SUNITA filed a consumer case on 02 Nov 2018 against O.I.C in the East Delhi Consumer Court. The case no is CC/470/2016 and the judgment uploaded on 14 Dec 2018.
DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)
GOVT. OF NCT OF DELHI
CONVENIENT SHOPPING CENTRE, FIRST FLOOR,
SAINI ENCLAVE, DELHI – 110 092
C.C. NO. 470/16
Mrs. Sunita Goyal
W/o Shri Vinod Goyal
R/o 272, Amarpali Apartments
56, I.P. Extension, Delhi – 110 091 ….Complainant
Vs.
M/s. Oriental Insurance Co. Ltd.
1st Floor, Scope Minar
Laxmi Nagar, New Delhi – 110 092 …Opponent
Date of Institution: 06.09.2016
Judgement Reserved on: 02.11.2018
Judgement Passed on: 16.11.2018
CORUM:
Sh. Sukhdev Singh (President)
Dr. P.N. Tiwari (Member)
Ms. Harpreet Kaur Charya (Member)
Order By: Sh. Sukhdev Singh (President)
JUDGEMENT
This complaint has been filed by Mrs. Sunita Goyal against M/s. Oriental Insurance Company Ltd. (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service.
2. The facts in brief are that the complainant had taken a Happy Family Floater Policy from M/s. Oriental Insurance Company Ltd. (OP) for a sum of Rs. 4,00,000/-, as follows:
Policy No. | Valid from / Renewed on | Valid till |
214300/48/2010/2352 | 24.12.2009 | 23.12.2010 |
214300/48/2011/3065 | 24.12.2010 | 23.12.2011 |
214300/48/2012/5229 | 24.12.2011 | 23.12.2012 |
214300/48/2013/5595 | 24.12.2012 | 23.12.2013 |
214303/48/2014/5139 | 27.12.2013 | 26.12.2014 |
The complainant on 12.08.2014, felt some problem and was admitted on 18.08.2014 in Fortis Escorts Hospital for treatment. The doctors of Fortis Escorts Hospital diagnosed that she was suffering from ASD for the first time and was advised immediate surgery. They gave their opinion that she had no past history of any ailment. The ASD was diagnosed on evaluation on 12.08.2014 accidently after murmur was picked up.
She immediately gave intimation to OP about the incidence and lodged her claim on the same day and supplied all the information that was required by TPA of OP. The TPA failed to approve cashless stay in the hospital on flimsy grounds, though, all the papers were sent on 28.08.2014. She has written many request letters regarding the claim, but there was no response. She visited several times, but officer of OP has not given any satisfactory reply to the complainant.
The complainant was surprised to receive the letter of dated 03.02.2015 where claim of the complainant was repudiated stating that it was a claim for Fossa Ovalis ASD + Normal Ventricular Function, which is internal disease, hence it was not payable under clause 4.8 of the policy. They have refused to pay the genuine and legal claim of the complainant. Thus, it has been stated that their action was unfair illegal and deficient in nature. Hence, she has claimed an amount of Rs. 2,12,752/- as compensation for medical bills; Rs.1,50,000/- as compensation for harassment, mental pain and agony, Rs. 25,000/- towards cost of litigation and Rs. 25,000/- for failing to given the reply of RTI application of dated 01.04.2015.
3. In the reply filed on behalf of M/s. Oriental Insurance Company Ltd. (OP), they have stated that she took the treatment from Fortis Escorts Heart Institute and was diagnosed with the history of “DYSPENA ON EXERTION GRADE II/IV ON AND OFF FOR LAST 1½ MONTHS. CARDIAC EVALUATION WAS SOUGHT WHICH REVEALED LARGE ‘ASD’. NOW SHE HAS BEEN ADMITTED AT FEHI FOR DEVICE CLOSURE OF ASD”, and as per policy terms and conditions it was not payable, cashless was also denied due to the “Claim for Fossa Ovalis ASD + Normal Ventricular Function, which is internal diseases, hence not payable under clause number 4.8”, hence, the claim was rightly repudiated vide repudiation letter dated 03.02.2015.
They have quoted Exclusion Clause 4.8 which states as:
“The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:
(4.1)……… to 4.8……………….to 4.23
In Exclusion Clause No. 4.8 it is provided as under:
Convalescence general debility “run down” condition or rest cure, congenital external and internal diseases or defect or anomalies, sterility, and fertility sub-fertility or assisted conception procedure, venereal diseases, intentional self injury suicide, all psychiatric and psychosomatic disorders and diseases/accident due to and use, misuse or abuse of drugs/alcohol or alcohol or use of intoxicating substances or such abuse or addiction etc”.
Thus, they have stated that there was no deficiency on their part. They have denied other facts also.
4. In support of its complaint, the complainant have examined herself. She has narrated the facts which have been stated in the complaint. She has got exhibited the documents such as copy of Adhaar Card (Ex.CW-1/1), copy of policy alongwith terms and conditions (Ex.CW-1/2), copy of medical record (Ex.CW-1/3), copy of request letters and emails to OP (Ex.CW-1/4), reply of RTI (Ex.CW-1/5) and copy of repudiation letters (Ex.CW-1/6).
In defence, M/s. Oriental Insurance Company Ltd. (OP) have examined Shri Jagdish Kumar, Sr. Divisional Manager of OP, who has also deposed on affidavit. He has narrated the facts which have been stated in the written statement.
5. We have heard the Ld. Counsel for the parties and have perused the material placed on record. The only point which has been hotly canvassed by both the parties has been as to whether the treatment taken by the complainant was excluded under Clause 4.8 of the Exclusion Clause.
The argument which has been advanced on behalf of complainant has been that the treatment taken by the complainant was not covered under Clause 4.8 of the Exclusion Clause as the exclusion clause was applicable only for the external treatment and not for the internal treatment. He has drawn attention of the Forum to Clause 4.8 of the terms and conditions of the policy which was provided to the complainant at the time of issuance of policy.
On the other hand, Ld. Counsel for the M/s. Oriental Insurance Company Ltd. (OP) have stated that the policy covered both internal and external diseases.
To appreciate the arguments of Ld. Counsel for the parties, a look has to be made to Clause 4.8 of the policy which was provided to the complainant at the time of issuance of policy. The relevant portion of Clause 4.8 of the policy is extracted hereunder:-
“Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases/accident due to, and/or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc., any disease or injury as a result of committing or attempting to commit a breach of Law with criminal intent”.
A bare reading of this clause reveals that it excludes only congenital external diseases or defects or anomalies. This clause does not use the word ‘Internal Diseases’ which have been stated in the repudiation letter (Ex. CW-1/6).
The treatment taken by the complainant has been for Fossa Ovalis ASD + Normal Ventricular Function which is an internal disease, hence was not payable under Clause 4.8 of the policy. This repudiation letter states that the treatment taken by the complainant for Fossa Ovalis ASD + Normal Ventricular Function was internal disease which was not payable under Clause 4.8 of the policy. However, Clause 4.8 of the policy as stated earlier does not use the word ‘Internal Disease’.
When the said clause does not use the word ‘Internal’, the question of having taken the treatment by the complainant for Fossa Ovalis ASD + Normal Ventricular Function which was an internal disease was not covered under Clause 4.8 of the policy. When it was not covered under Clause 4.8 of the policy, the repudiation of the claim was without any basis which amounts to deficiency in service.
Since, M/s. Oriental Insurance Company Ltd. (OP) was deficient in their service, the complainant was entitled for the claim amount as well as compensation for mental pain and harassment.
In view of the above, it is ordered that M/s. Oriental Insurance Company Ltd. (OP) shall pay an amount after permissible deductions under policy terms and conditions out of a sum of actual bill amount of Rs. 2,12,052/- of the medical bills of the complainant. We further award compensation of Rs. 20,000/- towards harassment and mental agony and an amount of Rs. 10,000/- towards cost of litigation.
The order be complied within a period of 45 days from the date of receipt of order.
Copy of the order be supplied to the parties as per rules.
File be consigned to Record Room.
(DR. P.N. TIWARI) (HARPREET KAUR CHARYA)
Member Member
(SUKHDEV SINGH)
President
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