CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/283/2017
No. DF/ Central/ Date
Shri Sachin Aggarwal,
S/o Late Sh. Vinod Kumar
R/o K-42, Vijay Vihar, Phase-II,
Sector-4, Rohini, Delhi-110082. …..COMPLAINANT
VERSUS
The Oriental Insurance Company Ltd.
2E/16, Swami Ram Tirah Nagar,
Jhandewalan Extn., New Delhi-110055.
M/s Park Mediclaim TPA Pvt. Ltd.
702, Vikrant Towers, Rajendra Place,
New Delhi-110008. …..OPPOSITE PARTIES
Quorum : Ms. Rekha Rani, President
Mr. R.C. Meena, Member
Ms. Manju Bala Sharma, Member
ORDER
Ms. Rekha Rani, President
1. Instant complaint has been filed by Sh. Sachin Aggarwal (in short the complainant) under Section 12 of the Consumer Protection Act, 1986 as amended against The Oriental Insurance Company Ltd. (in short OP) pleading therein that he is a mediclaim policy (Happy Family Floater Policy Schedule) holder of OP1 vide policy no. 272302/48/2017/1705 valid for the period 10.02.2017 to 09.02.2017. On 22.09.2017 he suffered from a severe headache followed by transient unconsciousness and fall and he was immediately shifted to Ekansh Nursing Home, where he got admitted on advice of Dr. R. Prashar. On the next day, he informed OP2 about his hospitalization. He was discharged on 25.09.2017. He submitted his claim of Rs. 39,513/- along with original documents to OP2 who thereafter raised a query on 16.10.2017 which was duly replied by him on 23.10.2017. Thereafter he did not receive any response from the OP. Hence, the instant complaint was filed seeking direction to OP to pay to the complainant a sum of Rs. 39,513/- towards the insured amount along with interest @ 12% per annum, Rs. 25,000/- as compensation for causing mental agony and Rs. 25,000/- towards litigation expenses.
2. On receipt of notice of the instant complaint, OP appeared and contested the claim vide reply. It is submitted that complainant failed to submit the documents required by OP for settlement of his claim as intimated vide letters dated 16.10.2017 and 17.11.2017 and he was given a final notice on 13.12.2017 that if in case he failed to submit the required documents/information within 15 days, the claim will be closed as NO CLAIM. It is further stated that there was a violation of condition no. 2.1 of the insurance contract as the complainant chose to take treatment from a hospital/nursing home which was not registered for 15 beds.
3. Both side adduced evidence by way of affidavits. We have heard Sh. Sandeep Kumar, counsel for complainant and Sh. Lokesh Kumar Rai, counsel for OPs.
4. Our attention is drawn to condition no. 2.1 of the policy contract which reads as follows:
“2. DEFINATIONS:
2.1 HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.
OR
b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under
i. It should have at least 15 in-patient medical beds in case of Metro cities A Class cities & B class cities or 10 in-patient medical beds in case of C class cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time.
ii. Should have fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, ECG etc. for the care and treatment of injured or sick persons as in-patient.”
Copy of registration certificate issued by Directorate General of Health Services Government of NCT of Delhi is placed on record bearing registration no. DGHS/NH/657 dated 07.06.2017 which reads as under:
“It is certified that Ekansh Nursing Home 122-123, Shahbad, Daulat Pur, Delhi-110042 with -10- beds is being run by Mr. Manish Gupta has been registered under Delhi Nursing Homes Registration Act, 1953 and is authorized to carry out permitted nursing home activities at the above said premises.”
As per condition no. 2.1 of the policy, hospital/nursing home in metro cities should have at least 15 in-patient beds. Delhi is a metro city. Therefore, the above said nursing home does not meet the requirement of having at least 15 in-patient beds.
5. In ICICI Prudential Life Insurance vs. Anil Kumar Jain First Appeal No. FA-09/27 vide its order dated 01.02.2010 our State Commission observed that:
“the complainant had a severe Chest Pain and the doctor attending him diagnosed Coronary Artery Disease (Unstable Angina III B), and placed an Stent inside his Right Coronary Artery (2.75 x 23 mm axxion) on 12.11.07, and his was a case of known type II Diabetes Mellitus and Hypertension.
10. The insurance company refused to pay the compensation on the ground that the disease suffered by the insured did not fulfill the conditions as mentioned in the Insurance Cover Note.
12. ……It is manifest that the respondent suffered a serious Heart Ailment and an arterie was found blocked and a stent was placed. It was a very serious condition and if such a Heart Ailment is not compensable, what other disease, will be required for grant of reimbursement. It is not open to the Insurance Company to place conditions which are unlikely to be fulfilled with a view to create a device to escape payment of compensation. It amounts to defrauding and cheating the customer. It is not open to Insurance Company to provide such particulars and details of the disease which quite often do not appear and which may provide a ground to the Insurance Company to avoid Payment of Compensation. Symptoms appearing in all kinds of Heart Ailment cannot always be the same, and merely because all symptoms are not 100% the same, the Insurance Company cannot avoid compensation. The ailment suffered by the respondent was highly serious and life threatening and the spirit and purport of the agreement must be assumed to be such, as to provide for such serious disease of Heart.”
State Commission accordingly held that insurer was not justified to withhold reimbursement of treatment charges and the compensation on the grounds enumerated in the Cover Note.
Insurance Company preferred Revision Petition No. 1234 of 2010 against the said order of the State Commission and vide its order dated 01.03.2017, National Commission observed that:
“Learned State Commission had no authority to rewrite terms & conditions of the policy as held by Hon’ble Apex Court in II (2013) CPJ 1(SC)- Export Credit Guarantee Corpn. of India Ltd. Vs. Garg Sons International; and in such circumstances, merely because opposite party has placed certain conditions which are unlikely to be fulfilled, insured cannot get benefits of the policy when his treatment is not covered by the policy.”
6. Hon’ble Supreme Court in United India Insurance Company Limited v. M/s. Harchand Rai Chandan Lal reported in JT 2004 (8) SC 8 has held that:
“The insurance policy has to be construed having reference only to the stipulations contained in it and no artificial farfetched meaning could be given to the words appearing in it….
In Oriental Insurance Co.Ltd. Vs. Sony Cheriyan reported in (1999) 6 SCC 451 Apex Court observed:
“The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy.”
Similarly in General Assurance Society Ltd. Vs. Chandumull Jain and Anr. (1966) 3 SCR 500 the Constitution Bench observed that the policy document being a contract has to be read strictly. It was observed, " In interpreting documents 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.”
7. As per the aforesaid judgments of Apex Court, policy documents have to be read strictly. Complainant having got treatment from Ekansh Nursing Home which was not recognized under the policy his claim was rightly repudiated. The complaint is dismissed. Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced this Day of 2019.
