Delhi

StateCommission

FA/12/1144

UNITED INDIA INSU. CO.LTD. - Complainant(s)

Versus

R.P. SINGH - Opp.Party(s)

26 Aug 2015

ORDER

IN THE STATE COMMISSION

(Constituted under section 9 of the Consumer Protection Act, 1986)

 

Date of Decision: 26.08.2015

 

First Appeal-1144/2012

 

(Arising out of the order dated 27.08.2012 passed by the Consumer Disputes Redressal Forum, M-Block, Vikas Bhawan, New Delhi in complaint case no. 495/2010)

 

United India Insurance Co. Ltd.

Kanchenjunga Building

8^th Floor, 18 Barakhamba Road,

New Delhi-110001                                                            …..Appellant

                                     

Versus

 

Col. R.P. Singh (Retd.)

R/o House No. G-46

Masjid Moth

Greater Kailash-II

Delhi-110048                    

                                                                        ....Respondent

 

CORAM

Justice Veena Birbal, President

Salma Noor – Member

1.  Whether reporters of the local newspaper be allowed to see the judgment?

2.  To be referred to the reporter or not?

 

Salma Noor, Member

 

1.             By this appeal challenge has been made to order dated 27.08.2012 passed by the Consumer Disputes Redressal Forum, M-Block, Vikas Bhawan, New Delhi in complaint case no. 495/2010.

2.             Brief facts of the case are that the complainant took “individual mediclaim policy” with the OP United India Insurance Co. Ltd. i.e. appellant herein vide insurance policy no. 040603/48/20/00000976 (from 00:00 hrs of 02.11.2008to midnight of 01.11.2009). The complainant/insured was admitted in Escorts Heart Institute & Research Centre, Okhla, New Delhi on 17.09.2009 and was discharged on 19.09.2009 with medical advice. Thereafter, the complainant filed a claim of Rs. 66,962/- to the TPA and the insurance company reimbursed Rs. 36,450/-. Thereafter, the complainant submitted another claim of Rs. 1,30,560/- of which Rs. 97,448/- was the costs of the CPAP machine was rejected by the OP i.e. appellant herein. Aggrieved by the repudiation of his claim the complainant filed a complaint before the District Forum with the following reliefs:

         “That the total expenditure incurred by the complainant on his treatment is as follows:

        A.     Bill at the time of discharge

                paid by the complainant after

                deducting the money paid by the TPA             Rs. 30,512/-

                (Total Bill= Rs. 66,962/-,

                less paid by TPA Rs. 36,450)

        B.     CPAC Machine purchased from D. Morgan               Rs. 97,448/-

        C.     Subsequent Consultation charges                   Rs. 1,100/-

        D.     Subsequent Tests                                                Rs. 1,500/-_

                                                                                Rs. 1,30,560/-

                                                                               

3.             The insurance company contested the claim and filed its written version reiterating that the case of the complainant does not fall within the terms and conditions of the policy issued by the insurance company. After considering the written version and evidence filed by both the parties the District Forum allowed the complaint of the complainant and passed the following orders:

        “We hold it guilty of deficiency and direct OP-I to pay Rs. 97,448/- cost of CPAP machine and other subsequent medical consultation and test charges of Rs. 2500/- claimed in the complaint and balance treatment cost of Rs. 30,512/- (after adjusting cashe already availed out of total bill of Rs. 66,962/-). Thus, OP-I is directed to pay Rs. 1,30,560/- with interest @ 9% from date of claim with OP-I till payment, and harassment damages of Rs. 25,000/- to complainant against her mediclaim policy No. 040603/48/08/20/000009 Exh.CW1/1”.

4.             Aggrieved by the aforesaid order of the Ld. District Forum the insurance company i.e. appellant herein filed the present appeal.

5.             We have heard, Ms. Jyoti Divya, Counsel for the appellant and Sh. Ravi Bhushan, counsel for the respondent and perused the material on record.

6.             The case of the appellant is that Rs. 30,512/- was not admissible in the first claim because these expenses were either in respect of costs of sleep study and diagnostic purpose which are not admissible under condition no. 4.10 of the policy. It is also submitted that the complainant has not filed any supporting documents to establish his claim therefore the claim was rejected. Further, the appellant has taken the plea that CPAP machine is an external device and costs of CPAP machine is therefore not payable under the exclusion clause 4.6 of the policy. It is contended that the CPAP machine is not like spectacles, contact lenses and hearing aids. It is comparable with pace maker which pumps necessary oxygen and controls the respiratory system. So far as, reimbursement is concerned this Commission earlier in so many cases has taken a view that CPAP machine is covered for reimbursement for the medical expenses incurred on it. In this regard clause 3.2 and 1 of the policy are relevant and as under:

        3.2. Post hospitalization Relevant medical expenses incurred during period upto 60 days after Hospitalization on disease/illness/injury sustained will be considered as part of claim as mentioned under item 1.0.

Clause 1.00 In the event of any claim/s becoming admissible under this Scheme, the Company will pay to the insured person the amount of such expenses as would fall under different heads mentioned below and as are reasonably and necessarily incurred thereof by or on behalf of such insured person, but not exceeding the sum insured in aggregate mentioned I the scheduled herein:

        A)     Room, boarding expenses as provided by the Hospital/Nursing Home.

        B)     Nursing Expenses

        C)     Sergeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees.

        D)     Anaesthesia, Blood, Oxygen, Operation Theater charges, Surgical appliances, Medicines and Drugs, Diagnostic, Maternal and X-ray.

E)     Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of organs and similar expenses”.

7.             As is apparent from this clause even those equipments are reimbursable which are essential for treatment of the disease and necessary for saving life, for instance pace maker and artificial limbs. So far as CPAP machine is concerned, any patient having the disease cannot survive long if such system is not used. Rather he or she can die any moment if such a device is not used. This system has to be used and is therefore part of the treatment of the disease and if patient does not use this device he or she puts himself or herself at risk of death or repeated problem of cardiac failure.

8.             It is further alleged by the appellant that the case of the respondent/complainant is also barred under the exclusion clause of 4.10 of the policy. The appellant has wrongly interpreted the exclusion clause 4.10 which reads as follows

“Charges incurred at hospital or Nursing Home primarily for diagnosis x-ray, Laboratory examinations or other diagnostic studies not consistent or incidental to the diagnosis and treatment of positive existence of presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.”

9.             In the present case the Lab expenses are incidental to the Sleep Disorder of the respondent/complainant and the same ought to have been honored by the appellant. The appellant has failed to understand the genesis of the ailment of the respondent/complainant of these tests and diagnoses were required for the treatment and was done. It is not the case of the appellant that the tests were not required at all. In our meaningful interpretation of the clause and keeping in view the nature of the disease and the cure and the remedy for the same. The disease and the treatment of hospitalization should have nexus with each other. It is universal rule that the contract has to be read as a whole and not in isolation and every clause of the contract should be provided meaning inconsonance with the aim and object of the contract.

10.            As discussed above applying this rule we do not find any ground for exclusion of the CPAP machine prescribed by the doctor. CPAP machine, even though not a cure for the disease being incurable, was essential to the extent that without it the life of the insured would always be at risk. The disease in question is such that it kills a person in sleep. Therefore, the CPAP machine is considered to be an essential part of the  treatment of the disease.

11.            In view of the above discussion, we maintain the order relating to the reimbursement of the amount of Rs. 1,30,460/- along with interest @ 9% from the date of claim but would like to reduce the amount of compensation of Rs. 25,000/- which appears to be an excessive side to Rs. 5000/-.

                Appeal is partly allowed and disposed of in aforesaid terms.

                A copy of this order as per statutory requirement be sent to the parties free of costs as per rules.

                FDR, if any, deposited by the appellant be released in its favour as per rules.

 

                File be consigned to record room.

                          

(Justice Veena Birbal)

President

 

 

(Salma Noor)

Member

 

 

 

Rakeeba