IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, ALAPPUZHA
Friday the 30thday of April, 2022
Filed on 25.08.2021
Present
1. Sri.S.SanthoshKumar BSc.,LL.B (President )
2.Smt.P.RSholy, B.A., LLB (Member)
In
CC/No.172/21
between
Complainant:- Opposite party:-
Sri. Jacob Abraham The Branch Manager
Vadakkeparambil National Insurance Co. Ltd
Veliyanadu P.O. Branch Office, Parakadavil Complex
Kuttanad, Alappuzha- 689 590 P.B. No. 70, Opp. No.1 PVT, Bus Stand
Ph: 9446920415 Palace Road, Changanassery
(Adv. K. George) Kottayam- 686 101
O R D E R
SRI. S.SANTHOSH KUMAR (PRESIDENT)
Complaint filed under Sec.35 of the Consumer Protection Act, 2019.
Material averments briefly discussed are as follows: -
1. Complainant had taken National medical policy 2013 issued by the opposite party M/s National Insurance co. Ltd. for a period of one year from 31.3.2020 to 30.3.21. On 05.03.21 Abraham Jacob who is the son of the complainant sustained a dog bite and was admitted at St. Johns medical college hospital, Bangalore and he was treated from 05.01.2021 to 02.02.2021. Since there was Covid 19 spread, over Bangalore the patient was not admitted in the hospital and advised to take rest at home. Complainant is entitled for the coverage of the medical insurance scheme.
2. Complainant lodged a claim with the opposite party along with relevant documents. The opposite party rejected complainant’s claim without any valid reason. An amount of Rs.29,728/- was spent for medical expenses. The action of the opposite party in not settling the claim is arbitrary, illegal and amounts to deficiency in service. Hence the complaint is filed for realizing an amount of Rs.29,728/- being the medical expenses and Rs.50,000/- as compensation for mental agony and loss of valuable time.
Opposite party filed a version mainly contenting as follows:-
3. There is absolutely no deficiency in service on the part of this opposite party. The claim of the complainant was duly entertained and found that the claim is not payable as per policy condition and the same was intimated. Opposite party issued a National mediclaim policy to Abraham Jacob for a period from 31.03.2020 to 30.03.2021 covering the above person, his wife and his son. Complainant submitted claim on 06.02.2021 for the expenses incurred for the dog bite for his son Abraham Jacob. On perusal of the records it was noticed that the son underwent OP treatment alone and no hospitalization. As per policy hospitalization at least for 24 hours is mandatory for entertaining the claim and as per exclusion clause 3.21 the outpatient treatment is not covered. Hence the claim was repudiated.
4. The policy is a contract between the parties and all conditions and stipulations there in are equally applicable to both sides. There is absolutely no deficiency in service on the part of this opposite party or there any unfair trade practice. The averment that IP was not done due to Covid 19 is an absolute falsehood and devoid of any merit. Complainant is not entitled to get any amount as medical expenses and amount as compensation. Hence the complaint may be dismissed with compensatory cost.
5. On the above pleadings following points were raised for consideration:-
- Whether there is any deficiency of service from the part of opposite parties as alleged?
- Whether admission as inpatient was possible for the son of the complainant due to spread of Covid 19 pandemic?
- Whether repudiation of claim by opposite party as per exclusion clause is justified?
- Whether the complainant is entitled to realise an amount of Rs.29,728/- along with interest as prayed for?
- Whether the complainant is entitled to realise an amount of Rs.50,000/- as compensation from the opposite party as prayed for?
- Reliefs and cost?
6. Evidence in this case consists of the oral evidence of PW1 and Exts.A1 to A4 from the side of the complainant and the oral evidence of RW1 and Ext.B1 to B4 from the side of opposite party.
Point No.1 to 5
7. PW1 is the complainant in this case. He filed an affidavit in tune with the complaint and marked Exts.A1 to A4.
8. RW1 is the Divisional Manager of opposite party. He filed an affidavit in tune with the version and marked Ext.B1 to B4.
9. PW1, the complainant availed a National Mediclaim Policy from the opposite party M/s National Insurance Company for himself and his family. It was for a period of one year from 31/3/2020 to 30/3/2021. On 5/1/2021 Sri.Abraham Jacob who is the son of the complainant had a dog bite and had under gone treatment at St. John Medical College Hospital, Banglore from 5/1/2021 to 2/2/2021. They issued a medical bill amounting to Rs. 29,728/-. According to the complainant though admission was necessary it was not possible due to spread of covid-19 pandemic. A claim form was filed before the opposite party claiming the bill amount of Rs. 29,728/-. However it was repudiated on a contention that In-Patient treatment is necessary to claim the amount. The rejection of claim without any valid reason amounts to deficiency of service and hence the complaint is filed claiming the bill amount to Rs. 29,728/- along with interest @ 9% per annum and Rs.50,000/- as compensation for mental agony, pain and loss of valuable time. Opposite party filed a version admitting the policy which is valid from 31/3/2020 to 30/3/2021. On 6/2/2021 a claim was filed claiming hospital expenses for the treatment of his son due to dog bite. However on a perusal of the medical records it was noticed that his son had only under went Out-Patient treatment and there was no hospitalization. As per policy hospitalization for 24 hours is mandatory for entertaining the claim petition and hence it was repudiated as per exclusion clause 3.21. It was contended that if the patient was serious in spite of covid-19 pandemic, the hospital has got sufficient facilities to admit a patient. Since there was no In-Patient treatment the claim was repudiated, as per Exclusion clause and there is nothing to interfere. Complainant got examined as PW1 and marked Ext.A1 to A4. The Divisional Manager of the opposite party was examined as RW1 and marked Ext.B1 to B4. Relying upon the oral evidence of PW1 coupled with Ext.A1 to A4 documents, the learned counsel appearing for the complainant pointed out that the complaint is proved as per law and the complainant is entitled for the amount along with interest and compensation. It was pointed out that a genuine claim was repudiated by the opposite party without valid reason and even noting a wrong reason as exclusion policy clause 3.21 in Ext.A1 rejection letter. Per contra the learned counsel appearing for the opposite party contented that even though the section quarted is 3.21 Ext.A1 (B4), the contents is stated below. The claim was rightly rejected since there was no In-Patient treatment which was mandatory. It was also pointed out that though the complainant stated that admission was not possible in the hospital due to Covid -19 pandemic, there is no iota of evidence to prove such a contention. Hence learned counsel appearing for the opposite party canvassed for a dismissal.
10. Here in this case issuance of policy is admitted. Ext.A4 (Ext.B1) is the true copy of policy effective from 31/3/2020 to 30/3/2021. The policy was issued for the complainant and his family consists of his wife and Sri. Abraham Jacob who is the patient in this case. The fact that PW1 sustained a dog bite on 5/1/2021 and he was treated at St. John Medical College Hospital, Bengaluru is also admitted. Ext.A3 (Ext.B3) is the medical records which shows that Sri. Abraham Jacob appeared in the department of emergency medicine St. John Medical College Hospital, Bengluru on 5/1/2021 at 1.25 AM. The alleged history was dog bite. He had a lacerated wound with multiple abrasions over right leg. He was given certain injections and advised to repeat the injection on 8/1/2021, 12/1/2021, 19/1/2021 and 2/2/2021. Ext.A2 (Ext.B2) is the claim form submitted on 3/2/2021 claiming an amount of Rs.29,728/- being the treatment expenses. As per Ext.A1 (Ext.B4) the claim was repudiated as per exclusion policy clause 3.21. As discussed earlier the learned counsel appearing for the complainant pointed out that there is no such exclusion clause. As per the policy conditions clause 3 deals with definitions and only in clause 4 exclusion is shown. Hence to resolve the dispute it is highly necessary to go through the definitions and exclusion clause in Ext.B1 Policy along with conditions.
11. Definition.
3.1 Accident means a sudden, unforeseen and involuntary event caused by external, visible and violent means.
3.12 deals with hospitalization:- “Hospitalization means admission in a hospital as an inpatient for a minimum period of 24 consecutive hours except for specified procedure/ treatment, where such admission could be for a period of less than 24 consecutive hours”.
3.14 defines In-Patient.:- “In-Patient means an insured person who is admitted in hospital upon the written advice of a duly qualified medical practitioner for more than 24 continuous hours, for the treatment of covered disease/injury during the policy period.”
Clause 4. Deals with exclusions:-
4.18 Out Patient Department treatment (OPD treatment)
4.19. Diagnostic and evaluation purpose where such diagnosis and evaluation can be carried out as outpatient procedure and the condition of the patient does not require hospitalization.
4.22 Stay in hospital which is not medically necessary.
12. So a combined reading of the definitions and exclusion clause which are extracted above, it is pellucid that for claiming the amount hospitalization as an inpatient for a minimum period of 24 consecutive hours is necessary. Further treatment under outpatient department is also excluded.
13. Here in this case as discussed earlier the patient was treated in the hospital as outpatient which is borne out from Ext.A3. Sri.Abraham Jacob presented at the department of emergency medicine on 5/1/2021 at 1.25.AM with alleged history of dog bite. He was treated with injections and advised to report injections on 8/1/2021, 12/1/2021, 19/1/2021 and 2/2/2021. So it is crystal clear that after administering injection Sri. Abraham Joseph was allowed to go. In other words there was no inpatient treatment. As discussed earlier inpatient treatment for 24 hours was mandatory for claiming the amount.
14. The law in this regard is well settled by various judicial pronouncements. It was held by the Hon’ble Supreme Court in Vikram Greentech (I) Ltd. and Another Vs. New India Assurance Co. Ltd. (AIR 2009 SC 2493)
“An insurance contract is a species of commercial transactions and must be construed like any other contract to its own terms and by itself. In a contract of insurance, there is requirement of uberimma fides i.e., good faith on the part of the insured. Except that, in other respects, there is no difference between a contract of insurance and any other contract.”
It was held by the Hon’ble Supreme Court in Export Credit Guarantee Corporation of India Ltd. Vs. M/s Garg Sons International (2013 KHC 4040)
“ 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.
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.”
It was held by the Hon’ble High Court in National Insurance Company Ltd. Vs. Sudhakaran and Others.(2018 (5) KHC 661)
“Insurance Law – Contract of Insurance – Interpretation of –Held, normal rule is that the conditions specified in a policy, which is contract of Insurance statutory in nature, has to be strictly construed.”
15. In the light of the above judicial pronouncements it can be seen that a contract of insurance is to be treated as any other contract. This commission has no right to add, substract or vary the terms and conditions of the contract. Here as discussed 24 hours inpatient treatment in hospital was mandatory to claim the benefit which is absent in this case. The learned counsel appearing for the complainant pointed out that due to covid-19 pandemic there was no inpatient treatment at the hospital and so Sri. Abraham Joseph could not be admitted. From Ext.A3 it is seen that Sri. Abraham Jacob had sustained only a lacerated wound with multiple abrasion over right leg. So it can be seen that the injury was trivial in nature. The treatment was done at St. Johns Medical College Hospital, Bengluru. Though it was contented that there was no inpatient treatment at St. Johns medical college hospital, Bengluru due to covid 19 pandemic, there is no iota of evidence to prove the same. Atleast complainant could have produced a letter from the medical college hospital to prove such a contention which is conspicuously absent in this case. In said circumstances the claim was rightly rejected by the opposite party on the basis of exclusion clause and no interference is warranted. Hence these points are found against the complainant.
Point No. 6
16. In the result complaint is dismissed. Parties are directed to bear their respective cost.
Dictated to the Confidential Assistant, transcribed by him corrected by me and pronounced in open Commission on this the 30th day of April, 2022.
Sd/-Sri.S.SanthoshKumar(President)
Sd/-Smt.Sholy.P.R (Member)
PW1 - Jacob Abraham (complainant)
Ext.A1 - Original claim rejection letter dt. 16-02-2021
Ext. A2 - True Copy of Claim Form
Ext.A3 - True Copy Of Treatment Records
Ext.A4 - True Copy of policy
Evidence of the opposite parties:-
RW1 - Sajeer S (witness)
Ext.B1 - Policy Copy with conditions
Ext.B2 - Copy of claim form submitted by the complainant
Ext. B3 - Medical Records
Ext. B4 - Copy of Repudiation letter
// True Copy //
To
Complainant/Oppo. party/S.F.
By Order
Senior Superintendent
Typed by:- Br/-
Compared by:-
