Chandigarh

StateCommission

A/197/2024

NATIONAL INSURANCE COMPANY LTD. - Complainant(s)

Versus

SHASHI GUPTA - Opp.Party(s)

ARJUN KUNDRA

23 Oct 2024

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T. CHANDIGARH

[Additional Bench]

 

Appeal No.	:	A/197/2024
Date  of  Institution	:	17/05/2024
Date   of   Decision	:	23/10/2024

 

 

 

 

 

1.     National Insurance Company Limited, through its Regional Manager, SCO 332-334, Sector 34-A, Chandigarh.

 

2.     The Regional Manager, National Insurance Company Limited, SCO 332-334, Sector 34-A, Chandigarh.

 

        Appellants now through its Authorized Signatory/ POA Holder Mrs. Sunita Verma, Assistant Manager, R.O., The National Insurance Co. Ltd., SCO 332-334, Sector 34-A, Chandigarh.

 

….Appellants/Opposite Parties

 

Versus

 

Shashi Gupta wife of Late Sh. Vijay Gupta, Resident of House No. 5792-B, Sector 38 West, Chandigarh.

 

…. Respondent/Complainant

 

BEFORE: MRS. PADMA PANDEY   PRESIDING MEMBER

                PREETINDER SINGH     MEMBER

 

PRESENT	:	Sh. Arjun Kundra, Advocate for the Appellants.
		Sh. Varun Bhardwaj, Advocate for the Respondent.

 

PER PADMA PANDEY, PRESIDING MEMBER

 

1.         The present appeal has been filed by the Appellants impugning the order dated 03.04.2024 vide which the Learned District Consumer Disputes Redressal Commission-I, U.T. Chandigarh (for brevity hereinafter to be referred as “the Ld. District Commission”), allowed the Consumer Complaint bearing no.CC/23/2023, in the following terms:-

“4.    In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under:-

 

(i)       to pay ₹3,65,166/- to the complainant alongwith interest @ 9% per annum from the date of claim settlement voucher i.e. 1.11.2022 onwards.

 

(ii)      to pay ₹40,000/- to the complainant as compensation for causing mental agony and harassment;

 

(iii)     to pay ₹10,000/- to the complainant as costs of litigation.

 

5.      This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.

 

 

2.         For the convenience, the parties are being referred to, in the present cases, as position held in Consumer Complaint before the Ld. District Commission.

 

3.         Before the Ld. District Commission, it was the case of the Complainant that for the first time in the year 2009, she purchased a Mediclaim Policy for herself from Opposite Party No.1 on payment of requisite premium and got the same renewed from time to time without any break and the last policy was issued in her favour which was valid w.e.f. 30.11.2021 to 29.11.2022 on payment of premium of ₹52,990/- with sum assured of ₹7.00 lacs.  In the month of September 2022, the complainant suffered from breathlessness and difficulty in breathing during sleep, as a result of which she visited the Kular Hospital, Ludhiana on 10.09.2022 for her medical check-up, where she was diagnosed to be suffering from Morbid Obesity with a BMI of 42.57 Kg/M2 with co-morbidities, breathlessness on exertion, Severe Obstructive Sleep Apnea etc. The Complainant was advised to get herself admitted for Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery). At that time the doctor informed that the cost of package for surgery would be ₹4,15,000/-. Accordingly, on the advice of doctor, Complainant got herself admitted in the Treating Hospital and underwent Laparoscopic Cholecystectomy (Gall Bladder Removal) with Laparoscopic Gastric Bypass (Bariatric Surgery - Weight Loss Surgery) on 11.09.2022 and she was kept under observation.  As per direction of the doctor, the Complainant deposited an amount of ₹4,15,000/- on 12.09.2022 and was discharged from the hospital on 15.09.2022.  Thereafter, the complainant lodged claim with the Opposite Parties for reimbursement of total amount spent by her to the tune of ₹4,17,166/- on 26.09.2022 supported with all the documents.  However, complainant was shocked to receive a sum of ₹52,000/- only against the claim amount of ₹4,17,166/- regarding which Claim Settlement Voucher was also issued.  OPs also informed the complainant that they have only paid amount for Laparoscopic Cholecystectomy (Gall Bladder Removal) that too after deduction of ₹43,000/- against claimed amount of ₹95,000/- and have not paid claim for other surgery and hospitalisation charges since four years waiting period has not lapsed. Hence, the aforesaid Consumer Complaint was filed before the Ld. District Commission, alleging deficiency in service and unfair trade practice on the part of the Opposite Party.

 

4.         The Opposite Parties contested the claim of the Complainant by filing reply inter alia, admitting the basic facts of the case that the subject policy was issued to the complainant and she had submitted total claim of ₹4,17,104/- out of which an amount of ₹52,000/- was paid to her and the remaining amount of ₹3,65,166/- was deducted on the ground that the obesity related treatment was not payable as there was waiting period of four years for Morbid Obesity under the Insurance Policy, which was revised w.e.f. October 2020. Denying all other allegations and pleading no deficiency in service, the Opposite Parties prayed for dismissal of the Complaint.

 

5.         On appraisal of the pleadings of the parties and the evidence adduced on the record, Ld. District Commission partly allowed the Complaint and issued directions to the Opposite Parties as noticed in the opening para of this order.

  

6.         Aggrieved against the aforesaid order passed by the Ld. District Commission, the instant Appeal has been filed by the Appellants/Opposite Parties.

 

7.         We have heard Learned Counsel for the parties and have gone through the evidence and record of the case with utmost care and circumspection.

 

8.         The core question that falls for consideration before us is as to whether the Ld. District Commission has rightly passed the impugned order by appreciating the entire material placed before it. 

 

9.         Having bestowed our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer to the question posed has to be in negative.

 

10.         It is the case of the Appellants/Opposite Parties that the Ld. District Commission while passing the impugned order has failed to appreciate the documentary evidence available on record, which resulted into perverse finding. Also, the impugned order was passed without taking into consideration the facts of the case and without appreciating the correct legal position, which resulted into gross miscarriage of justice and thus deserves to be set aside. The learned counsel further argued on the similar lines and prayed for acceptance of the present appeal.

 

11.         Conversely, it has been contended on behalf of the Respondent/Complainant that the order passed by the Ld. District Commission is quite just & right and does not call for any interference. The detailed finding of facts has already been recorded by the District Commission while rejecting the stand of the Appellants/Opposite Parties. The learned counsel further argued on the similar lines as stated in the complaint filed before the Ld. District Commission and prayed for dismissal of the present appeal. 

 

12.         The main thread which runs through the present controversy is whether the morbid obesity treatment of the Respondent/Complainant taken during the waiting period of four years under the revised policy w.e.f. October 2020, was covered/payable under the Mediclaim Policy, especially when prior to the revision said treatment was not covered under the subject policy.

 

13.         Perusal of the guidelines on standardization of exclusions in health insurance contracts dated 27.09.2019 (Annexure A-1), issued by the Insurance Regulatory & Development Authority of India, the health insurance policies were revised with effect from 01.07.2020 and in furtherance thereto, the old polices were withdrawn by the Appellants/Opposite Parties vide circular dated 23.06.2020 (Annexure A-2). It was only after the launch of new policies that the treatment of obesity/morbid obesity was covered and added for the first time, but subject to a waiting period of four years from the date of its inclusion.

 

14.         It is thus borne on record that the Opposite Parties have for the first time added morbid obesity treatment revised policy terms & conditions with effect from October 2020 and that the previously issued policies specifically excluded treatment of morbid obesity.  In this way, the treatment of morbid obesity was only covered after serving four years of waiting period. The Respondent/ Complainant was serving four years waiting period with effect from Oct. 2020.  To our mind, the Ld. District Commission gave an erroneous finding in Para 3(viii) while holding that if there is any revision of the terms & conditions of the subject policy that is one sided and has no binding effect upon the rights of the Complainant, in asmuch as, it failed to consider that the contracts and revised terms & conditions were strictly applicable prospectively and not retrospectively. The waiting period applicable to the revised policy terms & conditions for obesity related treatment (added for the very first time) was effective from the first revised policy and cannot go back to the old policy year as sought by the Respondent/Complainant. The insured – Respondent/ Complainant cannot remotely claim and seek the waiting period from ante date when the coverage itself was not there and the ailment was specifically excluded and even not covered at all. At any rate, the insured cannot claim anything more than what is covered by the insurance policy.

 

15.         It is a settled law that in 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. 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 to determine the extent of liability of the insurer.  Thus, in our concerted opinion, when the subject policy was running in its second year (2021-22), the claim for morbid obesity was rightly disallowed by the Opposite Parties as per terms & conditions of the insurance policy.  The impugned order passed by the Ld. District Commission is therefore based on wrong appreciation of evidence and law on the point and thus suffers from illegality or perversity. 

 

16.         No other point, was urged, by the Counsel for the Appellants.

 

17.         In the wake of the position, as sketched out above, the present appeal is allowed and the impugned order passed by the Ld. District Commission is set aside. Consequently, the Consumer Complaint is dismissed. No order as to costs.

 

18.         The pending application(s), if any, also stands disposed of accordingly.

 

19.         Certified Copies of this order, be sent to the parties, free of charge.  

 

20.         The files be consigned to the Record Room, after due completion.

Pronounced

23^rd October, 2024                                                                     

                                         Sd/-                         

                                                                (PADMA PANDEY)

PRESIDING MEMBER

 

Sd/-

(PREETINDER SINGH)

MEMBER

“Dutt”