Haryana

Ambala

CC/178/2020

Mandeep Singh - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Gurvinder Singh

08 Jul 2022

ORDER

 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                                      Complaint case no.         :     178 of 2020

                                                          Date of Institution           :      26.08.2020

                                                          Date of decision     :     08.07.2022.   

Sh. Mandeep Singh H.No.10, Friends Colony, Near Jagadhari Gate Behind Allahabad Bank, Ambala City.

                                                                             ……. Complainant.

                                                Versus

1. Oriental Insurance Company, SCO 325, IInd Floor, Sector 9, Panchkula.
2. Raksha Health Insurance TPA Ltd., 14/3, Mathura Road, Sector 27-A, Faridabad.
3. M/s Raksha Health Insurance, TPA Pvt. Ltd., SCO 39, 1^st Floor, Madhya Marg, Sector 26, Above Barbecue Pin 160019 Chandigarh
4. The Bank Manager, Oriental Bank of Commerce, Prem Nagar, Ambala City.

                                                                    ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.

 

Present:         Shri Gurvinder Singh, Advocate, counsel for the complainant.

                       Mrs. Upma Bhalla, Advocate, counsel for the OPs No.1 to 3.

                       Shri Rahul Vig, Advocate, counsel for the OP No.4.

 

Order:        Smt. Neena Sandhu, President.

1.                Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

A) To settle the MEDI CLAIM of the complainant i.e. Rs.34,000/-.

B) To pay Rs. 20,000/- as compensation and damages for causing harassment, inconveniences, anxiety to the complainant due to illegal and malafides act of opposite parties.

C) To pay Rs.20,000/- as cost of litigation due to forcibly thrusting litigation on complainant.

D) Any other relief to which complainant may be found entitled to in the facts and circumstances of the case. 

2.             Brief facts of the case are that the complainant is having Saving Account No.12032011001047, with the OP No.4 and purchased Policy No 231202/48/2020/1348, from OP No.1, through it. At the time of taking the policy, it was assured by OP No.1 that claims would be settled by OPs No.2 and 3. Complainant had undergone OZURDEX IMPLANT PROCEDURE from Bansal Hospital. However, when claim was submitted with the OPs, it was repudiated by them on the ground that  OZURDEX IMPLANT PROCEDURE was not covered in DAY CARE. When despite making various efforts, the grievance of the complainant was not redressed, he served Legal Notice dated 29.05.2020, Annexure C-3, upon the insurance company but to no avail. By not reimbursing the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.
3.                     Upon notice, OPs No.1 to 3 appeared and filed written version, raised preliminary objections with regard maintainability, jurisdiction and cause of action etc. On merits, it is stated that while admitting factual matrix of the case with regard to the fact that the complainant purchased Policy No 231202/48/2020/1348 from OP No.1 and that he underwent treatment of OZURDEX IMPLANT PROCEDURE from Bansal Hospital, it is stated that the policy in question was issued subject to certain terms and conditions and exclusions. The policy issued to the complainant covers the reasonable and customary charges with respect to Hospitalization only and the Hospitalization as per clause means admission in a Hospital for a minimum period of 24 hours in patient care consecutive hours except for specified procedures/ treatments where such admission could be for a period of less than 24 consecutive hours. Under clause 2 D of the policy relaxation to minimum 24 hours duration of hospitalization is allowed only in Specified Day care procedure/ surgeries (as per Appendix I). In the present case, the hospitalization of the complainant was less than 24 hours i.e. from 12 p.m to 5 p.m as stated in the Discharge Summary and the complainant took the Treatment i.e Ozuredex Implant Procedure" which is not covered under the admissible list of day care Procedures as listed in the Terms and conditions of the policy. Thus, after reviewing the documents and terms and conditions of the policy, the claim of the complainant was rightly rejected by the insurance company.  Rest of the averments of the complainant were denied by the answering OPs No.1 to 3 and prayed for dismissal of the present complaint with heavy and exemplary costs.
4.           Upon notice, OP No.4 appeared and filed written version, raised preliminary objections with regard to maintainable, bad for mis-joinder of unnecessary party and locus standi etc.  On merits, it is stated that its’ role was only as a facilitator and the insurance policy in question was issued by OPs No.1 to 3 and there is no privity of contract between the complainant and the answering OP. Rest of the averments of the complainant were denied by the answering OP No.4 and prayed for dismissal of the present complaint with special costs.
5.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-7 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs No.1 to 3 tendered affidavit of Shri Ashish Bhatnagar, Divisional Manager, Oriental Insurance Company Limited, Ambala Cantt as Annexure OP1/A and affidavit of Dr. Amandeep Singh, Raksha Health Insurance Company Limited, Chandigarh as Annexure OP-3/A alongwith documents Annexure Op1/1 to OP1/3 and closed the evidence on behalf of OPs No.1 to 3. Learned counsel for the OP No.4 tendered affidavit of Shri Vikas Malhotra, Branch Manager, Oriental Bank of Commerce, Now Punjab National Bank, Prem Nagar Branch, Ambala City as Annexure OP4/A and closed the evidence on behalf of OP No.4.
6.           We have heard the learned counsel for the parties and carefully gone through the case file.
7.           Learned counsel for the complainant submitted that since the complainant has taken medical cover under the policy in question therefore he was entitled to get the amount, which was spent by him on his treatment, yet, his genuine claim has been repudiated by OPs No.1 to 3 which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
8.           On the contrary, the learned counsel for the OPs No.1 to 3 submitted that because the Hospitalization of the complainant was less than 24 hours i.e. on 08.05.2020 from 12 p.m to 5 p.m as stated in the Discharge Summary, Annexure C-5 and at the same time, complainant took the Treatment i.e Ozuredex Implant Procedure" which is not covered under the admissible list of day care Procedures as listed in the Terms and conditions of the policy, Annexure OP1/1. The claim of the complainant was rightly repudiated by the insurance company, strictly as per terms and conditions of the insurance policy.
9.           Under these circumstances, the short question which falls for consideration is, as to whether, the claim of the complainant was rightly rejected the insurance company or not. In Clause 3.18 of the insurance policy, under the heading Hospitalization it has been specifically stated that “….Hospitalization means admission in a Hospital for a minimum period of twenty four (24) in-patient care consecutive hours except for specified procedures/treatments, where such admission could be  for a period of less than 24 consecutive hours….”.  Clause 2 D of the said insurance policy further provides that “….Relaxation to 24 hours minimum duration of hospitalization is allowed in specified Day Care procedures/Surgeries (as per appendix-I) where such treatment is taken by an Insured Persons in a Hospital/Day Care Centre (but not the Out-Patient department of a hospital) Or any other Day Care Treatment as mentioned in clause 3.14 for which prior approval from Company/TPA is obtained in writing….”.
10.           As per Clause-D of appendix-I, following treatment was covered for “Operation on the eyes”:-

• Incision of tear glands
• Incision of diseased eyelids
• Excision and destruction of diseased tissue of the eyelid
• Operations on the canthus and epicanthusv
• Corrective surgery for entropion and ectropion
• Corrective surgery for blepharoptosis
• Removal of a foreign body from the conjunctiva
• Removal of a foreign body from the cornea
• Incision of the cornea
• Operations for pterygium
• Removal of a foreign body from the lens of the eye
• Removal of a foreign body from the posterior chamber of the eye
• Removal of a foreign body from the orbit and eyeball
• Operation of cataract

 

11.           Admittedly, the complainant took treatment of OZURDEX IMPLANT DEXMETHASONE UNDER LA from Bansal Hospital, for which he was admitted in the said Hospital on 08.05.2020 at 12.00 P.M. and discharged on 08.05.2020 at 5.00 P.M. Thus, it is evident from the discharge summary that the complainant remained admitted in the said Hospital for less than 24 hours and does not satisfy the definition of “Hospitalization” under the policy in question. Hence, the nature of treatment given fell outside the scope of policy.
12.           Apart from above, even the treatment of OZURDEX IMPLANT DEXMETHASONE UNDER LA taken by the complainant from Bansal Hospital from 08.05.2020 at 12.00 P.M. and discharged on 08.05.2020 at 5.00 P.M. also did not find any place in the Appendix-1 of Clause 2 D extracted above. In our considered opinion, the insurance policy between the insurer and the insured represents a contract between the parties and the insured cannot claim  anything more than what is covered by the insurance policy. The Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) has held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”.
13.           Under similar circumstances, in Life Insurance Corporation of India & 2 Ors. Vs. Ramphal, Revision Petition No. 1479 of 2016, decided on 04 Oct 2016, the Hon’ble National Commission has held that since the treatment was undertaken by the complainant without hospitalization for 24 hours or more, he is not entitled to any reimbursement of claim. Relevant part of the said order is reproduced hereunder:-

“……5.      It would thus be seen that the benefit under the policy taken by the complainant was payable only in case of hospitalization exceeding a continuous period of 24 hours.  Admittedly, the complainant was not hospitalized in PGIMS, Rohtak for 24 hours or more.  Therefore, the expenditure incurred by him in taking treatment in the aforesaid hospital is not re-imbursable to him, under the policy taken by him. 

6.      It is contended by the learned counsel for the complainant/respondent that the terms and conditions attached to the insurance policy were not supplied to the complainant and therefore, he cannot be said to be bound by the said terms and conditions.  On a perusal of the insurance policy issued to the complainant/respondent, I find that the said policy was subject to the conditions and privileges attached thereto.  Therefore, in ordinary course, the terms and conditions forming part of the policy would be attached when the policy is issued to the policy holder.  More importantly, there is no allegation in the complaint that the terms and conditions attached to the insurance policy taken by the complainant were not provided to him.  There is a specific reference to policy number as well as the date of the policy in para 3 of the complainant, but there is no averment that the terms and conditions attached to the policy were not supplied to the complainant.  In case the said terms and conditions were not supplied to him as is submitted by his counsel, the complainant ought to have pleaded so in the complaint filed before the District Forum.  This is more so considering the fact that the reimbursement claimed by him was declined by the petitioner corporation on the ground that he had not been hospitalized and the policy did not cover the OPD treatment.  I am therefore, satisfied that the terms and conditions attached to the policy having been duly provided to the complainant, he was bound by the said terms and conditions.  Since the treatment was undertaken by him without hospitalization for 24 hours or more, he is not entitled to any reimbursement from the petitioner corporation.  The impugned orders are therefore, set aside and the complaint is hereby dismissed with no order as to costs.…”

14.           Since in the present case also, the complainant remained admitted in the Hospital for less than 24 hours and does not satisfy the definition of “Hospitalization” and also his treatment did not fall under Appendix-1 of  Clause 2 D, under the policy in question, as such, his claim was rightly repudiated by the insurance company, as the same was not admissible as per the terms of the policy in question.
15.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to costs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 08.07.2022.

 

          (Vinod Kumar Sharma)  (Ruby Sharma)               (Neena Sandhu)

              Member                         Member                       President