Charanjit Singh, President;

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant purchased from O.P. No. 1 a mediclaim insurance policy No 235302/48/2016/1618 cover note number CHT-C76377 and insured's code 72159003. In this policy, along with complainant, his wife Smt. Rekha Sodhi was also covered for a sum Insured of Rs. 1,00,000/- each. The policy was valid from 00.00 on 30.03.2016 to midnight of 29.03.2017. Due premium on the policy was paid by complainant and thus the complainant is a consumer under the Law. During the currency of this policy Smt. Rekha Sodhi, complainant's wife had post-menopausal bleeding and her D&C was done on 01.10.2016 at Adlakha Hospital, Amritsar. Subsequently Mrs. Rekha Sodhi had to go in for Hysterectomy i.e. removal of her uterus for which she remained as an indoor patient in Altec Laser and Super Speciality Centre, Ranjit Avenue, Amritsar, both her problems were covered under the policy. After discharge from Adlakha Hospital, Amritsar, after her D & C, complainant filed claim under the policy for reimbursement of medical expenses including cost of medicines to which complainant was entitled under the policy with all the supporting documents with Opposite party No.1 on 10.10.2016. The claim was filed for a sum of Rs. 13,070/-. Similarly after the discharge of his wife from Altec Laser and Super Speciality Centre Ranjit Avenue, Amritsar after her hysterectomy complainant again filed claim under the policy for reimbursement of medical expenses including hospital charges and cost of medicines amounting to Rs. 71,207/- with all the supporting documents with O.P. No-1 on 13.01.2017. Against a claim of Rs. 13,070/-, the opposite parties deposited in complainant's account a sum of Rs. 4,685/- and against a claim of Rs. 71,207/-, O.Ps deposited in complainant's account a sum of Rs. 23,687/- thereby implying that claim of the complainant qua the balance amount has been repudiated. No communication has been sent till date to the complainant giving any reason as to why the claims of complainant as sent were not passed and why such heavy deductions were made against the genuine claims of complainant offering him just peanuts. There was no reason for all O.Ps to pass the claim of complainant partly and to make such huge deductions (implying repudiation of the claim) from the otherwise genuine claims of the complainant in an arbitrary manner. The complainant wanted to avoid un pleasant litigation and so he served legal notice upon the opposite parties through his counsel dated-20.05.2017 which was duly served but still the opposite parties did not accede to the genuine demand of the complainant nor did they give any reason as to why the claim qua the balance amount was repudiated, hence the necessity of filing the present complaint. The complainant has prayed for the following reliefs

(i)      A sum of Rs. 55,905/- on account of claims of the complainant under the policy.

(ii)     A sum of Rs 25,000/- on account of compensation because of all the harassment, mental agony and avoidable stress to which the complainant was subjected because of the attitude of the O.P.

(iii)    Interest @ 18% per annum on the amounts above said from the date of part payment till the date of payment.

(iv)    Full costs of the proceedings.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 1 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not legally maintainable much less there is any deficiency in service and unfair trade practice on the part of opposite party as the amount claimed is not within the insurance coverage obtained by the complainant from the opposite party and as such the present complaint merits dismissal on this simple score only. The real state of affairs are that in this case the claimed amount was to the tune of Rs. 13,070/- and Rs.76,206/- respectively and whereas out of the said amount of Rs. 13,070/- an amount of Rs. 8,455/- was disallowed  amount as per terms and conditions being Rs.500/- as Admission Charges (not payable), Rs.1,000/- as Anesthesia (Linking applied), Rs.1,833 as Investigation-Lab Test (Linking applied), Rs.455/- as Pharmacy Charges (Charges of Gloves, Cap, Easyfix, Mask, Pas NP, Rs.2,000/- as Room Rent (Room Rent @ 1000 x1), Rs.2,667/- as Surgeon Charges (Linking Applied) and as such the grant amount was to the tune of Rs.4,685/- which was paid to the complainant on 16.11.2016. Likewise whereas out of the said amount of Rs.76,206/- an amount of Rs.52,519/- was disallowed amount as per terms and conditions being Rs.5,400/- as Admission Charges (not payable), Rs.5,040/- Anesthesia (Linking applied), Rs.4,704 as Consultant Charges (Linking applied), Rs.840/- as Investigation Lab Test (Linking Applied), Rs.1,800/- as Nursing Charges (Included in Room Rent), Rs.7,560/- as OT Charges (Linking Applied), Rs.375/- as Pharmacy Charges (Urobag, Gloves, Cotton are not payable), Rs.12,600/- as Procedure (Linking Applied), Rs.2,200/ as RMO Charges (Included in Room Rent), Rs.12,000/- as Room Rent (Room Rent @ 1000 x 3) and as such the grant amount was to the tune of Rs.23,687/- which was paid to the complainant on 28.3.2017 in lieu of settlement of claim of complainant as per the terms and conditions of the policy.  As per clause 1.2 of the policy terms and conditions the room rent is restricted to 1% of the sum assured. The admissibility of all the related charges/ expenses except for medicine/pharmacy bills and body implants shall also be as per the eligible/entitled category vis-a-vis room rent. In the present case the complainant is covered for a sum insured of Rs.1 Lac and as such eligibility as per the clause for the room rent is Rs.1,000/- and in order to appreciate this fact, the terms and condition of the insurance policy may please be read and as such it cannot be attributed that there is any lapse or deficiency in service on the part of opposite party. The complainant has not come to this commission with clean hands and has concealed material facts from this commission and as such the present complaint merits dismissal on this simple score only. The opposite party has already settled the claim of the complainant as per the payable amount as per terms and conditions.  No consumer dispute survives between the parties much less any cause of action has arisen in favour of the complainant.   The opposite party No.1  has denied the other contents of the complaint and prayed for dismissal of the same.

4        The opposite parties No. 2 and 3 appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is not maintainable against opposite party No. 2 as there is no privity of contract between the complainant and opposite party No. 2, as neither any premium was charged by the Opposite Party No. 2 nor there is any contract of insurance entered in between the complainant and opposite party No. 2, who is merely a Third Party Administrator. The opposite party No. 2 has no pecuniary / financial interest in any of the claims whatsoever as such we only process/settle the claim on behalf of insurance companies as per there guidelines and the final call is of the insurance company to reimburse the claims to the insured or not. The entire payments / liabilities are of the insurance company. The claimant Rekha Sodhi covered under the policy 235302/48/2016/1618 Mediclaim Insurance Policy (Individual) (1) for a Sum Insured of Rs 100,000/-. The claimant was hospitalised twice as follows:

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The claimant admitted at Adlakha Hospital for the treatment of Post Menopaual Bleeding on 1.10.2016 and discharged on 1.10.2016.  As per the clause 1.2 of the policy terms and conditions the room rent is limited to 1% if the Sum Insured and Admissibility of all related expenses, except for medicine/pharmacy bills and body implants, shall also be as per the entitled category vis-à-vis room rent. The clause states as under 1.2 COVERAGE: The policy covers reasonable and customary charges in respect of Hospitalisation and / or Domiciliary Hospitalisation for medically necessary treatment only for illness / diseases contracted or injury sustained by the Insured Person(s) during the policy period, upto the limit of Sum Insured (SI),  The claimant admitted at Altec laser and Super Specialty Hospital on 26.12.2016 and discharged on 29.12.2016 for the treatment of Fibroid Uterus. As stated above clause 1.2 of the policy restricts the Room rent at 1% of the Sum Insured. The admissibility of all the related charges shall also be as per the eligible category vis-à-vis Room Rent hence the linking was applied to all the related charges and a subsequent deduction of Charges. As the claimant is covered for a sum insured of Rs 1,00,000/- hence the eligibility as per the clause for the Room Rent is Rs 1000/-.  The opposite parties No. 2 and 3 have denied the other contents of the complaint and prayed for dismissal of the same.

4        To prove the case of the complainant, Ld. counsel for the complainant tendered in evidence affidavit of complainant Ex. CW1/A alongwith documents Ex. C-1 to Ex. C-61 and closed the evidence. The Ld. counsel for the opposite parties tendered in evidence affidavit of Sh. R.K. Sharma Divisional Manager Ex. OP 1, 2, 3/1, attested mediclaim insurance policy schedule alongwith its terms and conditions Ex. OP1,2,3/2 and closed the evidence.

5        We have heard the Ld. counsel for the parties and have gone through the record on the file.

6        In the present case there is no dispute regarding the medi claim insurance taken by the complainant. There is also no dispute regarding the treatment taken by the wife of complainant. As per complainant, claim of Rs. 13,070/- was submitted to the opposite parties, out of which the opposite parties have made the payment of Rs. 4,685/- to the complainant. Again claim of Rs. 71,207/- was submitted to the opposite parties, out of which the opposite parties have made the payment of Rs. 23,687/- to the complainant.  Therefore, the complainant alleged that an amount of Rs.55,905/- is due against the opposite parties and they prayed for that amount of Rs. 55,905/-. On the other hands, as per opposite parties an amount was to the tune of Rs. 13,070/- and Rs.76,206/- respectively and whereas out of the said amount of Rs. 13,070/- an amount of Rs. 8,455/- was disallowed  amount as per terms and conditions being Rs.500/- as Admission Charges (not payable), Rs.1,000/- as Anesthesia (Linking applied), Rs.1,833 as Investigation-Lab Test (Linking applied), Rs.455/- as Pharmacy Charges (Charges of Gloves, Cap, Easyfix, Mask, Pas NP, Rs.2,000/- as Room Rent (Room Rent @ 1000 x1), Rs.2,667/- as Surgeon Charges (Linking Applied) and as such the grant amount was to the tune of Rs.4,685/- which was paid to the complainant on 16.11.2016.  Out of Rs.76,206/- an amount of Rs.52,519/- was disallowed amount as per terms and conditions being Rs.5,400/- as Admission Charges (not payable), Rs.5,040/- Anesthesia (Linking applied), Rs.4,704 as Consultant Charges (Linking applied), Rs.840/- as Investigation Lab Test (Linking Applied), Rs.1,800/- as Nursing Charges (Included in Room Rent), Rs.7,560/- as OT Charges (Linking Applied), Rs.375/- as Pharmacy Charges (Urobag, Gloves, Cotton are not payable), Rs.12,600/- as Procedure (Linking Applied), Rs.2,200/ as RMO Charges (Included in Room Rent), Rs.12,000/- as Room Rent (Room Rent @ 1000 x 3) and as such the grant amount was to the tune of Rs.23,687/- which was paid to the complainant on 28.3.2017 in lieu of settlement of claim of complainant as per the terms and conditions of the policy.  As per clause 1.2 of the policy terms and conditions the room rent is restricted to 1% of the sum assured. The opposite parties have made the payment of Rs. 4,685/- and Rs. 23,687/- to the complainant as per terms and conditions of the policy which is not denied by the complainant.

7        Both the parties are bound by the terms and conditions of the policy. The terms and conditions of the Insurance Policy have to be strictly construed. Hon’ble Supreme Court in the case of Export Credit Guarantee Corporation of India vs. Garg Sons International 2013 (1) SCALE 410 (SC) held in Para Nos.8 to 11 as under:

“8.  It is a settled legal proposition that while construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled, that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Therefore, the endeavour of the Court should always be to interpret the words used in the contract in the manner that will best express the intention of the parties. (Vide: M/s. Suraj Mal Ram Niwas Oil Mills (P) Ltd. v. United India Insurance Co. Ltd., (2010) 10 SCC 567). 

9.  The insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. The clauses of an insurance policy have to be read as they are consequently, the terms of the insurance policy, that fix the responsibility of the Insurance Company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonize the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide : Oriental Insurance Co. Ltd. v. Sony Cheriyan AIR 1999 SC 3252; Polymat India P. Ltd. v. National Insurance Co. Ltd., AIR 2005 SC 286; M/s. Sumitomo Heavy Industries Ltd. v. Oil & Natural Gas Company, AIR 2010 SC 3400; and Rashtriya Ispat Nigam Ltd. v. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829). 

10.   In Vikram Greentech (I) Ltd. & Anr. v. New India   Assurance Co. Ltd. AIR 2009 SC 2493, it was held:  “An insurance contract, is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in rewriting the contract or substituting the terms which were not intended by the parties. (See also: Sikka Papers Limited v. National Insurance Company Ltd & Ors. AIR 2009 SC 2834).” 

11.  Thus, it is not permissible for the court to substitute the terms of the contract itself, under the garb of construing terms incorporated in the agreement of insurance. No exceptions can be made on the ground of equity. The liberal attitude adopted by the court, by way of which it interferes in the terms of an insurance agreement, is not permitted. The same must certainly not be extended to the extent of substituting words that were never intended to form a part of the agreement.” 

8        While repudiating the claim of the complainant the opposite party has not committed any deficiency in service and unfair trade practice and the claim has been validly repudiated by the oppoise party.

9        In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.

Announced in Open Commission

12.10.2022