Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. Smt.Ekta Kapoor has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that the husband of the complainant Sh.Rajan Kapoor has been purchasing mediclaim policies from Opposite Party continuously since the year 2000 under the name of Happy Family Floater Policy for himself and his family i.e. his wife (complainant) and two sons and has been paying the premium amount from time to time i.e. every year on obtaining the fresh policy under the same plan and the Opposite Party has been issuing only the cover note and never issued any document alongwith policies containing the terms and conditions. The disputed policy was purchased by the husband of the complainant from the Opposite Party bearing cover note No. 040868 dated 16.4.2015 till 30.4.2016 for which the premium of Rs.14,382/- was paid by him. Recently, this year also, the husband of the complainant had purchased the policy from the Opposite Party bearing cover note Number 106967 for the period from 1.5.2016 till 30.4.2017 for which he had paid the premium of Rs.19,815/- to the Opposite Party against receipt. During the validity of the policy in question, the complainant suffered from the disease scattered fibro glandular tissue in her breast for which she visited the Medanta Hospital and consulted the doctors and on 13.7.2015, all the required tests were done by the doctors and as per the medical tests reports, she was found to be suffering from said disease and she was suggested by the doctors to get her operated. As per the medical advise, the complainant opted to get her operated and accordingly she was admitted in the said hospital on 6.8.2015 and was operated upon on 7.8.2015 and was discharged from the hospital on 8.8.2015. At the time of her admission in the said hospital, she being the holder of the above said medical cashless policy, informed the hospital authorities as well as to the Opposite Party. For the operation, tests, medicines etc. the hospital authorities charged a total sum of Rs.96,565/- from the complainant which she paid. Accordingly, in order to get the claim from the Opposite Party regarding the expenses incurred by her on her treatment, she approached the Opposite Party and submitted claim form alongwith all the relevant documents to them and requested to make the payment of said amount, but the Opposite Party illegally, malafidely, unlawfully and arbitrarily repudiated the claim of the complainant by issuing a repudiation letter dated 22.12.2015 to her on the flimsy grounds that the claim is not payable as per section 4. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Party be directed to make the payment of Rs.96,565/- being the claim amount which she had incurred on her treatment and paid to the hospital alongwith interest @ 18% per annum from the date of payment till realization.
b) Compensation of Rs.20,000/- may be awarded to her on account of suffering mental pain, agony, harassment, inconvenience at their hands due to deficiency in service.
c) Costs of the proceedings of Rs.10,000/-.
d) Any other relief to which the complainant is found entitled.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complainant has violated the basic terms and conditions of the policy in question and hence the present complaint is not maintainable. In the light of the terms and conditions of the mediclaim policy, it was found that the claim was not payable, as per the Exclusion Clause 4.11 of the Insurance policy in question which reads as under:-
Section 4. Exclusions: “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 (4.11) Expenses incurred at hospital or nursing home primarily for evaluation/ diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period or expenses incurred for investigation or treatment irrelevant to the disease diagnosed during the hospitalisation or primary reasons for admissions, referred fee to family doctors, outstation consultants/ surgeons fees, doctor’s home visit charge/ attendant/ nursing charges during pre and post hospitalization period, etc.”
Accordingly, the claim was considered as inadmissible by competent authority of Opposite Party, therefore, the Opposite Party repudiated the claim on merits in accordance with law and intimated the complainant regarding the same vide repudiation letter dated 31.8.2015. On merits, the Opposite Party took the same and similar pleas as taken up by the Opposite Party in preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In her bid to prove the case, complainant tendered into evidence affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C53 and closed her evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Ravi Gupta, DM Ex.OP1 alongwith copies of documents Ex.OP2 to OP3 and closed the evidence on behalf of the Opposite Party.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. Ld.counsel for the complainant has reiterated the averments as narrated in the complaint and argued that the husband of the complainant Sh.Rajan Kapoor has been purchasing mediclaim policies from Opposite Party continuously since the year 2000 under the name of Happy Family Floater Policy for himself and his family i.e. his wife (complainant) and two sons and has been paying the premium amount from time to time i.e. every year on obtaining the fresh policy under the same plan and the Opposite Party has been issuing only the cover note and never issued any document alongwith policies containing the terms and conditions. The disputed policy was purchased by the husband of the complainant from the Opposite Party bearing cover note No. 040868 dated 16.4.2015 till 30.4.2016 for which the premium of Rs.14,382/- was paid by him. Recently, this year also, the husband of the complainant had purchased the policy from the Opposite Party bearing cover note Number 106967 for the period from 1.5.2016 till 30.4.2017 for which he had paid the premium of Rs.19,815/- to the Opposite Party against receipt. During the validity of the policy in question, the complainant suffered from the disease scattered fibro glandular tissue in her breast for which she visited the Medanta Hospital and consulted the doctors and on 13.7.2015, all the required tests were done by the doctors and as per the medical tests reports, she was found to be suffering from said disease and she was suggested by the doctors to get her operated. As per the medical advise, the complainant opted to get her operated and accordingly she was admitted in the said hospital on 6.8.2015 and was operated upon on 7.8.2015 and was discharged from the hospital on 8.8.2015. At the time of her admission in the said hospital, she being the holder of the above said medical cashless policy, informed the hospital authorities as well as to the Opposite Party. For the operation, tests, medicines etc. the hospital authorities charged a total sum of Rs.96,565/- from the complainant which she paid. Accordingly, in order to get the claim from the Opposite Party regarding the expenses incurred by her on her treatment, she approached the Opposite Party and submitted claim form alongwith all the relevant documents to them and requested to make the payment of said amount, but the Opposite Party illegally, malafidely, unlawfully and arbitrarily repudiated the claim of the complainant by issuing a repudiation letter dated 22.12.2015 to her on the flimsy grounds.
7. On the other hand, ld.counsel for the Opposite Party has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that the complainant has violated the basic terms and conditions of the policy in question and hence the present complaint is not maintainable. In the light of the terms and conditions of the mediclaim policy, it was found that the claim was not payable, as per the Exclusion Clause 4.11 of the Insurance policy in question which reads as under:-
Section 4. Exclusions: “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 (4.11) Expenses incurred at hospital or nursing home primarily for evaluation/ diagnostic purposes which is not followed by active treatment for the ailment during the hospitalised period or expenses incurred for investigation or treatment irrelevant to the disease diagnosed during the hospitalisation or primary reasons for admissions, referred fee to family doctors, outstation consultants/ surgeons fees, doctor’s home visit charge/ attendant/ nursing charges during pre and post hospitalization period, etc.” Accordingly, the claim was considered as inadmissible by competent authority of Opposite Party, therefore, the Opposite Party repudiated the claim on merits in accordance with law and intimated the complainant regarding the same vide repudiation letter dated 31.8.2015.
8. It is the case of the complainant that the husband of the complainant Sh.Rajan Kapoor has been purchasing mediclaim policies from Opposite Party continuously since the year 2000 under the name of Happy Family Floater Policy for himself and his family i.e. his wife (complainant) and two sons and has been paying the premium amount from time to time i.e. every year on obtaining the fresh policy under the same plan and the Opposite Party has been issuing only the cover note and never issued any document alongwith policies containing the terms and conditions. On the other hand, the case of the Opposite Party is that the complainant has violated the basic terms and conditions of the policy in question and hence the present complaint is not maintainable. In the light of the terms and conditions of the mediclaim policy, it was found that the claim was not payable, as per the Exclusion Clause 4.11 of the Insurance policy in question. But as per the contention of the complainant herself, if the complainant has been purchasing the policies since the year 2000 i.e. from the last more than 15 years, and never received the copies of terms and conditions or policy document, then why the complainant or her husband did not raise any demand from the Opposite Party for issuance of its terms and conditions. In such a situation, at this later stage, the complainant can not said that she has not received any cover note or its terms and conditions since the last continuous more than 15 years. Ld.counsel for the Opposite Party has further contended that the terms and conditions of the policy in question are binding inter se parties and while interpreting documents relating to contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is for the court to make or construe as it is and we can not add or subtract anything from the policy terms and conditions. Reliance in this regard has been placed on Bawa Singh Vs. M.D. India Health Care Services & Others 2015(2) CLT page 418 of Hon’ble Punjab State Commission, wherein it has been laid down that:-
Firstly taking the plea whether the terms and conditions were not supplied to the complainant, the perusal of the complaint there is no reference that he was not given the copy of the terms and conditions of the policy. In case the complainant is basing his claim on the basis of policy taken by him, there is presumption that he must have gone through the terms and conditions of the policy. A reference can be made to the judgement given by Constitutional bench of our Hon’ble Apex Court reported in 1966(7) CPSC 44 “General Assurance Society Limited Vs. Chandmull Jain” wherein it has been observed in para 11 (relevant extract as under):-
“…..The policy not only defines the risk and its duration but also lays down the special terms and conditions under which the policy may be enforced on either side. Even if the letter of acceptance went beyond the cover notes in the matter of duration , the terms and conditions of the proposed policy would govern the case because when a contract of insuring property is complete, it is a material whether the policy is actually delivered after the loss and for the same reasons the rights of the parties are governed by the policy to be, between acceptance and delivery of the policy. Even if no terms are specified the terms contained in a policy customarily issued in such cases, would apply.”
9. Since in view of the aforesaid facts and circumstances, the complainant has violated the basic terms and conditions of the policy in question and hence the present complaint is not maintainable. Instant complaint is nothing but an abuse of process of law and the complaint merits dismissal accordingly. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 21.06.2017.
