DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

Simerpreet Singh, resident of H.No. 1117, Sector 20-B, Chandigarh.

                                                                   ---Complainant

Vs

[1]      HDFC ERGO General Insurance Co. Limited, SCO No. 124-125, Sector 8-C, Madhya Marg, Chandigarh, through its Manager.

[2]      HDFC ERGO General Insurance Co. Limited, Ramon House, H.T. Parekh Marg, 169, Backbay Reclamation, Mumbai – 400020, through its Managing Director.

---- Opposite Parties

BEFORE:          SH.LAKSHMAN SHARMA                PRESIDENT

MRS.MADHU MUTNEJA              MEMBER

                    SH.JASWINDER SINGH SIDHU                    MEMBER

Argued By:       Sh. Gaurav Bhardwaj, Advocate for the Complainant.

Sh. P.M. Goyal, Advocate for the Opposite Parties.

PER MADHU MUTNEJA, MEMBER

1.                 The Complainant was a policy holder of ‘Health Suraksha’ and ‘Sarv Suraksha Advantage Policy’ issued by the Opposite Parties. The policy was valid from 29.5.2010 to 28.05.2011 with a limit of upto Rs.2,00,000/- for hospitalization.

                    Unfortunately, the Complainant slipped from the stairs on 20.08.2010 and suffered injury in his disc due to which he was advised for endoscopic surgery by the doctor. The Complainant was admitted in the Arthroscopy & Spinal Endoscopy Centre from 31.8.2010 to 2.9.2010. A total of Rs.69,517/- was spent on the treatment (medical treatment record, bills and discharge cards are from Annexure C-3 to C-13).  The Complainant thereafter lodged a claim with the Opposite Parties on 6.9.2010. However, his claim was repudiated on the ground that treatment had been taken from a hospital which is not registered and does not fall within the definition of hospital or nursing home. 

                    The Complainant contacted the Opposite Parties and showed them a certificate issued by the Mukat Hospital that the treating Centre i.e. Arthroscopy & Spinal Endoscopy Centre had an indoor bed arrangement with them. However, despite writing many letters to the Opposite Parties, the Opposite Parties have not yet paid the claim of the Complainant. The Complainant has thus filed the instant complaint with a request that the Opposite Party be directed to pay Rs.69,517/-, along with interest and compensation for deficiency in service and mental agony, besides costs of litigation.

2.                 After admission of the complaint, notices were sent to the Opposite Parties.

3.                 Opposite Parties in reply have maintained that as soon as the Complainant lodged his claim, the company started the process of claim as per the terms & conditions of the policy, which have been placed at Annexure R-1. As per terms & conditions of the policy, the Complainant was required to get treatment from a hospital approved by the Opposite Parties. The TPA while processing the claim observed that the hospital had infrastructure relating to diagnostic only and had two beds one OT and andioscopy room, furthermore the bill books and indoor patient register was also not maintained and was not present in hard copies. Hence, denying all allegations of the Complainant and maintaining that repudiation was on the ground that the treating hospital did not fulfill the criteria laid down by the insurance company, the Opposite Parties have prayed for dismissal of the Complaint. 

4.                 Parties led evidence in support of their contentions.

5.                 We have heard the learned counsel for the parties and have perused the record.

6.                 The Complainant is aggrieved by the repudiation of claim by the Opposite Parties, who have placed reliance on the Def.No.7 contained in the insurance policy with regard to the insurance claim (Page 15). The said definition is reproduced as under:-

Def.7. Hospital means any institution in India (including nursing homes) established for Medical Treatment which

i)              Either

(a) has been registered and licensed as a hospital with the appropriate local or other authorities competent to register hospitals in the relevant area and is under the constant supervision of a Medical Practitioner and is not, except incidentally, a clinic, rest home, or convalescent home for the addicted, detoxification centre, sanatorium, home for the aged, mentally disturbed, remodeling clinic or similar institution.

                                                (b)                Or

(i) is under the constant supervision of a Medical Practitioner, and

(ii) has fully qualified nursing staff (that hold a certificate issued by a recognized nursing council) under its employment in constant attendance and

(iii) maintains daily records of each of its patients, and

(iv) has at least 10 inpatients beds; and

(v) has a fully equipped and functioning operation theatre.”

7.                 The Complainant has taken treatment from Arthroscopy & Spinal Endoscopy Centre. The Complainant has also placed on record a certificate from Mukat Hospital that the said Centre has an indoor bed arrangement with Mukat Hospital.

8.                 The Opposite Parties by relying on the definition of hospital have stated that as the Center where the Complainant has obtained treatment is not covered under the definition of hospital, hence the claim of the Complainant can not be paid.  This is very interesting situation where the Opposite Parties have not denied the treatment or the expenses incurred, but have only refused the claim of the Complainant by stating that the place where the treatment was given is not as per terms of the Policy. In this regard, reference may be made to the landmark case of Surjit Singh Vs. State of Punjab and Others, (1996) 2 Supreme Court Cases 336. In that case, a govt. employee had been denied medical reimbursement as he had taken treatment from a Hospital abroad. The Hon’ble Apex Court while allowing the claim of the Appellant/Claimant therein had passed orders that the amount payable in the recognized Indian hospital for the same treatment i.e. Escorts be given. While allowing the claim, the Hon’ble Apex Court had held as under: -

“Self-preservation of one’s life is the necessary concomitant of the right to life enshrined in Article 21 of the Constitution of India, fundamental in nature, sacred, precious and inviolable. The importance and validity of the duty and right to self-reservation has a species in the right of self-defence is criminal law. Centuries ago thinkers of India conceived of such right and recognized it.”

The Hon’ble Apex Court had in this regard referred to the Division Bench in Sadhu R.Pall case (CWP No. 18562 of 1992, decided on 10.5.1995 (DB)), wherein it had been observed as under:-

“The Respondents appear to have patently used excusals in refusing full reimbursement, when the factum of treatment and the urgency for the same has been accepted by the Respondents by reimbursing the Petitioner the expenses incurred by him, which he would have incurred in the AIIMS, New Delhi. We cannot lose sight of factual situation in the AIIMS, New Delhi i.e. with respect to the number of patients received there for heart problem. In such an urgency, one cannot sit at home and think in a cool and calm atmosphere for getting medical treatment at a particular hospital or wait for admission in some govt. medical institute. In such a situation, decision has to be taken forthwith by the person or his attendants if precious life has to be saved.”

The Hon’ble Apex Court has also referred to Garuda Purana (A dialogue suggested between the Divine and Garuda, the bird) in the words of the Divine:-

“17. Vinaa dehena kasyaapi canpurushaartho na vidyate

Tasmaaddeham dhanam rakshetpunyakarnaani saadhayet

Without the body how can one obtain the objects of human life? Therefore protecting the body, which is the wealth, one should perform the deeds of merit.”

“18. Rakshayetsarvadaatmaanamaatmaa sarvasya bhaajanam

Rakshane yatnamaatishthejje vanbhaadraani pashyati

One should protect his body, which is responsible for everything. He who protects himself by all efforts, will see many auspicious occasions in life.”

“20. Sharirarakshaanopaayaah kriyante sarvadaa budhath

Necchanti cha punastyaagamapi kushthaadiroginah

The wise always undertake the protective measures for the body. Even the persons suffering from leprosy and other diseases do not wish to get rid of the body.”

 “22. Aatmaiva yadi naatmaanamahitebhyo nivaarayet

Konsyo hitakarastasmaadaatmaanam taarayishyati

If one does not prevent which is unpleasant to himself, who else will do it? Therefore, one should do what is good to himself.”

In the light of the observations of the Hon’ble Apex Court, the contention of the Opposite Parties that the Complainant did not take treatment from a proper hospital is not sustainable. As per the divine voice in the Garuda Purana, it is the duty of human life to protect the body by all efforts and a person will do so by the quickest means available. When a person is in suffering and pain, he cannot be expected to look at which hospital is covered and which is not covered as per the terms of the Policy.    

9.                We accordingly allow this complaint in favour of the Complainant and direct the Opposite Parties to make payment to the Complainant as per the claim amount due disregarding the objection that the hospital is not covered under the Policy.  The claim shall be paid to the Complainant within 30 days from the date of receipt of this order, failing which they will be liable for interest @12% p.a. from the date it became due, till the date of payment. Opposite Parties will also pay Rs.7,000/- as cost of litigation.

10.               Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

10^th April,  2012.                                                

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

MEMBER

Sd/-

 (JASWINDER SINGH SIDHU)