Dt. of filing – 26/03/2018

Dt. of Judgement – 16/04/2019

Mrs. Sashi Kala Basu, Hon’ble President

        This consumer complaint is filed by the Complainant namely Sri Subrata Dey under Section 12 of the Consumer Protection Act, 1986 against the Opposite Parties namely 1) The Managing Director, Star Health and Allied Insurance Company Limited 2) The Zonal Manager, Star Health and Allied Insurance Company Limited 3) Branch Manager, Star Health and Allied Insurance Company Limited and 4) The Superintendent, Nightingale Hospital alleging deficiency in rendering service on their part.

          Complainant’s case in short is that he purchased the policy under the Family Health Optima Insurance Plan vide Customer Code No. P/191117/01/2016/010174 through the policy issuing Branch i.e. Opposite Party No.3 valid for the period from 11/3/2016 to 10/3/2017 by making payment of Rs.15,217/- as yearly premium. Insured persons were the Complainant, Complainant’s husband, their daughter and also son. The total coverage for four insured persons was Rs.3,75,000/-  as per the said Medi-claim policy. On 2/5/2016 Complainant felt seriously upper-abdomen pain and chest pain and was forced to get admitted in the Nightingale Hospital i.e. Opposite Party No.4. She was examined and diagnosed by the Doctors. She was admitted on 2/5/2016 and was discharged on 5/5/2016 after important pathological test was done. Complainant claimed the benefit as an insured patient and all the medical documents were also sent. But the Opposite Parties vide their letter dated 24/6/2016 rejected the claim of the Complainant. Complainant had made payment of medical bills of Rs.24,650/-. So the present complaint has been filed by the Complainant for directing the Opposite Party Nos. 1 to 3 to pay medical bills of Rs.24,650/-, to pay compensation of Rs.50,000/- and the litigation cost of Rs.20,000/-.

          Complainant has annexed with the complaint petition, copy of the insurance policy, medical bills, copy of the letters sent to Opposite Party Nos.1 to 3 by the Complainant dated 21/7/2016, copy of reply by OPs dated 24/06/2017 and copy of demand notice.

          Case has been contested by Opposite Party No.4 by filing separate written version stating inter alia that the Complainant/patient was admitted on 12/5/2016 and after examination by the Doctors she was discharged on 5/5/2016. Opposite Party No.4 has no role about the reimbursement claim made by the Complainant and so has prayed for dismissal of the case against it.

     Opposite Party Nos.1 to 3 have also contested the case by filing written version denying and disputing the allegation made in the complaint petition contending inter alia that on perusal of the medical documents by the Opposite Party, it was found that the insured patient was admitted mainly for investigation and evaluation purpose. No specific treatment was given and all reports are found normal and so as per exclusion clause of the policy, company was not liable to make payment for expenses incurred by the Complainant which was accordingly intimated to the Complainant. Thus Opposite Party Nos.1 to 3 also prayed for dismissal of the complaint.

          During the course of the evidence Complainant and the Opposite Party Nos.1 to 3 filed their respective evidence by way of filing affidavit-in-chief followed by filing of questionnaire and reply thereto and ultimately argument has been advanced by both the parties. Written notes of argument have also been filed.

          So the following points require determination:-

1) Whether there has been any deficiency in service on the part of the Opposite Party Nos.1 to 3?

          2) Whether the Complainant is entitled to the relief as prayed for?

Decision with reasons

 Point No.1 & 2

         Both these points are taken up together for discussions for the sake of convenience and in order to avoid repetition.

          It is an admitted fact that the Complainant, her husband, daughter and son were covered under the Medi-claim Policy issued by Opposite Party No.3. It is also an admitted fact that the Complainant was admitted at Nightingale Hospital/Opposite Party No.4 from 2/5/2016 to 5/5/2016 during the validity period of the policy. She had paid medical bill of Rs.24,650/- and to this effect she has also filed the medical bills but the question which requires to be considered is whether the case of the Complainant falls under the exclusion clause of the policy?

          It is apparent from the complaint petition as well as medical documents filed by the Complainant that after she was admitted, diagnosis was done including important pathological test but apparently no treatment for any specific ailments was done. As per USG report of the Nightingale Hospital impression was ‘normal study’. The medical documents suggest that after those tests, no specific disease/ailment was found and Complainant was discharged.

          As per clause 19 of the policy which deals with exclusions that “charges incurred on diagnostics that are not consistent with the treatment for which the insured is admitted in the hospital/nursing home. Admission primarily for diagnostic purpose with no positive existence of sickness disease/ailment/injury and no further treatment is incurred”.

          So as per the said exclusion clause, it is very categorical that admission primarily for diagnostic purpose will not entitle the insured to make  any claim towards the said Medi-claim Policy. Complaint petition is very clear that no specific treatment for any ailment or disease was given to Complainant and thus her case falls within the said exclusion clause.

     In the case of Vikram Greentech (I) Ltd and Anr Vs New India Assurance Co Ltd, Hon’ble Supreme Court has held “since upon issuance of insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the insurance policy, its terms have to be strictly construed to determine the extent of liability of the insurer. The endeavour of the court must always be to interpret the words in which the contract is expressed by the parties. The court while construing the terms of policy is not expected to venture into extra liberalism that may result in re-writing the contract or substituting the terms which were not intended by the parties. The insured cannot claim anything more than what is covered by the insurance policy”.

          So in view of the legal proposition in the above mentioned case law, as per exclusion clause in clause 19 of the policy, Complainant is not entitled to reimburse of the amount as claimed by her. Thus the complaint is liable to be dismissed.

          These points are answered accordingly.

Hence,

                  Ordered

CC/155/2018 is dismissed on contest.