DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II U.T. CHANDIGARH [Complaint Case No:448 of 2011] Date of Institution: 22.09.2011 Date of Decision : 04.04.2012 Sh. Gulzari Lal Anand son of Late Sh. Inder Singh resident of House No.3162, Sector 23-D, Chandigarh. ---Complainant. (VERSUS) The New India Assurance Company Limited, Divisional Office-I, SCO No.36-37, Ground Floor, Sector 17-A, Chandigarh through its Divisional Manager. ---Opposite Party. BEFORE: SHRI LAKSHMAN SHARMA PRESIDENT SMT. MADHU MUTNEJA MEMBER SH. JASWINDER SINGH SIDHU MEMBER Argued By: Sh. Parminder Singh, Advocate for the complainant. Sh. Sanjeev K. Arora, Advocate for the OP. PER LAKSHMAN SHARMA, PRESIDENT 1. Sh. Gulzari Lal Anand has filed this complaint under section 12 of the Consumer Protection Act, 1986 praying therein that OP be directed:- i) To pay a sum of Rs.24,523/- spent on the treatment of the complainant; ii) To pay Rs.25,000/- as compensation for physical harassment and mental tension; iii) To pay Rs.15,000/- as litigation charges; iv) Award any other relief, which the Forum deems fit in the facts and circumstance of the case. 2. In brief the case of the complainant is that he took a Mediclaim Policy (2007), for himself and his wife and two children, bearing No.350100/34/09/11/0000464 (Annexure C-1) for Rs.1,25,000/- from the OP valid for the period from 29.10.2009 to 26.10.2010. The complainant paid a premium of Rs.7,286/-. It is averred that in the month of July 2010, the complainant had suffered from the disease FISTULA IN ANO. On 09.07.2010, he was admitted in G.M. Nursing Home and Clinic, Sector 34-D, Chandigarh where he was medically treated. After recovering from the said disease, the complainant was discharged the next day i.e.10.07.2010. He spent a total sum of Rs.24,523/- on his treatment vide Bills [Annexure C-3(Colly)]. The complainant, thereafter, sent all the original bills to the OP and Raksha TPA for settling his claim. He also supplied all the relevant documents along with a Certificate (Annexure C-5) as demanded by the OP. However, the said Raksha TPA repudiated the claim vide letter dated 27.09.2010 (Annexure C-6) on the ground that the G.M. Nursing Home and Clinic from where the complainant had taken treatment does not come under the definition of the Hospital as per the Policy Guidelines (4 Bedded). According to the complainant, no terms and conditions/ Guidelines of the Mediclaim Policy were ever supplied to him by the OP either at the time of taking the policy or at the time of repudiation of the claim. Thereafter, the complainant wrote letter dated 29.12.2010 (Annexure C-7) to the OP as well as the Raksha TPA for redressal of his grievance but to no effect. Thus, according to the complainant, repudiation of his genuine claim by the OP amounts to deficiency in service and unfair trade practice. In these circumstances, the present complaint has been filed seeking the reliefs mentioned above. 3. In the written statement filed by the OP, the factum of issuance of Mediclaim Policy (2007) bearing No.350100/34/09/11/0000464for Rs.1,25,000/-, valid for the period from 29.10.2009 to 26.10.2010, has been admitted. It is also been admitted that the complainant submitted all the original bills to the TPA of the OP. According to the OP, the complainant took the treatment from a Nursing Home, which was neither registered nor fulfilled the condition of having capacity of at least 10 In-Door patients. It is also pleaded that the complainant is not entitled for complete reimbursement as per Policy Condition No.21, which states that the Room, Boarding and Nursing Expenses should not exceed 1% of the sum insured (excluding Cumulative Bonus). According to the complainant, since the complainant has not fulfilled the condition of getting himself treated in at least 10-Bedded Hospital, so, his claim was rightly repudiated. According to the OP, there is no deficiency in service on their part. So, the complaint deserves dismissal. 4. We have heard the learned counsel for the parties and perused the record carefully. 5. It is the admitted case of the parties that the complainant had taken treatment from G.M. Nursing Home and Clinic, Sector 34-D, Chandigarh. The claim filed by the complainant was repudiated vide letter dated 27.09.2010 (Annexure C-6). The relevant para of the same reads as under: - “Observation and Opinion. PATIENT SUFFERED FROM FISTULA IN ANO. HOSPITALIZED AT G.M. NUSRING HOME AND CLINIC FROM 9/7/2010 (7 AM) TO 10/7/2010 (10 PM). ON GOING THROUGH THE RECORDS IT IS FOUND THAT HOSPITAL DO NOT FULFIL THE DEFINATION OF HOSPITAL AS PER POLICY GUIDELINES (4 BEDDED). THEREFORE, CLAIM IS NON PAYABLE AS PER CONDITION 3.4 FISTULA IN ANO.” 6. Annexure R-1 is the copy of Mediclaim Policy containing the terms and conditions of the contract. Clause 3(2) of the said policy defines “HOSPITAL/ NURSING HOME” as under: - “3.2. HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which has been registered either as a hospital or nursing home with the local authorities and is under the supervision of a registered and qualified medical practitioner, or complies with minimum criteria as under: (a) Must have a minimum of: 10 in-patient beds if located in towns having population of less than 10 Lacs or 15 in-patient beds if located in other towns. (b) Fully equipped operation theatre of its own wherever surgical operations are carried out. (c) Fully qualified Nursing Staff under its employment round the clock. (d) Fully qualified Medical Practitione4r should be in-charge round the clock. (e) Maintains daily medical record for each of its patients. Note: In case of Ayurvedic Homeopathic/Unani Treatment (b) is not applicable. In case of Day Care Centre, (a) is not applicable. For the purpose of this definition the term Hospital/Nursing Home/Day Care Center shall not include an establishment, which is a place of rest, a place for the aged, a place for drug addicts or place for alcoholics, a hotel or any other like place.” 7. There is nothing on record to prove that the said G.M. Nursing Home and Clinic is registered as a “Hospital” or “Nursing Home” with the appropriate local authoritiesnor there is any material on record to prove that it is a 10 Bedded Hospital. The learned counsel for the complainant has failed to draw our attention to any document to prove that the said Nursing Home and Clinic falls within the definition of “HOSPITAL/NURSING HOME”. From the Certificate (Annexure C-5) issued by G.M. Nursing Home and Clinic itself, it is proved that the said Nursing Home and Clinic does not fall within the definition of “HOSPITAL/NURSING HOME” as defined in Clause 3(2) of the terms and conditions of the Policy. 8. Faced with this situation, it was argued vehemently by the learned counsel for the complainant that neither the terms and conditions mentioned above were conveyed to the complainant along with the policy nor the complainant was made aware about this exclusion clause. So, the said clause is not binding on the complainant and the repudiation of the claim on this score is illegal and unjustified. 9. Our attention has been drawn to Para No.7 of the complaint wherein the complainant has pleaded as under: - “…….It is pertinent to mention here that neither at the time of taking the policy the Specific terms and Guidelines of Policies were intimated to the complainant nor even at the time of repudiation, these Guidelines were shown to the complainant.” 10. The averment made in Para No.7 of the complaint is also supported by the affidavit of the complainant. 11. In the written statement, the contents of this paragraph have not been specifically denied. The above said averments have not been specifically denied. So, the said averments go unrebutted. Furthermore, the complainant has placed on record the copy of the policy supplied to him. From perusal thereof, it is apparent that the said terms and conditions are not the part of the same. No doubt, it has been mentioned in this document that “CLAUSE ATTACHED HEREWITH” but according to the complainant, the said clause was not attached with it and was not supplied to him. As mentioned above, the averments to this effect go unrebutted. So, the said averments have to be accepted, which are supported by an affidavit of the complainant. So, there is nothing on record to prove that the Exclusion Clause, on the basis of which the claim has been repudiated, was brought to the notice of the complainant at the time of issuance of the policy or thereafter. 12. In the case titled United India Insurance Co. Ltd. Vs. S.M.S. Tele Communications & Anr., III (2009) CPJ 246 (NC), the Hon’ble National Consumer Disputes Redressal Commission, New Delhi has held in Para No.15 as under: - “15.Being aware of the existence of the policy is one thing and being aware of the contents and meaning of the clauses of the policy is another. It is not the case of the Insurance Company that the contents and the meaning of the policy were made known to the complainant (SMS). It is also nowhere on record that the Insurance Company had explained the meaning of all the exclusion clauses to the Bank and requested them in turn to bring them to the notice of the complainant.” 13. The ratio of the case titled United India Insurance Co. Ltd. Vs. S.M.S. Tele Communications & Anr. (Supra) is squarely applicable to the facts of the present complaint. 14. In these circumstances, to our mind, as the Exclusion Clause was not brought to the notice of the complainant at the time of issuance of the policy or thereafter. So, repudiation of the claim is illegal and unjust. It amounts to deficiency in service. 15. In view of the above findings, this complaint is allowed with following directions to the OP to:- i) To pay a sum of Rs.24,523/- to the complainant being the claim amount; iii) Pay a sum of Rs.15,000/- to the complainant as compensation mental agony and physical harassment; iv) Pay a sum of Rs.7,000/- to the complainant as costs of litigation. 16. This order be complied with by the OP within 45 days from the date of receipt of its certified copy, failing which OPs shall be liable to pay Rs.39,523/- i.e. [Rs.24,523 + Rs.15,000] along with interest @18% per annum from the date of filing the present complaint i.e.22.09.2011 till actual payment besides payment of Rs.7,000/- as costs of litigation. 17. Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room. Announced. 4th April 2012. (LAKSHMAN SHARMA) PRESIDENT (MADHU MUTNEJA) MEMBER (JASWINDER SINDH SIDHU) MEMBER Ad/- C.C.No.448 of 2011 PRESENT: None. --- Arguments heard on 03.04.2012. The case was reserved for orders. As per separate detailed order of even date, this complaint has been allowed. After compliance file be consigned. Announced. 04.04.2012 Member President Member
| | MRS. MADHU MUTNEJA, MEMBER | HONABLE MR. LAKSHMAN SHARMA, PRESIDENT | MR. JASWINDER SINGH SIDHU, MEMBER | | 
