PER:
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite parties on the allegations that the complainant is holder of New India Floater Mediclaim Policy, hereinafter called “the policy” since 2017 issued by New India Assurance Co. Ltd. i.e. the O.P No.1. The said policy is being renewed every year/periodically by paying the regular premium and the current policy bears No.36100134222800000261 having policy period 30.03.2023 to 29.03.2024. The said policy is valid and covers the complainant (self), Ms. Pooja Rani (spouse) and Day one Baby Cover. The floater sum insured under the policy is Rs.5,00,000/- (Rs. Five Lakhs only). The wife of the complainant namely Pooja Rani has delivered a baby girl on 09.05.2023 and the baby has been born pre-mature at Gupta Hospital, Amritsar. As per advice of the doctor and due to some medical reasons the baby was advised to be referred for treatment as such the complainant has got admitted the baby at Florem hospital, Majitha Road, Amritsar, where the baby was given medical treatment at NICU in the hospital. During the treatment, in the entire hospital record, the baby was being referred as “Baby of Pooja Rani”. During the treatment, on 31.5.2023, the complainant has intimated the opposite parties through its officials through e-mail that the treatment of his newly born daughter is undergoing in the Florem Hospital, Amritsar and also conveyed that the above policy also includes “day one baby cover”. The complainant also submitted that he will send all the required documents to them for reimbursement of expenses incurred upon treatment within 7-10 days after discharge from hospital. The O.Ps have acknowledged the receipt of information and have provided the claim intimation number 3732157 through email dated 01-06-2023. The baby was given the required medical treatment by the concerned doctor in the above said hospital and the total expenditures upon the treatment including the hospital charges, lab tests and medicines etc. comes to Rs.4,21,693/- which were paid by the complainant to the hospital. Thereafter, the baby got discharged from the hospital on 6.6.2023 as such the baby remained admitted in the Hospital from 9.5.2023 to 6.6.2023. Afterwards on 12.6.2023 vide registered post dated 12.6.2023, the complainant has sent to opposite party No.3 all the original documents i.e. the Discharge Card, investigation reports, Lab bills, Medicine bills, hospital bills, payment receipts, breakup of bills, complete ledger of expenditures, claim form duly filled, Adhar Card, PAN card, copy of cancelled cheque as demanded by the opposite parties. Further the complainant has intimated the O.Ps in this regard vide e-mail dated 13.6.2023 and the O.Ps have acknowledged the receipt of documents and further demanded birth certificate of baby vide e-mail dated 14.6.2023 and the complainant has also sent copy of birth certificate to O.Ps through e-mail dated 15.6.2023. Thereafter the, O.Ps have spent more than one month in completing the formalities and 20.7.2023, they have intimated the complainant that the reimbursement claim, against the claim documents submitted, has been registered. After waiting for some period, the complainant has asked the O.Ps with regard to status of the claim vide e-mail dated 15.8.2023. On 16.8.2023, the O.P No.3 has forwarded an email to the complainant, which is reproduced as follows “Pre term expenses are not payable. Baby was admitted with diagnosis as pre term resp distress syndrome. Please find below policy clause 3.4 and screen shot of discharge summary.” The complainant has sent an e-mail dated 18.8.2023 to O.Ps and the complainant has asked O.Ps that whether it is repudiation or some clarification is demanded by O.Ps vide the e-mail dated 16.8.2023 and further the complainant has submitted that clause 3.4 is not causing any hindrance in the way of the O.P’s for settling the claim. It is very much clear from the e-mail dated 16.8.2023 that O.Ps have taken one phrase from first line i.e "pre-term" and other phrase from second line i.e. "resp distress syndrom" from the discharge card. It is nowhere mentioned in the medical record that the baby was diagnosis as pre term resp distress syndrome as alleged by the O.P’s and the O.P’s have given their self created interpretation in this regard. The same is not desirable from the reputed company like NIA Ltd. & Paramount TPA as the whole contents of the discharge card are requires to be read in conjunction. As such, the above conduct of the O.P’s is gross unbussinesslike conduct. Afterwards, in the last week of August 2023, the complainant has received repudiation letter dated 21.7.2023 dispatch on 18.8.2023 issued by O.P No.2 to O.P No.1 as well as repudiation letter dated 1.8.2023 issued by the O.P No.1 to the complainant vide which the claim was repudiated. Thereafter the complainant has sent an e-mail dated 15.9.2023 to the O.P No.3 & others and the complainant has submitted that the claim is not requires to be repudiated on both the grounds as mentioned in the repudiation letter and further requested them to re-consider the claim and convey about your final decision but the O.P’s have given no reply to the same. Further the complainant has again sent an e-mail dated 10.10.2023 to the O.P No.3 and the complainant has again requested them to re-consider the claim and further submitted that if they do not wish to reconsider the claim then to return back the original documents or at least reply to the mail. The officials of the O.P’s are so much adamant that they did neither return back the documents nor are bother to give reply to the e-mail. The companies/ employees should be honest towards its customer or least bother to give reply to the queries made by its customers but the O.P No.3 has shown so much undesirable/bad conduct. The above conduct of the O.P No.3 is in itself is grave deficiency in services as well as unbusinesslike conduct, for which the O.P no.3 is separately liable. The exclusion clause did not exist when the complainant purchased the insurance policy. Even upon renewal, the complainant was not informed about the alleged exclusion clauses. Moreover the alleged grounds for repudiation of claim are baseless, misconceived and on arbitrary grounds, which are neither having any relevancy nor applicable as per the facts of the present case, which is clear from the following discussion:-
- First ground taken by the O.P’s for repudiation is as follows:- “Date of joining of policy is 09-05-2023 and date of admission is 09-05-2023. The claim is not admissible as expenses related to the treatment of any illness within 30 days from the first policy commencement date are not admissible as per clause 4.3 of the policy.”
In this regard it is first submission that first policy commencement date is of the year 2017 and the policy is continuous from more than 6 years. Further the Day One Baby Cover is also included from the year 2021, which is depicted in the policy valid from 30-03-2021 to 29-03-2022 and also in the policy covers of subsequent years. The clause 4.3(b) itself says that this exclusion clause shall not, however, apply if the insured person has continuous coverage for more than twelve month.
It is second submission that the clause 3.3 describes that “A new born baby is covered for any illness or injury from the date of birth till the expiry of this policy”.
All the above submissions in itself clarifies that a new born baby is covered for any illness from the day of birth.
- Second ground taken by the O.P’s for repudiation is as follows:- “Any expenses incurred towards post-natal care, pre-term or pre-mature care or any such expenses incurred in connection with delivery of such new born baby would not covered”.
In this regard, first submission is that as per discharge card, baby was diagnosed with neonatal feed intolerance and further the chief complaints were severe respiratory syndrome, poor infusion as such baby was kept in NICU and during the treatment the baby was given antibiotics, other medicines etc. as mentioned in the discharge card. It is nowhere mentioned in the discharge card that the baby was admitted for pre-term or pre-mature care.
The second submission is that as per policy clause 3.3, the expenses of "pre-term or pre-mature care" are excluded and the said clause does not excludes the expenses on hospitalization, the expenses incurred upon medical treatment given to baby born pre-term or pre-mature. In the present case, the baby was given the required medical treatment as detailed in discharge card, medical record, reports & voluminous pharmacy bills, which never comes within the narrow definition of "care only" rather the same comes within the definition of "treatment given due to medical reasons" and the same is not excluded.
Thirdly if this commission finds the alleged Clause 3.3 was hit by the Contra Proferentum rule: being ambiguous, it had to be interpreted in favour of the insured.
The important & Fourth submission in this regard is that there are some guidelines issued by the IRDAI, which are binding on the O.P’s. The circular dated 12th October 2022 issued by IRDAI speaks that “It is reiterated that all insurance products that cover newborns/unborn shall comply with the above referred provisions without any deviation and provide, coverage from day one (1) without imposing any waiting periods/sub-limits or any other restrictive conditions”. The said guidelines issued by IRDAI are having force of law and applicable upon all the insurance companies and consequently the alleged waiting periods/sub limits / restrictive conditions are not applicable to the policy in question.
As such it is clear from the above discussion that the complainant is entitled for the reimbursement of the expenses as per the policy and the repudiation of the claim by the O.P’s on the alleged grounds is unlawful, arbitrary and not legally maintainable. Thus the reasons for rejection of claim were only lamed objections and have no iota of logical reasoning.
The claim of the complainant was repudiated on flimsy grounds by the opposite parties. The complainant is entitled for the claim amount which has been wrongly withheld by the company and there is no bar to the claim of the complainant in this regard and the opposite parties is legally bound to pay the same. The repudiation of the claim by the opposite parties clearly amounts to committing gross negligence and utter deficiency in providing services. The complainant prayed that the following relieves may kindly be granted to the complainant.
- That the Opposite party No.1 may be directed to pay/reimburse the amount of Rs.4,21,693/- along with interest @ 12% per annum from the date of entitlement till actual realization to the complainant in the interest of justice.
- That the Opposite party No.1 may also be directed to pay compensation of Rs.1,00,000/- to the complainant on account of mental pain, agony, harassment and inconvenience suffered by the complainant due to repudiation of genuine claim.
- The O.P’s may be directed to pay the cost of proceeding/litigation expenses to the tune of Rs.55,000/- to the complainant.
- That the O.P No.3 may also be separately directed to pay compensation to the tune of Rs.1,00,000/- to the complainant on account of its unbusinesslike conduct and for mental pain and inconvenience suffered by the complainant in the interest of justice.
Alongwith the complaint, the complainant has placed on record the complainant has placed on record Self attested affidavit of the complainant Ex C-1, Self attested copy of insurance policy schedule 2023-24 pages) Ex C-2, Self attested copy of PHS card Ex C-3, Self attested copy of insurance policy schedule 2022-23 (3 pages) Ex C-4, Self attested copy of insurance policy schedule 2021-22 (3 pages) Ex C-5, Self attested printout of email extract dated 31-05-2023 & 01-06-2023 Ex C-6, Self attested printout of email extract dated 01-06-2023 & 10-06-2023 Ex C-7, Self attested copy of medical reports (11 pages) Ex C-8, Self attested copy of Hospital Bill (1 page) Ex C-9, Self attested copy of ledger of bill (1 pages) Ex C-10, Self attested copy of medicine bill ledger (2 pages) Ex C-11, Self attested copy of Discharge Card (2 pages) Ex C-12, Self attested copy of envelop of post (1 page) Ex C-13, Self attested copy of postal receipt (1 page) Ex C-14, Self attested copy of acknowledgement receipt (2 pages) Ex C-15, Self attested copy of declaration form attested by Hospital (1 page) Ex C-16, Self attested copy of claim form (4 pages) Ex C-17, Self attested printout of email extract dated 13-06-2023 Ex C-18, Self attested printout of email extract dated 14-06-2023 & 15-06-2023 Ex C-19, Self attested copy of birth certificate Ex C-20, Self attested copy of email dated 20-06-2023 of claim registration Ex C-21, Self attested printout of email extract dated 15-08-2023 & 16-08-2023 Ex C-22, Self attested printout of email extract dated 18-08-2023 Ex C-23, Self attested printout of email extract dated 15-09-2023 Ex C-24, Self attested copy of envelop of post by insurance (1 page) Ex C-25, Self attested copy of postal receipt dated 22-08-2023 (1 page) Ex C-26, Self attested copy of repudiation letter dated 21-07-2023 bearing dispatch date 18-08-2023 Ex C-27, Self attested copy of repudiation letter dated 01-08-2023 (1 page) Ex C-28, Self attested copy of clause 4.3 of policy (1 page) Ex C-29, Self attested copy of clause 3.3 of policy (2 pages) Ex C-30, Self attested copy of notification by IRDAI dated 12-10-2022 (1 page) Ex C-31, Self attested printout of email extract dated 10-10-2023 Ex C-32, Certificate under section 65-B of the Evidence Act regarding e-mails Ex C-33, Self attested copy of Aadhar Card Ex C-34.
2 Notice of this complaint was sent to the opposite parties and opposite part No. 1 appeared through counsel and filed written version by interalia pleadings that the complaint filed by the complainant is not legally maintainable against the opposite party No. 1 and is liable to be dismissed. The complainant is approaching this commission with unclean hands and is suppressing the true and material facts from the notice of this commission. The complainant be estopped by his act and conduct from filing such complaint. This Commission has no jurisdiction to try and adjudicate the present complaint. As per Terms and Conditions of NEW INDIA FLOATER MEDICLAIM POLICY(Annexure -1), as per clause 5.18 Any dispute arises as to the amount payable for any claim the same shall be decided by reference to ARBITRATION. The terms of the policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition and deletion or substitution. The Commission cannot pass any order in contravention to the terms and conditions of the policy contract. There is no deficiency on the part of OP No. 1 as alleged by the complainant in the complaint. The deficiency in service cannot be alleged without attributing fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be proved by a person in pursuance of a contract or otherwise in relation to any service. The burden of proving the deficiency in service is upon the person who alleges it. The complainant has, on facts, been found to have not established any willful fault, imperfection, shortcoming or inadequacy in the service of OP No 1. The deficiency in service has to be distinguished from the tortious acts of the opposite party. In the absence of deficiency in service the aggrieved person may have a remedy under the common law to file suit for damages but cannot insist for grant of relief under the Act for the alleged acts of commission and omission attributable to the opposite party which otherwise do not amount to deficiency in service. If on facts it is found that the person or authority rendering service had taken all precautions and considered all relevant facts and circumstances in the course of the transactions and that their action or the final decision was in good faith, it cannot be said that there had been any deficiency in service. In interpreting a document relating to a contract of insurance, the duty of the Court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves. The baby of the complainant and complainant is not a Consumer as defined in the Act and mere nomination does not have the effect of conferring to the nominee any beneficial interest in the amount payable under the policy. The complaint filed by the complainant is without any cause of action. In the complaint, the complainant has not mentioned in Para No 4 of the complaint and in correspondence by the complainant about the medical reasons why the Baby was advised to be referred for treatment. On one hand, it is admitted case of the complainant that Baby has been born PRE MATURE at Gupta Hospital, Amritsar. Neither the complainant has filed nor tendered in evidence any record/ bed head ticket of Gupta Hospital, Amritsar in question. Hence the complaint is without any cause of action and is liable to be dismissed. The complaint filed by the complainant is time barred. Policy bearing No. 36100134222800000261 was issued in the name of policy holder Sh Mohinder Pal Arora and period of commencement of policy was 30.03.2023 to 29.03.2024 and as per the policy, the insured members were Sh Mohinder Pal Arora and Smt Pooja Rani. The wife of the complainant Smt Pooja Rani delivered a baby girl through caesarean operation at Gupta Hospital Amritsar on 9.5.2023 and the baby has been born PRE MATURE at Gupta Hospital Amritsar and this fact is admitted by the complainant in Para No 4 of the complaint. The complainant is concealing the true and material facts from this commission and intentionally has not mentioned the material reasons regarding caesarean operation in the complaint and why the new born baby was advised to refer to Florem Hospital Amritsar, as such, the complaint is liable to be dismissed on ground of concealment of true and material facts. As per the terms (Annexure 1) of the policy in question the baby of the complainant does not cover in the policy nor fall under the category of the Consumer, detailed objections have been raised in the above preliminary objections same be read as part and parcel of this para here also. Even in the e mail dated 31.5.2023 forwarded by the complainant, the complainant has not disclosed the medical reasons for referring the baby to Florem Hospital, Amritsar and also the complainant kept mum about the caesarean operation of his wife and pre term born baby. As per the terms of the policy, the complainant is not entitled to any relief from OP. Even the complainant has not filed the bed head tickets and other relevant documents of Florem Hospital Amritsar with the complaint nor tendered in evidence, even more the complainant has not mentioned the name of concerned doctor who treated the baby of the complainant. The claim of complainant has been rightly repudiated by OP as per the terms of the policy. The claim of the complainant has been rightly repudiated by the OP for the reasons mentioned therein, in view of the terms of the policy (Policy clause 4.3.2). Repudiation document dated 1.8.2023 is annexure 2. The opposite party No. 1 has denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite party No. 1 has placed on record affidavit Ex. OP1/1, New India Floater Mediclaim Policy terms and conditions Ex. OP1/2, Nil Endorsement document New India Floater Mediclaim Policy Ex. OP1/3, Claim repudiation document Ex. OP1/4, Letter dated 18.4.2024 Ex. OP1/5, Patient discharge Card Ex. OP1/6.
3 Notice of this complaint was sent to the opposite parties No. 2, 3 but no one appeared on behalf of opposite parties No. 2, 3 and consequently, the opposite parties No. 2, 3 were proceeded against exparte.
4 We have heard the Ld. Counsel for the complainant and opposite party No. 1 and have carefully gone through the record.
5 Ld. Counsel for the complainant contended that the complainant is holder of New India Floater Mediclaim Policy, hereinafter called “the policy” since 2017 issued by New India Assurance Co. Ltd. i.e. the O.P No.1. The said policy is being renewed every year/periodically by paying the regular premium and the current policy bears No.36100134222800000261 having policy period 30.03.2023 to 29.03.2024. The said policy is valid and covers the complainant (self), Ms. Pooja Rani (spouse) and Day one Baby Cover. The floater sum insured under the policy is Rs.5,00,000/- (Rs. Five Lakhs only). The wife of the complainant namely Pooja Rani has delivered a baby girl on 09.05.2023 and the baby has been born pre-mature at Gupta Hospital, Amritsar. As per advice of the doctor and due to some medical reasons the baby was advised to be referred for treatment as such the complainant has got admitted the baby at Florem hospital, Majitha Road, Amritsar, where the baby was given medical treatment at NICU in the hospital. During the treatment, in the entire hospital record, the baby was being referred as “Baby of Pooja Rani”. He further contended that during the treatment, on 31.5.2023, the complainant has intimated the opposite parties through its officials through e-mail that the treatment of his newly born daughter is undergoing in the Florem Hospital, Amritsar and also conveyed that the above policy also includes “day one baby cover”. The complainant also submitted that he will send all the required documents to them for reimbursement of expenses incurred upon treatment within 7-10 days after discharge from hospital. The O.Ps have acknowledged the receipt of information and have provided the claim intimation number 3732157 through email dated 01-06-2023. The baby was given the required medical treatment by the concerned doctor in the above said hospital and the total expenditures upon the treatment including the hospital charges, lab tests and medicines etc. comes to Rs.4,21,693/- which were paid by the complainant to the hospital. Thereafter, the baby got discharged from the hospital on 6.6.2023 as such the baby remained admitted in the Hospital from 9.5.2023 to 6.6.2023. Afterwards on 12.6.2023 vide registered post dated 12.6.2023, the complainant has sent to opposite party No.3 all the original documents i.e. the Discharge Card, investigation reports, Lab bills, Medicine bills, hospital bills, payment receipts, breakup of bills, complete ledger of expenditures, claim form duly filled, Adhar Card, PAN card, copy of cancelled cheque as demanded by the opposite parties. Thereafter, the opposite party further demanded birth certificate of the baby vide email dated 14.6.2023 and same was sent through email. Thereafter the, O.Ps have spent more than one month in completing the formalities and 20.7.2023, they have intimated the complainant that the reimbursement claim, against the claim documents submitted, has been registered. After waiting for some period, the complainant has asked the O.Ps with regard to status of the claim vide e-mail dated 15.8.2023. On 16.8.2023, the O.P No.3 has forwarded an email to the complainant, which is reproduced as follows “Pre term expenses are not payable. Baby was admitted with diagnosis as pre term resp distress syndrome. Please find below policy clause 3.4 and screen shot of discharge summary.” The complainant has sent an e-mail dated 18.8.2023 to O.Ps and the complainant has asked O.Ps that whether it is repudiation or some clarification is demanded by O.Ps vide the e-mail dated 16.8.2023 and further the complainant has submitted that clause 3.4 is not causing any hindrance in the way of the O.P’s for settling the claim. It is very much clear from the e-mail dated 16.8.2023 that O.Ps have taken one phrase from first line i.e "pre-term" and other phrase from second line i.e. "resp distress syndrom" from the discharge card. It is nowhere mentioned in the medical record that the baby was diagnosis as pre term resp distress syndrome as alleged by the O.P’s and the O.P’s have given their self created interpretation in this regard. The same is not desirable from the reputed company like NIA Ltd. & Paramount TPA as the whole contents of the discharge card are requires to be read in conjunction. As such, the above conduct of the O.P’s is gross unbussinesslike conduct. Afterwards, in the last week of August 2023, the complainant has received repudiation letter dated 21.7.2023 dispatched on 18.8.2023 issued by O.P No.2 to O.P No.1 as well as repudiation letter dated 1.8.2023 issued by the O.P No.1 to the complainant vide which the claim was repudiated. Ld. Counsel for the complainant further contended that the alleged grounds for repudiation of claim are baseless, misconceived and arbitrary grounds, which are neither having any relevancy nor applicable as per the facts of the present case, which is clear from the following discussion:-
First ground taken by the O.P’s for repudiation is as follows:- “Date of joining of policy is 09-05-2023 and date of admission is 09.05.2023. The claim is not admissible as expenses related to the treatment of any illness within 30 days from the first policy commencement date are not admissible as per clause 4.3 of the policy.”
In this regard it is first submission that first policy commencement date is of the year 2017 and the policy is continuous from more than 6 years. Further the Day One Baby Cover is also included from the year 2021, which is depicted in the policy valid from 30.03.2021 to 29.03.2022 and also in the policy covers of subsequent years. The clause 4.3(b) itself says that this exclusion clause shall not, however, apply if the insured person has continuous coverage for more than twelve month.
It is second submission that the clause 3.3 describes that “A new born baby is covered for any illness or injury from the date of birth till the expiry of this policy”.
All the above submissions in itself clarifies that a new born baby is covered for any illness from the day of birth.
Second ground taken by the O.P’s for repudiation is as follows:- “Any expenses incurred towards post-natal care, pre-term or pre-mature care or any such expenses incurred in connection with delivery of such new born baby would not covered”.
In this regard, first submission is that as per discharge card, baby was diagnosed with neonatal feed intolerance and further the chief complaints were severe respiratory syndrom, poor infusion as such baby was kept in NICU and during the treatment the baby was given antibiotics, other medicines etc as mentioned in the discharge card. It is nowhere mentioned in the discharge card that the baby was admitted for pre-term or pre-mature care.
The second submission is that as per policy clause 3.3, the expenses of "pre-term or pre-mature care" are excluded and the said clause does not excludes the expenses on hospitalization, the expenses incurred upon medical treatment given to baby born pre-term or pre-mature. In the present case, the baby was given the required medical treatment as detailed in discharge card, medical record, reports & voluminous pharmacy bills, which never comes within the narrow definition of "care only" rather the same comes within the definition of "treatment given due to medical reasons" and the same is not excluded.
Thirdly if this commission finds the alleged Clause 3.3 was hit by the Contra Proferentum rule: being ambiguous, it had to be interpreted in favour of the insured.
The important & Fourth submission in this regard is that there are some guidelines issued by the IRDAI, which are binding on the O.P’s. The circular dated 12th October 2022 issued by IRDAI speaks that “It is reiterated that all insurance products that cover newborns/unborn shall comply with the above referred provisions without any deviation and provide, coverage from day one (1) without imposing any waiting periods/sub-limits or any other restrictive conditions”. The said guidelines issued by IRDAI are having force of law and applicable upon all the insurance companies and consequently the alleged waiting periods/sub limits / restrictive conditions are not applicable to the policy in question.
6 One the other hands, Ld. Counsel for the opposite party No. 1 contended that the complainant is not legally maintainable and is liable to be dismissed. As per Terms and Conditions of NEW INDIA FLOATER MEDICLAIM POLICY, as per clause 5.18 Any dispute arises as to the amount payable for any claim the same shall be decided by reference to ARBITRATION. He further contended that the baby of the complainant and complainant is not a Consumer as defined in the Act and mere nomination does not have the effect of conferring to the nominee any beneficial interest in the amount payable under the policy. Further the counsel for the opposite party No. 1 contended that it is admitted case of the complainant that Baby has been born PRE MATURE at Gupta Hospital, Amritsar. Neither the complainant has filed nor tendered in evidence any record/ bed head ticket of Gupta Hospital, Amritsar in question. Hence the complaint is without any cause of action and is liable to be dismissed. The complaint filed by the complainant is time barred. Policy bearing No. 36100134222800000261 was issued in the name of policy holder Sh Mohinder Pal Arora and period of commencement of policy was 30.03.2023 to 29.03.2024 and as per the policy, the insured members were Sh Mohinder Pal Arora and Smt Pooja Rani. The wife of the complainant Smt Pooja Rani delivered a baby girl through caesarean operation at Gupta Hospital Amritsar on 9.5.2023 and the baby has been born PRE MATURE at Gupta Hospital Amritsar and this fact is admitted by the complainant in Para No 4 of the complaint. The complainant is concealing the true and material facts from this commission and intentionally has not mentioned the material reasons regarding caesarean operation in the complaint and why the new born baby was advised to refer to Florem Hospital Amritsar, as such, the complaint is liable to be dismissed on ground of concealment of true and material facts. As per the terms of the policy in question the baby of the complainant does not cover in the policy nor fall under the category of the Consumer. Even in the e-mail dated 31.5.2023 forwarded by the complainant, the complainant has not disclosed the medical reasons for referring the baby to Florem Hospital, Amritsar and also the complainant kept mum about the caesarean operation of his wife and pre term born baby. Even the complainant has not filed the bed head tickets and other relevant documents of Florem Hospital Amritsar with the complaint nor tendered in evidence, even more the complainant has not mentioned the name of concerned doctor who treated the baby of the complainant. As such, the opposite party No. 1 has rightly repudiated the claim of the complainant and there is no deficiency in service on the part of the opposite party. No. 1.
7 From the combined and harmonious reading of documents and pleadings is going to prove on record that in the present case insurance is not disputed as perusal of record i.e. Ex. C-2, the complainant is obtaining insurance policy of the opposite party No. 1 since the year 2017 and in the said policy there is day one baby cover since the inception of the policy and sum assured in the said policy was Rs. 5,00,000/- . As such, the daughter of the complainant is under the insurance cover since day one. The opposite party No. 1 has repudiated the claim of the complainant as per Ex. C-28 firstly on the ground that date of joining of policy is 9.5.2023 and date of admission is 9.5.2023 and further stated in repudiation letter that the claim is not admissible as expenses related to the treatment of any illness within 30 days from the first policy commencement date are not admissible. But we are not agreed with the version of the opposite party No. 1 because the complainant is obtaining the said policy since the year 2017 and with the day one baby cover and this version is very much clear from Ex. C-2 to Ex. C-5. This fact is also very much clear from the terms and conditions of the opposite party No. 1 i.e. 4.3(b) whereby, it has been mentioned that this exclusion shall not however, apply, if insured person has continuous coverage for more than twelve months. Hence, the opposite party No. 1 cannot raise this point that the treatment of illness is within 30 days from the inception of 1st policy. Secondly, the opposite party No. 1 repudiated the claim on the ground that any expenses incurred towards postnatal care, pre term or pre mature care or any such expenses incurred in connection with delivery of such new born baby would not cover, hence claim is not admissible under policy clause 4.3.2. But we are not agreed with the opposite party No. 1 as it is not a postnatal care, it was a postnatal treatment which is duly covered under the insurance policy. As per Ex. C-12 i.e. patient discharge card of Florem Hospital whereby in the diagnosis column it has been written PT(33 weeks)/ singrton/ SGA/Female/ RDS/EOS/Neobatal shock…… In the chief complaint it has been written baby was born pre term and admitted and in discharge card treatment course in the hospital has also been mentioned. So it is very much clear that it is not a postnatal care rather it is a course of treatment. As per clause 3.3 of terms and condition of policy of opposite party No. 1 New Born Baby coverage is reproduced as follows:-
A new Born Baby is covered for any illness or injury from the date of birth till the expiry of this policy, within the terms of this Policy. Any expense incurred towards the post-natal care, pre term or pre-mature care or any such expense incurred in connection with delivery of such New Born Baby would not be covered.
If this commission finds the alleged Clause 3.3 was hit by the Contra Proferentum rule: being ambiguous, it had to be interpreted in favour of the insured.
In this clause it has been specifically mentioned that pre term or pre mature care is not covered. But in the present complaint, the daughter of the complainant has not under gone pre mature care but she has been treated for illness which is duly covered under this clause. Hence, the opposite party No. 1 cannot repudiate the claim on this ground. Moreover, as per Ex. C-31 which is a circular of IRDA which was written to CEOs/ CMDs of all insurance companies(except ECGC and AIC) and the subject is insurance cover for new born/ infants under health insurance polices, in which it has been categorically stated at point No. 3 that in view of the above, it is reiterated that all insurance products that cover newborns/ unborns shall comply with the above referred provisions without any deviation and provide, coverage from day one (1) without imposing any waiting periods/ sub-limits or any other restrictive conditions. So this is very much clear from this circular of IRDA that the insurance companies cannot imposes any waiting period / sub limits or any other restrictive conditions which has been imposed by the opposite party No. 1 in the repudiation letter where by it has been written that pre term or pre mature care is not covered. But as per the circular, the insurance companies cannot impose any restrictive conditions. Consequently, the grounds taken by the opposite party No. 1 in repudiation letter are not genuine. Moreover, the opposite party No. 1 has withheld the genuine claim of the complainant on the above said baseless grounds, the opposite party No. 1 has also not made any effort to bring on record any expert opinion of some specialized doctor to ascertain that whether it was the postnatal care and postnatal treatment and also failed to establish on the record that the nexus between the treatment and care. As per terms and conditions of the opposite party No. 13, the complainant is entitled to the insurance claim as prayed for.
8 It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9 The opposite party No. 1 has not released the genuine claim of the complainant, as such, it amounts to deficiency in service and unfair trade practice on the part of the opposite party No. 1.
10 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Party No. 1 is directed to make the insurance claim i.e. Rs. 4,21,693/- to the complainant. The complainant has been harassed by the opposite party No. 1 unnecessarily for a long time. The complainant is also entitled to Rs. 25,000/- as compensation on account of harassment and mental agony and Rs 11,000/- as litigation expenses. Opposite Party No. 1 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. The present complaint against the opposite parties No. 2 and 3 stands dismissed. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.
Announced in Open Commission
17.09.2024
