainant and opposite parties No. 1, 2 and have gone through the record on the file.
7 In the present complaint, the complaint purchased one medical insurance policy with sum assured of Rs. 3,50,000 each for himself as well as for his wife namely Mrs. Purnima from the opposite party 1 and 2 having policy number 404402/48/16/8500000360 for the period 30.05.2016 to 29.05.2017. The complainant was regularly renewing his medical policy from opposite parties No. 1 and 2 since 2007. In the month of September 2016 complainant No. 2 suddenly fell ill and was admitted to Sukh Sagar Hospital Amritsar for the period from 13th September 2016 to 19 Sept 2016 for which intimation was duly given through email to the opposite parties. Later on she again was hospitalised from 21st September 2016 to 27 September 2016 in the Gupta Hospital and again information was given to the opposite parties by email. Further, the complainant submitted all the required documents in the shape of bills and medical records along with the duly filled prescribed claim form to opposite parties for the disposal of medical claim. The additional documents on request of opposite parties vide letter dated 26th December 2016 having reference No NICCHI/27338 were given to opposite parties. The opposite parties were legally bound to pay medical claim to the complainant but instead of making the payment , the opposite party in a wrong and illegal way repudiated the claim of the complainant vide order dated 30th March 2017. The Opposite parties stated in their written version that in the light of terms and conditions of the mediclaim policy it was found that the claim was not payable as per exclusive clause 4.7 of the insurance policy in question which read as below:-
Section 4 exclusion“ Treatment arising from or traceable to pregnancy or childbirth including caesarean section,, miscarriage, surrogate or vicarious pregnancy, Abortion or complication dear of including changes in chronic conditions arising out of pregnancy other than ectopic pregnancy which may be established by medical reports.”
As per the opinion Of DR. A.K Batra of OP No. 3 , the patient was hospitalized from 21st sep2016 to 27th sep2016 with diagnosis stricture Terminal Ileum and she underwent Exploratory Laparotomy. The patient had history of caesarean section 16 years back and it was further confirmed through the submitted certificate of Gupta Hospital dated 06th Jan 2017 that Terminal Ileum was narrow due to the presence of a band which had developed during surgery. Since the Mediclaim policy does not cover by expenses incurred on treatment rising from or traceable to pregnancy including caesarean section and its complication. Therefore the opposite party number 1 and 2 repudiated the claim on dated 30th March 2017. The complainant was duly provided the terms and conditions of the insurance policy and both the parties (insured and insurer) are bound by the same. Hence the complainant is not entitled to any claim that is not covered under the insurance policy.
8 It is the admitted case of the parties that the complainant insured with the OP bearing policy No . 404402/48/16/8500000360 after paying the premium amount in which complainant alongwith his wife and children was covered and the sum assured for the said policy was Rs 3,50,000 each (Ex C 1) . During the subsistence of this policy , the wife of the complainant Mrs. Purnima got admitted in Sukh Sagar Hospital from 13.09.2016 to 19.09.2016 and later admitted to Gupta Hospital from 21.03.2016 to 27.09.2016 and in total spent Rs. 1,07,863/- . To prove this fact the complainant has placed on record copy of claim bill submitted to park mediclaim (TPA) which includes the detail of all the expenditure made by the complainant (Ex C 18) . As original bills and receipts are not attached but a note was written on (Ex.C-18) that “ all original reports and bills are attached here with” , further e-mail send by park mediclaim on dated 20/09/2016 clearly stated that “ submit the documents as required – original bills, receipts and discharge certificate/ card from the hospital ”. Further, there is no dispute with regards to the bills submitted by the complainant with the opposite parties. The contention of the complainant is that the opposite parties wrongly and illegally repudiated the claim of the complainant vide letter dated 30.03.2017 (Ex.C-20) by mentioning the clause 4.7 of the said mediclaim policy stating the reason that since complaint No. 2 had history of caesarean section 16 years back and as such current medical condition has occurred due to that caesarean, since the mediclaim policy not cover the expenses incurred on treatment arising from pregnancy.
9 As we have gone through the documents placed on the records :-
- The statement of Dr. Surinder Gupta , Gupta Hospital Amritsar. – “there is narrow terminal Ileum due to the presence of band which was discovered during surgery. It is remote possibility that this band was due to caesarean operation/any other surgery relating to said complication 17 years ago .
As per Doctor’s written statement it is a remote possibility . Hence , it’s no where proved fact that the surgery falls under the Exclusion Clause 4.7 of the insurance policy .
- The Ops repudiated the claim as it falls under the Exclusion Clause of 4.7 of the medical policy stating the reason that since complainant No. 2 had history of caesarean section 16 years back and as such current medical condition has occurred due to that caesarean . However , relating the current medical treatment of complainant, with the cesarean operation of the complainant No.2 which occurred 16 years ago, to defeat the claim of complainant is not justified . Further, as per policy pre-existing clause 4.1 “ all pre-existing disease when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from preexisting aliment/disease/ injuries will be considered as a part of the preexisting health condition or disease.” But in present case the caesarean operation of the complainant No.2 occurred 16 years ago.
- Regarding terms and conditions, complainant said that since the buying of first medical policy in 2007 from the Opposite parties till buying the current medical policy , no such terms and conditions were ever signed by the complainant. However , OP has failed to prove that they supplied or explained the terms and conditions to the complainant . Therefore, unless terms and conditions have been supplied to the complainant at the time of execution of policy , exclusion clause cannot be enforced.
He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored.
- As per certificate issued by Gupta Hospital, it is stated that “band was not caused by surgery itself, but was discovered as a surgical finding and was divided during surgery” (Ex .C25) Hence , it’s nowhere proved fact that the surgery falls under the Exclusion Clause 4.7 of the insurance policy . Further, as per document submitted by OP (EX. OP 1,2/4) certificate issued by Gupta Hospital which stated that “patient was suffering from pain abdomen and vomiting for the last ten days . Terminal Ileum was narrow due to the presence of a band which divided during surgery.” Again OP failed to prove their point that surgery falls under the Exclusion Clause 4.7 of the insurance policy because of which the claim was not payable.
From the aforesaid discussion, it transpires that the genuine claim of the complainant has been repudiated by the Opposite Parties without any reasonable excuse. Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
By repudiating the claim of the complainant there is deficiency in service on the part of the opposite parties Nos. 1 and 2.
10 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties are directed to make the payment of Rs. 1,07,863/- to the complainants. The complainants have been harassed by the opposite parties unnecessarily for a long time. The complainants are also entitled to Rs.10,000/- ( Rs. Ten Thousand only) as compensation on account of harassment and mental agony and Rs 7,500 ( Rs. Seven Thousand Five Hundred only) as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.
Announced in Open Commission
12.10.2022
