Order dictated by:

Sh.S.S. Panesar, President.

1.       Smt. Neelam complainant has brought the instant complaint under section  12 & 13 of  the Consumer Protection Act, 1986 on the allegations that  complainant is permanent resident of  5799/20, Gali No.10, Nawan Kot, Abadi Gurbaksh Nagar, Amritsar . The son of the complainant namely Deepanshu Gulati had obtained a Happy Family Floater Mediclaim Insurance by paying premium of Rs. 7594/- from opposite party No.1 through opposite party No.2 in which the family members and the complainant is also included as assured vide Cover note No. HD-C-027527 commenced from 20.2.2015 to 19.2.2016. On 1.3.2015 complainant became unconscious and fell down   and she was immediately admitted to nearest hospital i.e. Gurpreet Hospital, 100ft Road,  Opposite Prince Tower, Amritsar. Doctor namely Sh.Gurpreet Singh after diagnosing the complainant advised  to get admitted the complainant in the complainant on the same day i.e. 1.3.2015. After investigation the complainant was admitted in the hospital till 5.3.2015 and incurred an expenditure of Rs. 34,777/- on her treatment. Copies of the bills are enclosed. Thereafter the complainant approached the opposite party No.1  for reimbursement of the bill amount spent on her treatment . The complainant also lodged claim by filing claim form and submitted the requisite documents required for the settlement of the claim. Thereafter complainant personally visited opposite party No.2, where the official concerned handed over a denial letter dated 26.6.2015 to the complainant  and told that company is not liable to pay any expenses whatsoever incurred by the insured person/complainant. The act of the opposite party in denying the claim of the complainant amounts to deficiency in service. The complainant has sought  for the following reliefs vide instant complaint :-

(i)      Opposite party be directed to pay Rs. 34,777/- incurred upon the treatment of the person insured.

(ii)     Opposite party be also directed to pay compensation to the tune of Rs. 50,000/- for the mental pain, agony, harassment  caused to the complainant alongwith Rs.15000/- as litigation expenses.

Hence, this complaint.

2.       Upon notice, opposite parties No.1 & 2 appeared and contested the complaint by filing collective written statement taking certain preliminary objections therein inter alia that  complainant has filed a baseless, frivolous and an imaginary claim with an ulterior motive. The complainant has fabricated a false story  to extract unlawful gains to which he is otherwise not entitled  ; that complainant is estopped by her own act and conduct to file the present complaint and the present complaint is not maintainable under law; that complainant does not fall within the ambit of consumer under section 2 of the  Consumer Protection Act ; that no cause of action has arisen to the complainant to file the present complaint as the averments of the present complaint does not depict any consumer dispute between the parties and the present complaint is premature  ; that complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum. On merits, it is stated that averments regarding  issuance of the policy and payment of premium are matter of record. Averments with regard to lodge of claim and submitting of necessary documents  which are required for scrutinizing, processing of the claim of the complainant are concerned, the same are matter of record. However, replying opposite parties after processing  the claim of the complainant have repudiated the same vide letter dated 26.6.2015 as per the terms and conditions contained in the policy  especially condition No. 4.8 mentioned in section 4 exclusion clause which is reproduced hereunder :

“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 (4.8) Convalescence, General debility, “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, any fertility or assisted conception procedure, venereal diseases, internal 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.”

Keeping in view of the aforesaid terms and conditions of the policy , the treatment record of the complainant shows that the exclusion clause section 4 read with clause 4.8 of the terms and conditions of the policy is fully applicable to the facts of the present case and therefore, the claim of the complainant is rightly repudiated . Intimation to this respect has already been given to the complainant  and therefore, the claim of the complainant has already been decided and the present complaint is not maintainable under the law. Remaining facts mentioned in the complaint have also been denied  and a prayer for dismissal of the complaint with cost was made.

3.       Opposite parties No.3 & 4 did not put in appearance and were ordered to be proceeded against ex-parte.

4.       In his bid to prove the case  Sh. Vishal Khanna,Adv.counsel for the complainant tendered into evidence affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-22 and closed the evidence on behalf of the complainant.

5.       To rebut the aforesaid evidence Sh.Subodh  Salwan,Adv.counsel for opposite parties No.1 & 2 tendered into evidence affidavit of Sh. R.K.Sharma,Divisional Manger Ex.OP1,2/1 alongwith documents Ex.OP1,2/2 to Ex.OP1,2/10 and closed the evidence on behalf of opposite parties No.1 & 2.

6.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file as well as written synopsis of arguments submitted on behalf of complainant as well as opposite parties No.1 & 2.

7.       Ld.counsel for the complainant has vehemently contended that son of the complainant namely Deepanshu Gulati purchased Happy Family Floater Mediclaim Insurance  policy in which the complainant is also included as assured person which was in operation w.e.f. 20.2.2015 uptil 19.2.2016, copy of the mediclaim policy is Ex.C-2 on record. On 1.3.2015 complainant became unconscious and fell down and she was immediately admitted to the nearest hospital i.e. Gurpreet Hospital, Amritsar. Dr. Gurpreet Singh diagnosed the complainant  and advised her to get herself admitted in the hospital on the same day i.e. 1.3.2015 and she remained admitted in the hospital uptil 5.3.2015, copy of the medical treatment as well as bills account for Ex.C-6 to Ex.C-19. The complainant spent an amount of Rs. 34,377/- on her treatment. Thereafter complainant approached the opposite party No.2 for refund of the amount spent by her on her treatment and made several visits to the office of opposite party No.2. However, on 26.6.2015 opposite party No.2 repudiated the claim of the complainant in view of condition 4.8 of the terms and conditions of the Insurance policy in dispute. The repudiation has been wrongly made. The complainant is entitled to reimbursement of medical expenses . As the rejection amounts to deficiency in service on the part of opposite party No.2 and it is requested that complainant may be refunded the treatment amount to the tune of Rs. 34,777/- alongwith compensation and expenses for litigation to be assessed by this Forum.

8.       But however, from the appreciation of the facts and circumstances of the case, it becomes evident that there is no dispute that the complainant is a beneficiary under Happy Family Floater Mediclaim Insurance policy , copy whereof is Ex.C-5 on record which was in operation w.e.f. 20.2.2015 to 19.2.2016. It is also not disputed that the complainant fell ill and was admitted in  Gurpreet Hospital for treatment and she remained admitted in the hospital w.e.f. 1.3.2015 to 5.3.2015. The complainant was diagnosed and treated for ailment known as “dissociative Motor Disorders”. The opposite party has adduced on record medical literature  drawn from traumadissociation.com, copy whereof is Ex.OP1,2/10 in which Dissociative Movement Disorder has been described to be including ‘psychogenic aphonia and psychogenic  dysphonia. As per exclusion clause 4.8 following diseases are not covered under the Insurance policy in dispute:-

“ Convalescence, General debility, “run down” condition or rest cure, congenital external and internal diseases or defects or anomalies, sterility, any fertility or assisted conception procedure, venereal diseases, internal 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.”

9.       Since the complainant was suffering from psychiatric and psychosomatic disorders, therefore, claim of the complainant has been rightly repudiated . Since terms and conditions of the Insurance policy in dispute are binding inter-se parties, therefore, this Forum cannot  interpret  the term to suit to the convenience of the complainant rather the interpretation of the terms and conditions of the policy in dispute has to be in order with meaning attributed to the clause/term in the Insurance policy in dispute. Reliance in this connection can be had on M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co.& Ltd and another respondents 2010(IV) CPJ 38 (SC) wherein it has been laid down that “in interpreting documents relating to a 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 not for the court to make a new contract, however reasonable, if the parties have not made it themselves.” To the similar effect is the ruling given by the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh in Bawa Singh Vs. M.D. India Health Care Services & Others 2015(2) CLT page 418 wherein it has been laid down that 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. It is none of the case of the complainant that terms and conditions of the Insurance policy in dispute were not supplied, therefore, all the terms and conditions including exclusion clause was binding on her.

10.     In the case in hand the complainant cannot wriggle out from the terms and conditions of the Insurance policy in dispute. It is also not the case of the complainant that she was not provided with the terms and conditions of the policy in dispute . In such a situation the terms and conditions of the Insurance policy in dispute are binding  on the complainant. Since the case of the complainant falls within the ambit of  clause 4.8 of the Insurance Policy in dispute in which the disease suffered by the complainant falls within the purview of exclusion clause and therefore, claim of the complainant has rightly been repudiated vide repudiation letter , copy whereof is Ex.C-21 on record. There is absolutely no deficiency of service on the part of the opposite party and as such instant complaint fails and the same is ordered to be dismissed accordingly. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Forum

Dated : 05.09.2016

/R/