Haryana

Ambala

CC/39/2016

Jatinder Singh - Complainant(s)

Versus

The New India Assurance Co.Ltd. - Opp.Party(s)

Vishal Mittal

19 Jan 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 39 of 2016.

                                                          Date of Institution         : 06.01.2016.

                                                          Date of decision   : 19.01.2018

 

Jatinder Singh son of Sh.Daya Singh resident of H.No.69-A, Shastri Colony, Ambala Cantt.

……. Complainant.

                                      Versus

 

The New India Assurance Company Limited 5406, Shree Complex, 2^nd Floor, Cross Road No.3, Punjabi Mohalla, Ambala Cantt. through its Branch Manager.

 

                                                                             ….…. Opposite party.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER         

                   MS. ANAMIKA GUPTA, MEMBER                 

 

Present:       Sh.Vishal Mittal, counsel for complainant.

                   Sh.J.S.Rathore, counsel for OP.

 

ORDER

                   The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that he had purchased a joint medi-claim policy bearing No.35350134142500000173 alongwith his wife Daljeet Kaur having validity from 26.05.2014 to 25.05.2015 wherein all the diseases have been covered.  In the month of January, 2015, the complainant got himself examined from doctor on 14.01.2015 as there was infection in his foot and the doctor had advised that the complainant is suffering from severe diabetic infection in the foot and referred him to diabetic foot care & wound care Centre New Delhi. He visited the doctor at New Delhi on 16.01.2015 and remained there till 27.01.2015 in a hotel adjacent to the hospital of doctor and took treatment and thereafter took follow up treatment upto 07.04.2015 and also spent Rs.2,33,598/- on treatment. The complainant submitted his claim alongwith requisite documents to the Op but vide letter dated 03.12.2015 it repudiated the same on false and flimsy grounds.  The act and conduct of the OPs clearly amounts to deficiency in service. In evidence, the complainant has tendered affidavit Annexure CX and documents Annexure C1 to Annexure C40.

2.                On notice, OP appeared and filed reply to the complaint wherein preliminary objections such as maintainability, locus standi, non-joinder of necessary parties and concealment of material facts from this Forum etc. have been taken. It has been submitted that all the terms and conditions were duly mentioned in the medi-claim policy and explained to the complainant.  The claim of the complainant has rightly been rejected as he has been failed to comply with the terms and conditions of the policy in question.  There is no deficiency in service on the part of OP. Other contentions made in the complaint have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OP has tendered affidavit Annexure RX and documents Annexure R1 & Annexure R2.

3.                We have heard learned counsel for the parties and gone through the case file very carefully.

4.                Learned counsel for the complainant has argued that the complainant had purchased the medi-claim policy by paying a sum of Rs.29,913/- as premium (Annexure R1) from the Op. He felt ill during the subsistence of the policy and spent Rs.2,33,598/- on treatment but the OP has wrongly repudiated the claim.

                   On the other hand learned counsel for the Op has argued that the complainant might have fallen ill and spent Rs.2,33,598/- but the OP has rightly repudiated the claim of the complainant as per Clause No.2.16.1 of the terms and conditions of the policy.

5.                          After hearing learned counsel for the parties and going through the record available on the case file it is desirable to reproduce Section 2.16.1 of the terms and conditions of the policy, which is as under:

“2.16.1 Hospitalization means admission in a hospital for a minimum period of twenty four in-patient care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than twenty four consecutive hours”.

Perusal of this condition reveals that the complainant would become entitle for the claim in case he remains hospitalize atleast 24 consecutive hours  but there is nothing on the file to suggest that he ever remained hospitalized for 24 consecutive hours. Documents Annexure C3 reveals that the complainant was referred to Foot Care Centre and thereafter he visited the hospital for Diabetic Foot Care & Wound Centre at New Delhi (Annexure C4).  The treating doctor has also given certificate Annexure C38 wherein he has mentioned that Sh.Jatinder Singh was suffering with severe Diabetic Foot infection & ulcer for which has to undergo emergency surgical debridement on 16.01.2015 at our day care centre at Nariana. He was admitted from 8 A.M. to 8 P.M. on 16.01.2015 for I.V.antiboitics and surgical debridement after which he was shifted to hotel nearby to our centre. We do not do 24 hours/overnight admission at our centre.   Undisputedly, the complainant has taken treatment from the doctor at New Delhi but when the treating doctor himself has specifically certified that he was not having any 24 hours/overnight admission service therefore it is clear that the complainant has not been hospitalized for 24 consecutive hours which was mandatory as per Clause 2.16.1 of the terms and conditions of the policy.  It is a settled law that terms and conditions are applicable to both the parties as they are bound by the same.  On this point Hon’ble Supreme Court of India in case cited as Suraj Mal Ram Niwas Oil Mills (P) Ltd. Vs. United India Insurance Co. Ltd. & Anr., - 2011 CTJ 11 (SC)(CP) wherein the Division Bench of the Hon’ble Apex Court consisting of Hon’ble Mr. Justice D.K. Jain and Hon’ble Mr. Justice T.S. Thakur, held that:

 

“22.   Before embarking on an examination of the correctness of the grounds of repudiation of the policy, it would be apposite to examine the nature of a contract of insurance. It is trite that in a contract of insurance, the rights and obligations are governed by the terms of the said contract. Therefore, the terms of a contract of insurance have to be strictly construed, and no exception can be made on the ground of equity…..”     

 

24.    Thus, it needs little emphasis that in construing the terms of a contract of insurance, the words used therein must be given paramount importance, and it is not open for the Court to add, delete or substitute any words. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed to determine the extent of liability of the insurer. Therefore, the endeavour of the court should always be to interpret the words in which the contract is expressed by the parties.

 

The complainant has failed to prove on the case file that he was hospitalized for 24 consecutive hours by leading cogent and reliable evidence; therefore, the present complaint deserves dismissal.

                             Keeping in view the facts and circumstances of the case we have no hitch to reach at a conclusion that the OP has rightly repudiated the claim of the complainant. Accordingly, we dismiss the present complaint leaving the parties to bear their own costs. Copy of this order be supplied to both the parties free of costs.  File be consigned to the record room after due compliance.

 

ANNOUNCED ON:      19.01.2018

                                               

(PUSHPENDER KUMAR)     (ANAMIKA GUPTA)      (D.N.ARORA)                      MEMBER                  MEMBER                          PRESIDENT