Haryana

Ambala

CC/42/2016

Lal Chand Mittal - Complainant(s)

Versus

The Oriental Inss Co. - Opp.Party(s)

Deepak Kumar

27 Mar 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AMBALA

 

                                                          Complaint case no.        : 42 of 2016

                                                          Date of Institution         : 08.01.2016.

                                                          Date of decision   : 27.03.2018.

 

1. Lal Chand Mittal son of Shri Siri Ram aged 60 years.
2. Santosh Kumari wife of Shri Lal Chand Mittal aged 56 years both residents of house No.18, A/D, Rani Bagh, Ambala Cantt.

……. Complainant.

                                      Versus

 

The Oriental Insurance Company Ltd. through its Authorised Signatory LIC Building, Ground Floor, Ambala City.

                                                                             ….…. Opposite party.

 

BEFORE:   SH. D.N. ARORA, PRESIDENT

                   SH. PUSHPENDER KUMAR, MEMBER         

                   MS. ANAMIKA GUPTA, MEMBER                 

 

Present:       Sh.Deepak Kumar, counsel for complainants.

                   Sh.Raj Kumar Jindal, counsel for OP.

 

ORDER

                   The complainants have filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that they had purchased a medi-claim policy and the Op had issued policy certificate No.261101/ 48/ 2011/ 1748 having validity from 16.02.2011 to midnight of 15.02.2012 which was further renewed vide policy No.261101/48/2012/1679 valid from 16.02.2012 to 15.02.2013 and prior thereto the complainant No.2 had taken policy from National Insurance Company and the same remained continue from 2004 till 2012. At the time of renewal of policy No. 261101/ 48/ 2011/ 1748 the complainants have brought the factum of policy in the name of complainant No.2 from NIC and also produced relevant documents and the Op had assured that the said policy shall be deemed as continue and further assured that the risk cover of his wife would be continue since the date of purchasing of policy. On 17.11.2012, the complainant no.2 was admitted in Rotary Ambala Cancer & General Hospital due to acute pain in her chest she was admitted in hospital on 18.11.2012 with advice for Angiograhy. She was again admitted in said hospital on 21.11.2012 for Angiograhy where she suffered paralysis attack and was referred to Fortis Hospital. The complainants have spent Rs.1,13,750/-  on her treatment and as per directions and requirement the complainants submitted the claim form with it for reimbursement of the claim but it has failed to settle the claim. They got served legal notice upon the OP but to no avail. The act and conduct of the OP clearly amounts to deficiency in service. In evidence, the complainants have tendered affidavit Annexure CX and documents Annexure C1 to Annexure C20.

2.                On notice, OP appeared and filed reply to the complaint wherein preliminary objections such as maintainability, locus standi, jurisdiction and concealment of material facts from this Forum etc. have been taken. It has been submitted that the hospitalization period was less than 24 hours as the procedure performed was a day care procedure and not covered under the list of produce as listed at 2.3 (A) and 2.3 (C). Moreover, the complainant has been suffering from hypertension & Diabetes prior to inception of the policy, therefore, the claim of the complainant has been rightly repudiated vide letter dated 23.04.2014. There is no deficiency in service on the part of OP. Other contentions have been controverted and prayer for dismissal of the complaint has been made. In evidence, the OP has tendered affidavit Annexure RA and documents Annexure  R1 and Annexure R2.

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

4.                Learned counsel for the complainants has argued that the complainants had purchased the medi-claim policy Annexure C1 from the Op and complainant No.2 felt ill during the subsistence of the policy, therefore, she was hospitalized and spent a sum of Rs.1,13,750/- but the OP did not pay the insured amount wrongly and illegally.

5.                On the other hand learned counsel for the Op has argued that the complainant No.2 might have fallen ill and spent Rs.1,13,750/- but the OP has rightly repudiated the claim of the complainants because the hospitalization period was less than 24 hours as the procedure performed was a day care procedure and not covered under the list of produce as listed at 2.3 (A) and 2.3 (C) of the terms and conditions of the policy.  

6.                          After hearing learned counsel for the parties and going through the record available on the case file it is desirable to reproduce Section 2.3 (A) 2.3 (C) of the terms and conditions of the policy, which are as under:

“2.3 : Hospitalization Period- Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 (Twenty Four) Hours.

1. (A) The time limit shall not apply to following specific treatment taken in the network hospital/nursing home where the insured is discharged on the same day. Such treatment shall be considered to be taken under Hospitalization benefit.

i.Dialysis (haemo dialysis, Peritoneal dialysis)

ii. Parental Chemotherapy (injectible)

iii. Radiotherapy,

iv. Eye Surgery,

v. Lithotripsy (kidney stone removal),

vi. Tonsillectomy,

vii. Dilation and Curettage (D&C)

viii. Dental surgery following an accident

ix. Hysterectomy

x. Coronary Angioplasty

xi. Coronary Angiography

xii. Surgery of Gall bladder, Pancreas and bile duct

xiii. Surgery of Hernia

xiv. Surgery of Hydrocele.

xv. Surgery of Prostrate.

xvi. Gastrointestinal Surgery.

xvii. Genital Surgery.

xviii. Surgery of Nose.

xix. Surgery of throat and ear.

xx. Surgery of Appendix.

xxi. Surgery of Urinary System.

xxii. Treatment of fractures / dislocation excluding hair line fracture, Contracture releases

and minor reconstructive procedures of limbs which otherwise require

hospitalisation.

xxiii. Arthroscopic Knee surgery.

xxiv. Laproscopic therapeutic surgeries.

xxv. Any surgery under General Anaesthesia.

xxvi. Any such disease / procedure agreed by TPA/Company before treatment.

2.3 (C) Other than the treatments mentioned under 2.3 (A) the condition of minimum 24 hours hospitalization SHALL also not apply provided

1. The treatment is that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitals,

          OR

3)Surgical procedure involved has to be done under General Anesthesia

          BUT

II) Due to technological advances hospitalization in either of the case is required for leass than 24 (Twenty Four) hours.”

As such the relaxation of admission of 24 hours can be given as per 2.3.   

Perusal of the above said conditions reveal that the complainants would become entitle for the claim in case any of the complainant remains hospitalize atleast 24 consecutive hours  but there is nothing on the file to suggest that complainant No.2 ever remained hospitalized for 24 consecutive hours. Documents Annexure C9, Annexure 11, Annexure C12 to Annexure C16 are the medical record of the complainant No.2 but it does not show that she has ever remained admitted in hospital for atleast 24 hours therefore it is clear that the complainant No.2 has not been hospitalized for 24 consecutive hours which was mandatory as per Clause 2.3 (A) 2.3 (C) of the terms and conditions of the policy.  Moreover, as per Annexure 14 the complainant has taken treatment for Enhanced External Counter Pulsation (EECP) one hour daily from 21.05.2013 to 09.07.2013 in Drss Heart Clinic from Dr.Kavi Sharma (BHMS (Pb) MD Hom.) and not in any hospital, the alleged therapy taken by complainant No.2 did not require hospitalization, procedure and General  Anesthesia. As such the alleged therapy/treatment taken by the complainant No.2 does not cover the treatment mentioned in the 2.3 (A), 2.3 (B) 2.3 (C) because as per Clause 2.3 of the terms and conditions of the policy in question the complainants are not entitled to the amount spent by them on the alleged treatment. 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 complainants have failed to prove on the case file that complainant No.2 was hospitalized for 24 consecutive hours by leading cogent and reliable evidence; therefore, the present complaint deserves dismissal.

7.                          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:      27.03.2018

                                               

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