Chandigarh

StateCommission

A/191/2023

LIC OF INDIA - Complainant(s)

Versus

PAL SINGH - Opp.Party(s)

RAJNEESH MALHOTRA

30 Nov 2023

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Appeal No.	:	191 of 2023
Date of Institution	:	09.08.2023
Date of Decision	:	30.11.2023

 

 

 

 

 

 

LIC of India, Divisional Office, Jeevan Parkash Building, Sector 17-B, Chandigarh through its Sr. Divisional Manager.

…..Appellant/opposite party no.1.

Versus

1. Pal Singh, House No.503, GH-62, Sector 20, Panchkula, Haryana.

…Respondent/complainant.

2. The New India Assurance Company Limited having its Corporate Office at Mumbai, through its Regional Office in Chandigarh at SCO 36-37, Sector 17-A, Chandigarh through its Regional Manager.
3. MD India Health Insurance TPA Pvt. Ltd., having its Head Office at S.No.46/1, E-Space, A2 Building 3^rd Floor, Pune Nagar Road, Vadgaonsheri, Pune, Maharashtra – 411014.

...Respondents/opposite parties no.2 & 3.

ARGUED BY :-  

 

Ms. Mansi Verma, Advocate proxy for Sh. Rajneesh Malhotra, Advocate for the appellant.

Sh. Neeraj Gupta, Advocate for respondent No.1.

Sh. J.P. Nahar, Advocate alongwith Ms. Meenakshi Bali, Advocate for respondents No.2 & 3.

 

Appeal No.	:	213 of 2023
Date of Institution	:	01.09.2023
Date of Decision	:	30.11.2023

 

 

 

1. The New India Assurance Company Limited having its Corporate Office at Mumbai, through its Regional Office at SCO 36-37, Sector 17-A, Chandigarh through its Regional Manager.
2. MD India Health Insurance TPA Pvt. Ltd., having its Head Office at S.No.46/1, E-Space, A2 Building 3^rd Floor, Pune Nagar Road, Vadgaonsheri, Pune,– 411014.

…..Appellants/opposite parties no.2 & 3.

Versus

1. Pal Singh, House No.503, GH-62, Sector 20, Panchkula, Haryana.

…Respondent/complainant.

2. LIC of India, Divisional Office, Jeevan Parkash Building, Sector 17-B, Chandigarh through its Sr. Divisional Manager.

...Respondent/opposite party No.1.

 

BEFORE:   JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                MR. RAJESH K. ARYA, MEMBER

 

ARGUED BY :-  

 

Sh. J.P. Nahar, Advocate alongwith Ms. Meenakshi Bali, Advocate for the appellants.

Sh. Neeraj Gupta, Advocate for respondent No.1.

Ms. Mansi Verma, Advocate proxy for Sh. Rajneesh Malhotra, Advocate for respondent No.2.

 

PER  RAJESH  K. ARYA, MEMBER

 

                    Vide this common order we are deciding aforesaid two appeals i.e. appeal No.191 of 2023 filed by opposite party No.1 - Life Insurance Corporation of India and appeal No.213 of 2023 filed by opposite parties No.2 & 3 - The New India Assurance Company Limited & MD India Health Insurance TPA Pvt. Ltd. against order dated 13.06.2023 passed by District Consumer Disputes Redressal Commission-II, U.T., Chandigarh (in short ‘District Commission), vide which, consumer complaint No.683 of 2020 filed by the complainant – Sh. Pal Singh (respondent No.1 in both the appeals) has been partly allowed against the appellants by directing them to pay the balance claim amount to the complainant i.e. Rs.3,82,469/- (Rs.4,40,241- Rs.57,772), the medical expenses incurred by him on the treatment of his insured daughter (Ann.-A), along with interest @10% p.a. from the date of filing the complaint – 15.12.2020 till its realization besides awarding compensation amount of Rs.25,000/- for harassment and mental agony on account of deficient service along with litigation cost of Rs.15,000/-. The order has been directed to be complied with jointly & severally within a period of 45 days from the date of receipt of copy of order, failing which the appellants have been made liable to pay additional cost of Rs.20,000/-.

2]             Briefly stated the facts as narrated in the impugned order passed by the District Commission are that the complainant,  retired employee of opposite party No.1 as well as his family members were duly covered by Medical Claim Policy taken by opposite party No.1 from opposite party No.2 for the year 2019-2020 having coverage of sum assured of Rs.30 Lakhs. During the coverage period of the said policy, the daughter of the complainant namely Ms. Rajni Devi was detected with lung Cancer. She took treatment at different hospitals, medical institutes i.e. General Hospital, Sector 6, Panchkula, Fortis Hospital, Mohali, Denvax Cancer Cetre, Delhi etc. for the same and unfortunately died on 18.1.2020.  The medical expenditure incurred by complainant on the cancer treatment of her insured daughter was settled by the opposite parties only to the tune of Rs.57,772/- and denied the balance amount of Rs.3,96,932/- on the ground that she had undergone Stem Cell Transplantation Procedure, which was not payable under the policy. 

3]                In its reply, opposite party No.1 stated that the complainant submitted a bill of Rs.1,84,772/- on 11.10.2019 out of which Rs.57,775/- was settled and the unsettled/repudiated amount was Rs.1,27,000/-. A bill of Rs.2850/- was submitted, out of which, Rs.2500/- was settled by the insurer on 9.1.2020.  After repudiation on 13.11.2019, the case was again reconsidered and on 18.12.2019, it was finally repudiated by the TPA for the balance amount of Rs.1,27,000/- as this particular treatment was not covered under the policy and hence, repudiated which was valid and was as per policy terms & conditions. 

4]                In its reply, opposite party No.2 stated that the claim was filed for treatment taken for metastatic carcinoma of lungs during policy period and the complainant was informed that the remaining claim fell outside the scope & ambit of policy as Dendritic Cell Therapy being stem cell therapy was excluded in respect of cancer and there were sub-limit for different stem cells transplantation provided in the policy. As per terms & conditions of the policy, the stem cell therapy was excluded from the reimbursement except in certain type of cancer i.e. bone marrow, blood cancer, myeloma etc. The claim was rejected after examining every aspect of the controversy being fell in the exclusive clause. 

5]                Opposite party No.3 did not appear before the District Commission despite service of notice sent through regd. post, hence it was proceeded exparte vide order dated 17.11.2021.

6]                We have heard the counsel for the parties and have also gone through the impugned order, record and the written arguments filed by the appellant/opposite party No.1.

7]                In its appeal bearing No.191 of 2023, the appellant/opposite party No.1 – Life Insurance Corporation of India has stated that it had taken the insurance policy for its employees from opposite Party No.2 – New India Assurance Company and thus, the insurance claim, if any, was to be assessed by opposite party No.2 and its TPA. It has further been stated that there is no policy issued by it (opposite party No.1) under which any claim has been made. It has further been stated that respondent No.1/complainant had deposited the premium for his master policy to the appellant – LIC of India, which was remitted to opposite party No.2 – Insurance Company. It has further been stated that the District Commission has failed to take into consideration that under Section 64VB of the Insurance Act, no insurer shall assume any risk in India in respect of any insurance business unless and until the premium payable is received by him in advance or is guaranteed to be paid to the insurer in the manner prescribed by the rules framed under the Insurance Act. It has further been stated that LIC of India, being a Master Policy holder, is only an intermediary between the insured employee and the Insurance provider and as such, had no role in repudiation of mediclaim of respondent No.1/complainant.

8]                In appeal bearing No.213 of 2023 filed by appellants/ opposite parties No.2 & 3 - The New India Assurance Company Limited & MD India Health Insurance TPA Pvt. Ltd., there is a delay of 10 days in filing the said appeal, for condonation whereof, a miscellaneous application bearing No.671/2023  is also pending for disposal. The said application has not been opposed or contested. Further, the said application is duly supported by an affidavit. For the reasons given in the application, the delay in filing appeal No.213 of 2023 stands condoned. Accordingly, MA/671/2023 stands disposed of. Now taking up the said appeal for disposal on merits, the appellants/opposite parties No.2 & 3, while assailing the order of the District Commission, have submitted that the claim for lung cancer was paid as per the terms of the policy but the remaining claim fell outside the scope of the insurance policy. It has further been stated that the District Commission has lost sight of the fact that the Exclusion Clause F(xv)(b) provides for Stem Cell therapy for certain type of diseases, fixing the percentage of admissible claim and does not totally exclude Stem Cell therapy. It has further been stated that the exclusion clause has not destroyed the contract. The appellants have placed reliance on the judgments of Hon’ble Supreme Court of India in cases Vikram Greentech v. New India Assurance Co. Ltd., II (2009) CPJ 34 (SC) and United Insurance Co. Ltd. vs. Harchand Rai Chandan Lal, AIR 2004 SC 4974. It has further been stated that the judgment relied upon by the District Commission in case M/s Texco Marketing Pvt. Ltd. Vs. TATA AIG General Insurance Company Ltd. & Ors., Civil Appeal  No.8249 of 2022 [arising out of SLP (Civil) No.25457 of 2019], decided on 09.11.2022 is distinguishable on facts as the said case relates to a claim under Standard Fire & Special Perils policy. Lastly prayer for setting aside of impugned order has been made. 

9]                First coming to appeal bearing No.191 of 2023 filed by appellant/opposite party No.1 – Life Insurance Corporation of India, it may be stated here that the premium paid by respondent No.1/complainant to LIC of India, for the master policy, was further remitted to the Insurance Company with whom respondent No.1/complainant and his family members were insured. The Corporation being only a commercial undertaking and as in pursuance thereof, it had merely extended the facility of collection of premium payable by the employees through the employer, the same would not make it liable to pay the assured sum in terms of the policy. The employer acted only as the agent of the employees and not that of the Corporation for any purpose and in that view of the matter, the Corporation would not be liable to pay the assured amount. Had there been any default on the part of the LIC of India in remitting either the premium or the claim papers to the Insurance Company, then the matter would have been different and in that eventuality, both could be jointly and severally held liable. Though in the relief clause, respondent No.1/complainant had prayed for relief against all the opposite parties but not even a single averment or allegation qua deficiency in rendering service or unfair trade practice has been leveled by respondent No.1/complainant in the complaint against LIC of India. The claim was to be settled by the Insurance Company (opposite parties No.2 & 3), who settled it partially. The District Commission, in our concerted view, while passing the impugned order has failed to take note of this aspect of the case. Thus, the appeal filed by appellant/opposite party No.1 – Life Insurance Corporation of India is liable to be accepted and the impugned order is liable to be set aside qua it.

10]              Now coming to appeal bearing No.213 of 2023 filed by the appellants/opposite parties No.2 & 3 - The New India Assurance Company Limited & MD India Health Insurance TPA Pvt. Ltd., we do not find any force in the contention raised that the remaining claim fell outside the scope of the insurance policy and the exclusion clause provides for Stem Cell therapy for certain type of diseases, fixing the percentage of admissible claim and does not totally exclude Stem Cell therapy. The District Commission has rightly held that any clause in the policy either exclusion or otherwise, cannot be read or introduced to the disadvantage of the policy holder and the insurance companies, as in the present case, could not deny the claim on technical ground. As regards the contention that judgment relied upon by the District Commission in case M/s Texco Marketing Pvt. Ltd. (supra) is distinguishable on facts as the said case relates to a claim under Standard Fire & Special Perils policy, it may be stated here that the District Commission while deciding the consumer complaint has only cited the law laid down by Hon’ble Apex Court in the said case wherein it was held that “An exclusion clause has to be understood on the touch-stone of the doctrine of reading down in the light of the underlining object and intendment of the contract. It can never be understood to mean to be in conflict with the main purpose for which the contract is entered. A party, who relies upon it, shall not be the one who committed an act of fraud, coercion or mis-representation, particularly when the contract along with the exclusion clause is introduced by it. Such a clause has to be understood on the prism of the main contract. The main contract once signed would eclipse the offending exclusion clause when it would otherwise be impossible to execute it. A clause or a term is a limb, which has got no existence outside, as such, it exists and vanishes along with the contract, having no independent life of its own. It has got no ability to destroy its own creator, i.e. the main contract. When it is destructive to the main contract, right at its inception, it has to be severed, being a conscious exclusion, though brought either inadvertently or consciously by the party who introduced it.” As regards judgments relied upon by appellants/opposite parties No.2 & 3 in cases Vikram Greentech v. New India Assurance Co. Ltd. (supra) and United Insurance Co. Ltd. vs. Harchand Rai Chandan Lal (supra) to contend that the insured cannot claim anything more than what is concerned by the insurance policy, it may be stated here that respondent No.1/complainant is not claiming anything in excess. The claim filed was with regard to cancer treatment and stem cell therapy/transplantation so taken and provided to the daughter of the complainant, who finally did not survive. The claim could not be considered in piecemeal. The appellants/opposite parties No.2 & 3 settled the claim partially only. In our concerted view, the impugned order passed by District Commission is well based, legal and valid in the eyes of law and as such, this Commission finds no reason to interfere in the same so far as the liability of the appellants/opposite parties No.2 & 3 is concerned. Thus, the appeal filed by the appellants/opposite parties No.2 & 3 is liable to be dismissed and the impugned order is liable to be upheld qua them.

11]              For the reasons recorded above, the appeal bearing No.191 of 2023 filed by LIC of India is accepted and the impugned order is set aside qua the appellant/opposite party No.1 – LIC of India. However, the appeal bearing No.213 of 2023 filed by the appellants/opposite parties No.2 & 3 - The New India Assurance Company Limited & MD India Health Insurance TPA Pvt. Ltd. is dismissed being devoid of any merit with no orders as to costs.

12]              Pending miscellaneous application(s), if any, also stands disposed of having been rendered infructous. 

13]              Certified copy of this order be placed in the file of appeal No.213 of 2023.

14]              Certified copy of this order be sent to the parties free of charge.

15]              Files be consigned to the Record Room after completion.

Pronounced.

30.11.2023.

(RAJ SHEKHAR ATTRI)

PRESIDENT

 

 

 

 

 

(RAJESH K. ARYA)

MEMBER

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