O R D E R
K.S. MOHI, PRESIDENT
The complainant has filed the present complaint against the O.Ps u/sec. 12 of Consumer Protection Act, 1986. The facts as alleged in the complaint are that the complainant had taken a mediclaim policy from the O.P-1 in the year 2003-2004. It is alleged that the policy was renewed from time to time and at the relevant time the policy bearing No.215402/48/2007/1144 for the period from 16.07.2006 to 15.07.2007. On 28.09.2006 complainant fell ill and was admitted in Loknaik Jai Prakash Narain Hospital, New Delhi and was discharged on 29.09.2006 with advice to follow-up treatment and weekly review. It is further alleged that complainant intimated the O.Ps regarding his illness and consequent hospitalization vide his letter dated 28.09.2006. It is alleged that on 20.12.2006 complainant had lodged claim with the O.Ps and the said claim of the complainant was processed and passed by the O.Ps. It is further alleged that the complainant submitted all the original medical Hospital bills etc. with the O.Ps to reimbursement of the amount which was paid by the complainant for his treatment. It is alleged that O.Ps have not given any claim to the complainant. It is further alleged that complainant send various reminders and orally requested the O.Ps to reimburse the claim amount but all in vain. Complainant has also sent a notice dated 09.07.2007 but of no avail. It is alleged that complainant received a letter dated 28.06.2007 from the O.P-1 along with enclosed letter from Raksha TPA dated 29.01.2007 whereby alleging that the claim of the complainant has been closed as “No Claim.” On these facts complainant prays that O.Ps be directed to pay the mediclaim amount of Rs.1,67,518/- alongwith interest and also to pay cost and compensation as claimed.
2. O.P appeared and filed its written statement. In its written statement O.P has not disputed that complainant had taken policy refer to above. It is alleged that as per clause 2.3 of mediclaim policy terms and conditions the expenses on hospitalization are admissible and payable when the treatment is such that it necessitates hospitalization but in the present case hospitalization is not so necessitated and the whole treatment was taken on O.P.D. basis. If the claim on hospitalization is not payable then claim for subsequent treatment on O.P.D. automatically not payable. It is further alleged that the complainant has taken O.P.D. treatment for about two months. The doctor Mr. Moin Khan of the Raksha TPA in his opinion report dated 29.01.2007 observed that “patient was admitted as a diagnosed case of Psoriasis Mlgans Iastbralgia, investigated & treated conservatively and discharge with follow-up advice. This claim is non-tenable because long-term O.P.D. treatment and does not required hospitalization. Hence we recommended this claim as no-payable.” Therefore, following the opinion report of the above said doctor, the O.P has repudiated the claim of the complainant with the observation “this claim is non-tenable because long-term O.P.D. treatment and does not required hospitalization.” It is alleged that there is no clear proof or finding that the complainant was remain hospitalized for a period of 24 hours as required under the terms and condition of the policy. Dismissal of the complaint has been prayed for.
3. Complainant has filed rejoinder reiterating all the facts as mentioned in the complaint. He has also filed his affidavit in evidence and has proved documents exhibited as Ex. CW-1/1 to CW-1/24. On the other hand Shri Ram Sukh, Sr. Divisional Manager has filed affidavit in evidence on behalf of O.Ps (OIC) testifying all the facts as stated in the written statement. Dr. Moin Khan has also filed his affidavit in evidence on behalf of Raksha TPA Pvt. Ltd. Parties have also filed their respective written submissions.
4. We have carefully gone through the record of the case and have heard submissions of Ld. Counsels for the parties.
5. The main controversy involved in the present case is as to whether the repudiation of claim of the complainant by O.Ps was justified or not. Needless to say that the claim filed by the complainant was rejected by the O.Ps while relying on clause 2.3 of mediclaim policy terms and conditions regarding expenses on hospitalization. It has been submitted that in the present case hospitalization was not necessitated and whole treatment was taken by complainant as outdoor patient, therefore, the repudiation of claim was rejected as “No Claim.” Admittedly the complainant remained admitted only for one day i.e. from 28.09.2006 to 29.09.2006 and the medicines as prescribed by doctor were taken by him as outdoor patient and probably this was reason of rejection of claim that treatment continued as outdoor patient. It sounds illogical if the claim of insured is rejected barely on the ground that after admission but follow-up treatment was carried out on the advice of doctor was in admissible as per terms and conditions of the policy. It is ironical that the medicines taken by the insured as outdoor patient are in admissible. In the instant case the insured though was hospitalized for one day but his treatment continued for several days after his discharge. Thus it would be quite irrational if the medicines are taken being an outdoor patient by insured as a consequence of his admission for the illness in the hospital. Therefore, we are of the opinion that the rejection of the claim by O.P was totally untenable and illogical.
6. Secondly, the insurance company cannot be permitted to press into service clause 2.3 of terms and conditions of the policy for the simple reason that said terms and conditions were not supplied to the insured at the time of inception of policy. There is plethora of decisions of higher courts that insurance policy cannot reject the claim on the basis of terms and conditions which were not furnished to the insured. In case titled IV (2014) CPJ 14A (CL) HAR. Oriental Insurance Co. Ltd. Vs Vivek Rekhan, the claim filed on the basis of mediclaim policy was repudiated by the insurance company on the basis of exclusion clause. The court held that the insurance company vaguely denied without pointing out as to in which manner and on which date terms and condition were supplied to the complainant. Therefore, unless terms and condition have been supplied to the complainant before taking a policy, exclusion clause cannot be enforced.
7. Keeping in view the discussion above the O.Ps repudiate the claim on frivolous grounds, therefore, deficiency in service. We award a sum of Rs.1,67,518/- with interest @ 6% from the date institution of the complaint till payment, the further award of Rs.10,000/- towards harassment mental agony loss of time which will also include cost of litigation.
Copy of this order be sent to the parties as per rules.
Announced this 09th day of March, 2016.
(K.S. MOHI) (SUBHASH GUPTA) (SHAHINA)
President Member Member
