| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA RBT/Consumer Complaint No.84 of 2018 Date of institution: 05.02.2018 Date of Decision: 18.05.2022 Yogesh Kumar son of Lt. Sh. Harbans Lal, aged about 48 years, resident of House No.797/18-A, Madhopuri-7, District Ludhiana ….Complainant Versus
- The New India Assurance Company Limited, Branch Office situated at BN Chowk, Ferozepur Road, Ludhiana through its Manager/ Executive Officer
- The New India Assurance Company Limited, registered and head office : the New India Assurance Building 87, Mahatma Gandhi Road, Fort, Mumbai 400 001, through its Manager/ Executive Officer. ……..Opposite Parties
Complaint under Consumer Protection Act Quorum: Shri Ranjit Singh, President. Mrs. Ranvir Kaur, Member Present: Sh. Nitin Jain, Adv. for complainant Sh. RK Chand, Advocate, for OPs
Order dictated by :- Shri Ranjit Singh, President Order The present order of ours will dispose of the above complaint filed under Consumer Protection Act, received by way of transfer from District Consumer Disputes Redressal Commission, Ludhiana by the complainant against the Opposite Parties on the ground that the complainant has taken a new india floater mediclaim policy from the Ops in the year 2005, which is being renewed continuously till today. Under the said policy, the complainant is insured to the extent of Rs.8,00,000/-. The said policy is valid w.e.f. 21.3.2017 to 28.03.2018. In the month of October 2017, the complainant was suffered from Dizziness and uneasiness. On 11.10.2017, the complainant became unstable and he immediately was got admitted in CMC Hearth Research Centre Department of Cardiology in Christian Medical College and Hospital, Ludhiana, where his MRI Brain and Colour Doppler Echocardiography and other necessary test was done, where he was got admitted on 11.10.2017 in ICU under Dr. Rajneesh Calton and discharged on 13.10.2017 from the hospital with final diagnosis of Unstable Angina. On his treatment, he spent Rs.38408/-. It is further alleged that regarding, this, intimation was given to the Ops and the complainant lodged the claim vide claim form dated 27.10.2017 which they were received on 2.11.2017 but they repudiate the claim of the complainant vide letter dated 7.11.2017 on false ground that patient admitted only for investigation and evaluation purpose, hence claim non payable as per policy conditions, which clearly show unfair trade practice and deficiency in service on the part of the Ops. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:- - To direct the Ops to pay the claim amount of Rs.38408/- incurred on 13.10.2017 along with interest @ 12% per annum
- To pay Rs.50,000/- as compensation to the complainant in the interest of justice.
- To pay Rs.20,000/- as litigation expenses.
- Upon notice, the O.Ps. has filed written reply taking preliminary objections; that the present complaint is not maintainable; that the complainant has suppressed the material facts from this Hon’ble Commission; that the complainant has not come to this Commission with clean hands. On merits, it is stated that as per clause 4.4.11 of the terms and conditions of the policy, the claim of the complainant is not payable. It is well settled law laid down by the appellate authorities that where the officials or any authorities of the company after applying the minds in terms of the insurance policy and after adopting the procedure laid down for the settlement of the claim repudiates the claim then there is no deficiency in service. It is admitted that the complainant had obtained medi claim policy valid w.e.f. 21.3.2017 to 20.3.2018 and the same was issued along with terms and conditions of the policy and the said terms and conditions of the policy are binding upon the parties. The complainant has neither produced on record the said policies nor he has mention the policy number from 2005 to onwards and in the absence of said particulars, it cannot be ascertained as to whether the complainant had obtained insurance policies from 2005. The complainant admitted in the hospital for investigation and evolution and there was no active management during hospitalization. The complainant had lodged the claim with the Ops but the same was not payable as per the policy condition and clause 4.4.11 and claim has been repudiated vide letter dated 2.1.2018 as per terms and conditions of the policy. Rest of allegations leveled by the complainant have been denied by the Ops and prayed for dismissal of the complaint.
- The complainant has tendered various documents in the shape of evidence. On the other hand, the OPs have also tendered various documents in the shape of evidence.
- We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
- It remains undisputed that the complainant has taken a floater medi claim policy with the OPs and sum insured under the said policy was Rs.8,00,000/-. It also remains undisputed that the policy was valid from 1.3.2017 to 20.3.2018.
- Pursuant to the Floater Mediclaim Policy (Clause 4.4.11) the OP/insurer repudiated the claim of the complainant. In clause 4 it is stipulated that what are exclude under the policy.
- Undisputedly, clause 4.4.11 stipulated that Charges incurred at Hospital primarily for diagnosis, X Ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any illness or injury for which confinement is required at a hospital. On scrutiny of the documents annexed by the complainant in support of his claim, The complainant was admitted in the hospital for unstable angina. Discharge certificate speaks that the complainant was discharged by the hospital in better condition.
- From the perusal of the file, we find that there is no active management during hospitalization, patient admitted only for investigation and evaluation purpose. On reading of the documents supported by both the parties, it is clear that as per condition, the insurance company is not liable to make any payment under the policy in respect of any expenditure incurred by the complainant/ insured in view of the clause 2.10 and clause 4.4.11 of the Floater Medi claim Policy. In the relevant contract i.e. insurance policy under the question, exclusion clauses 2.10 and 4.4.11 have been incorporated. Therefore, it is binding on the parties. If the complainant/insured was not agreed able to the said exclusion clauses, he could have opted out the contract by seeking refund of the annual premium paid by him. The purpose of medical insurance is to reimburse the insured for treatment of any disease or ailment during the period of insurance policy. In the instant case, the complainant is seeking reimbursement in respect of hospitalization and post hospitalization treatment, which are not covered under clauses 2.10 and 4.4.11 of the mediclaim insurance contract.
- In view of the above discussion, we are of the opinion that the complainant is not entitled to get reimbursement as claimed. In the absence of the proper cogent, reliable or trustworthy evidence from the side of the complainant, we are not inclined to give any relief to the complainant. Therefore, the complaint stands dismissed. However, no order as to cost. Free certified copies of this order be sent to the parties, as per rules. The files be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the record room.
Announced May 18, 2022 (Ranjit Singh) President (Ranvir Kaur) CC No.84 of 2018 Sh. RK Chand, Adv. For OPs Vide our separate detailed order of today, the complaint stands dismissed. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana for consigning the same to the record room. May,18 2022 (Ranjit Singh) (Ranvir Kaur) | |
