Order-21.
Date-18/01/2018.
Shri Anupam Bhattacharyya, President.
The instant complaint has been filed by the complainant u/s.12 of the C.P. Act, 1986 praying for payment of Rs.44,993/- towards hospitalization expenses, Rs,15,000/- Mental agony and harassment, Rs.10,000/- for deficiency in service, Litigation expenses Rs.10,000/- and conveyance etc. for Rs.5,000/- i.e. Rs.84,993/- in total along with interest at the rate of18% p.a. till date of payment .
The complainant’s case, in brief, is that Easy Health Floater Insurance Policy bearing no.150300/11112/100231086-01 issued to the complainant for the period from 01-09-2013 to 21-08-2014 which is renewed time to time and that policy of Apollo Munich Health Insurance Co. Ltd. was issued in the terms that it will cover all insured persons under this policy up to the sum insured and the insurance cover is governed by and subject to the terms and Exclusion of Policy. During risk period on 27-09-2014 complainant got admitted and discharged on 06-10-2014 from Jindal Nature Cure Institute a Hospital approved by the Govt. of Karnataka for the treatment of a person. Total expenses incurred by the complainant as per bill is Rs.39,000/- and claimed against the OP for compensation on account of medical expenses for Rs.44,993/-. OP repudiated the claim by letter dated 01-02-2016 and with the decision of repudiation complainant made a complaint before Insurance Ombudsman, State of West Bengal, Sikkim and UT of Andaman & Nicober Islands but it was blocked. Complainant submitted that the repudiation is unlawful and illegal. Finding no other alternative complainant filed this complaint to this Forum. Hence, the instant complaint filed by the complainant.
Written version filed by the OP, in short, is that complainant is the policy holder being policy no.150300/11112/100231086-01 for the period between 01-09-2013 to 30-08-2014 and he availed Naturepathy treatment admitted himself to Jindal Nature Cure Institute from 27-09-2014 to 06-10-2014 and claimed an amount of Rs.44,993/- by a claim dated 10-10-2014 which was received by OP on 14-10-2014 and rejected the claim by letter dated 31-10-2014 due to the reasons that the claim was for naturopathy is excluded from the insurance policy which is evident from clause Medical Exclusion which reads as General Exclusions under Section V-Special Terms and Conditions of the said insurance policy. The claim raised by the insured for non-allopathic treatment including and not limited to naturopathy as in the instant case is excluded from the coverage of the said insurance policy. Insurer may provide coverage to non-allopathic treatments provide the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health or any other suitable institutions. OP came to the conclusion that the said hospital is neither a government hospital and /or no certificate was provided by the complainant to prove its recognition by the government etc. OP states that coronary heart disease for which insured took treatment was the consequence of pre-existing diseases, namely Dyslipidemia and Diabetes Mellitus with which insured was suffering. Insured cannot claim anything more than what is covered by the insurance policy. An insurance contract is a species of commercial transactions and must be construed like any other contract to its terms and by itself. They prayed for dismissal with exemplary cost. Hence, the instant written version.
Considering the pleading of both sides the following points have been raised.
Points for Decision
- Whether the case is maintainable in its present form and law?
- Whether there is any cause of action to file the case?
- Whether the case is barred by limitation?
- Whether the complainant is entitled to get the relief as prayed for?
- What other relief/reliefs the complainant is entitled to get?
Decision with Reasons
Points No.1 to 5 . All the points are taken up together for the brevity of discussion and convenience.
The instant complaint is for payment of Rs.84,993/- in total (i.e. Rs.44,993/- towards hospitalization expenses, Rs,15,000/- Mental agony and harassment, Rs.10,000/- for deficiency in service, Litigation expenses Rs.10,000/- and conveyance etc. for Rs.5,000/-) on the basis of mediclaim policy along with interest at the rate of18% p.a.
Complainant’s main case is for realization of mediclaim policy for treatment of Naturepathy being admitted in Jindal Nature Cure Institute which was repudiated illegally by the OP on the ground of Exclusion Clause of the terms of the policy being the said treatment of naturopathy was not approved by any Government Hospital. Hence, the instant complaint case.
On the other hand, OP Insurance Company’s main case is that the treatment of the complainant of Naturepathy was obtained, being admitted in the Jindal Nature Cure Institute, which is not a Government Hospital and for that they have validly repudiated the claim.
To prove the case both the parties have adduced Evidence on Affidavit and they have filed questionnaires and replies vis-à-vis along with relevant documents in support of their respective case.
Admittedly, the complainant is the policy holder and he was treated in the Jindal Nature Cure Institute by Naturepathy and the claim amount for the medical expense for Rs.44,993/- has been supported by the relevant document.
Both parties have filed BNA.
In the BNA filed by the OP Insurance Company they have clearly mentioned referring the regulation 5(1) of the IRDA that Insurers may provide coverage to non-allopathic treatments provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health or any other suitable Institutions.
In the written argument as well as during the course of hearing argument the Ld. Lawyer for the OP Insurance Company has referred different decisions wherein the principle of law is that the insured cannot claim anything more what is covered by the insurance policy and insurance contract is based on good faith.
All these points of law are admitted position and there is nothing to dispute.
Now, in this particular case only the question left to decide that whether the institute wherein the complainant was admitted and got the naturepathy treatment is a Government Institute or approved by any Govt.
In this regard, information obtaining from the internet it is clear from that document that the naturopathy treatment of Jindal Naturepathy Cure Institute is approved by Ayush which is approved by Government body in India purposed with developing, education and research in ayurveda (Indian traditional medicine), yoga, naturepathy, unani, siddha, homoeopathy, Sowa Rigpa Traditional Tibetan medicine and other Indigenous Medicine systems and the same document is kept with the record. That being so, we can safely conclude that the complainant is entitled to get the claim. Considering the above discussions as a whole we find that all the points are disposed of in favour of the complainant in part and as such, the complainant is entitled to get Rs.44,993/- towards medical expenses along with 7% p.a. along with litigation cost of Rs.5,000/-.
Hence,
Ordered
That the instant case no.104 of 2017 be and the same is allowed in part on contest against the OP.
OP is directed to pay an amount of Rs.44,993/- along with interest at the rate of7% p.a. from the date of filing of this case till realization along with litigation cost of Rs.5,000/- within 30 days from the date of this order, in default, the OPs 1 and 2 is to pay fine at the rate ofRs.100/- per day delay and the amount so accumulated should be deposited to this Forum.
According to settled principle interest being allowed, the complainant is not entitled to get any further compensation.
Failure to comply with the order will entitle the complainant to put the order into execution under appropriate provision of the C.P. Act.
