Delhi

North

CC/209/2017

POONAM YADAV - Complainant(s)

Versus

THE ORIENTAL INSUARNCE CO. LTD. & Ors. - Opp.Party(s)

RAM KISHOR SINGH YADAV

05 Oct 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No. 209/2017

In the matter of

Ms.Poonam Yadav        

W/o Sh. Kaushal Yadav

D-121, First floor, Ramprastha Colony

Ghaziabad, U.P                                                                                                                                       ... Complainant

Versus

The Oriental Insurance Company Ltd.

Through its General Manager

Oriental House, P.B. No.7037

A-25/27, Asaf Ali Road, New Delhi-110002                                                                                         …Opposite Party-1

 

Medicare TPA Services (I) Pvt. Ltd.

Through its Regional Manager

13J, 13^th floor, Gopala Towers

Rajendra Place, New Delhi-110008                                        

Also at:

Flat No.10, Paul Mansion 6-B

Bishaq Lefroy Road, Calcutta-700020                                                                                                    …Opposite Party-2

 

 

Supreme Court Bar Association (Regd.)

Through its secretary

Supreme Court Compound, Tilak Marg

New Delhi                                                                                                                                               …Opposite Party-3

ORDER
05/10/2023

Ms.Harpreet Kaur Charya, Member:                                                                      The present complaint has been filed by Ms. Poonam Yadav, the complainant against, the Oriental Insurance Company Ltd. as OP-1; Medicare TPA Services (I)Pvt. Ltd. as OP-2 and Supreme Court Bar Association (Regd.) as OP-3.

1. Facts necessary for the disposal of the present complaint are that in the year 2015, the husband of the complainant, Sh. Kaushal Yadav purchased the comprehensive SCBA Advocate Group Medical Policy at a premium of Rs.6,498/-. Membership card No.09101304679A and 09101304679B were issued, under policy No.212800/482016/46 for a period from 16/10/2015 to 15/10/2016.  A booklet containing the benefits under the policy and the procedure to be followed for availing the benefits was provided by OP-2.
2. As per the booklet, under the head “Benefits under the Group Medi-claim Insurance” the waiting period for the first year and the second year was waived off, besides disclosing the procedure for cashless benefit and reimbursement of claim settlement.
3. On 07/10/2016, a claim for reimbursement of Rs.81,487/- was registered with OP-2,  as the complainant had undergone IVF treatment/procedure at AIIMS, Delhi . It has been stated that OP-2 had been informed well in advance through email about the IVF treatment.
4. The claim was received by OP-2 on 08/10/2016 and was rejected and communicated by OP-3, through email dated 23/03/2017on the ground under the Exclusion Clause, the policy clause 4.4.6.  The complainant has stated that as per the present booklet provided by OP-1, there is no clause 4.4.6. under para 4 of the exclusion of the policy, in fact, there is clause 4.8 which excludes the diseases mentioned therein when the same arise due to and or use, misuse or abuse of drugs, alcohol or use of intoxicating substance or such abuse or addiction etc. which was not applicable to the case of the complainant.
5. Despite, sending an email dated 18/04/2017 to OP-2 and OP-3, explaining/distinguishing the case of the complainant from the Exclusion Clause 4.8 of the policy terms and conditions, the claim of the complainant was not settled even after a lapse of one year.  The complainant has prayed for reimbursement of Rs.81,487/- along with interest @ 24% p.a. from 07/10/2016 till realization; compensation of Rs.5,00,000/- on account of mental agony and harassment and compensatory cost in favour of the complainant.
6. The complainant has annexed copy of circular dated 15/10/2015 as Annexure C-1, copy of the membership card and Guide book as Annexure C-2 (colly), copy of the booklet of the OP-1 as Annesrue-C-3, copy of the entire mediclaim alongwith postal receipt as AnnexureC-4 (colly), copy of the email dated 22/03/2017 and 18/04/2017 as Annexure C-5 and Annexure C-6 respectively.
7. Notice of the present complaint was served upon OP-1 to OP-3.  None appeared on behalf of OP-2 despite service, hence, they were proceeded ex-parte vide order dated 23/04/2018.
8. Written statement on behalf of OP-1 was filed, where they have taken several preliminary objections such as: complaint is frivolous and vexatious; there is no deficiency on their part.  It has been submitted that OP-1 had issued Group Mediclaim Insurance Policy bearing No.212800/48/2016/46 with  a policy period from 16/10/2015 to 15/10/2016, in the favour of members of SCBA with the policy risk cover of Rs.5,00,000/- (Overall liability) subject to strict compliance of terms and conditions. 
9. It has been submitted that the OP-2 after scrutiny found that the claim of the complainant was not payable as per clause 4.4.8 of the policy terms and condition, hence, it was denied.

Clause 4.4.8-Exclusion: -  the company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by insured person in connection with or in respect of –Convalescence, general debility, run down condition or rest cure, congenital external diseases or defect or anomalies, Sterility, any fertility, sub fertility or assisted conception procedure, venereal  disease, intentional self-injury /suicide, all psychiatric  and psychosomatic disorders and diseases/accident due to and or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc. under the terms and conditions of the insurance policy.

 

10. As, the complainant was admitted at AIIMS hospital for the treatment of IVF, which is an assisted conception procedure as mentioned in the Exclusion Clause No.4.8 of the policy therefore, the reimbursement for the said treatment/procedure was not covered under the insurance contract.  Hence, OP-1 was not liable to pay the claim. 
11. They have further submitted that there was typographical error of 4.4.6 on rejection mail/letter issued by TPA, the claim was rejected under clause 4.4.8 of the Exclusion Clause.  The said claim was rejected on the ground of the sterility, fertility and sub fertility ‘and’ not on use, misuse or abuse of drug, alcohol or use of intoxicating substance. Rest of the content of the complaint have been denied with the prayer of dismissal of the present complaint with heavy cost.  Copy of the Group medi-claim tailor-made policy schedule along with terms and condition is Annexure R-1 (colly)
12. Rejoinder to the written statement on behalf of OP-1 was filed by the complainant. The contents of the written statement have been denied and those of complaint have been reiterated.  It has been reaffirmed that as per the rejection dated 23/03/2017, the claim was denied under Clause 4.4.6 which was not applicable to the case of the complainant.
13. Evidence by way of affidavit was filed on behalf of the complainant, where the complainant has got herself examined and Sh.Vikrant Yadav, Secretary, Supreme Court Bar Association, Supreme Court of India.  The complainant has reiterated the assertion made in the complaint and has got exhibited the circular dated 15/10/2015 as Ex.CW-1.  The presentation booklet and the membership card with policy document are Ex.CW-2 and Ex.CW-3 respectively.  It has been stated that the husband of the complainant had informed OP-1 vide email dated 03/09/2016 about the starting of the treatment and again through an email dated 01/09/2016, regarding the deposit of Rs.60,000/- which was never objected by OP-1  on the ground that the same was excluded under the policy terms and conditions.  The said emails have been exhibited as Ex.CW-4. Claim Form along with bill and receipts of the expenses are Ex.CW-5 (colly).  An email dated 23/02/2017 rejecting the claim under clause 4.4.6 is Ex.CW-6. 
14. Sh.Vikrant Yadav has deposed on oath that, in the year 2015, the SCBA had introduced a Group Insurance Policy for the benefits of its member and   OP-1 was the vendor of the said medical policy.  The said policy was divided under three proposals namely proposal A, B and C.  The complainant being spouse of the member was covered under the policy vide membership No.09101304679A and 09101304679B.  He has further deposed that the OP had assured the waiver of the congenital diseases and has got the booklet exhibited as Ex.CW-1/B and has supported the claim of the complainant.
15. Sh. Sunmeet Sachdeva, Senior Manager has been examined on behalf of   OP-1.  He has deposed that he is the Authorised Representative of OP-1. He has got exhibited the copy of the insurance policy along with terms and condition as Ex.R-1 and has repeated the content of their written statement. 
16. We have heard the arguments made by the Ld. Counsel for the complainant and the Ld. Counsel for the OP (appearing through VC) and have perused the material placed on record. The claim for reimbursement of Rs. 81,487/- has been rejected by OP-1, on the ground that same is not payable under Exclusion Clause of the policy terms and conditions. This was communicated to the complainant vide email dated 23/03/2017, sent by   OP-2 and the same is being reproduced here under :-

Claims arising out of sterility, treatment whether to effect or to treat infertility, Sub fertility, Assisted Conception Procedure, Surrogate or Vicarious Pregnancy, Birth Control, Contraceptive Supply or Services are not covered under the scope of the policy. Hence, the claim is not payable. On scrutinizing the submitted claim documents, it had been observed that this 31 years old female patient admitted for the procedure of OOCYTE PICK UP, which is under IVF treatment. It attacks the policy clause 4.4.6 which states that Exclusion of.

17.  It is pertinent to note that it states as per policy clause 4.4.6 of the Exclusion Clause. Clause 4.6 & 4.8 are being reproduced hereunder :-

4.6. Surgery for correction of eye sight. Cost of spectacles, contact lenses, hearing aids etc. However, eye vision correction applicable to more than or equal to +7.5/ -7.5 number. (The sentence in bold is not there in the policy terms & conditions filed by OP-1).

4.8. convalescence, general debility, “run down” condition or rest cure, congenital external disease or defects or anomalies, sterility, any fertility, sub fertility or assisted conception procedure, venereal disease, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and disease / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.

18. The clause 4.4.6 deals with surgery for correction of eye sight cost of spectacles, contact lenses hearing aids etc. However, eye vision correction applicable to more than or equal to +7.5/ -7.5 number, which is absolutely not applicable in the present case. It is important to note that clause 4.4.6 of the policy terms and conditions filed by OP and complainant are different.
19. Confining ourselves to the limited purpose as to whether the claim was rejected as per policy terms and conditions or not, we are guided by principle laid down in “Saurashtra Chemicals Ltd. v/s National Insurance I (2020) CPJ 93 (SC)” by Hon’ble Supreme Court that, insurance company cannot travel beyond the repudiation letter. In an mail dated 23/03/2017, the rejection is based on clause 4.6 of the Exclusion Clause of policy terms and conditions, whereas in the Written Statement, OP-1 has stated that the rejection was on ground of clause 4.4.8 and it was typographical error, however, OP had every opportunity to issue corrigendum rectifying their mistake, which has not been done in the present case. OP had the opportunity to rectify the error upon receipt of email sent by the husband of the complainant on 18/04/2017, but they failed to do so.
20. At the same time, as admitted by the complainant that she had underwent the treatment for IVF, this fact cannot be ignored that the said treatment is excluded under policy terms and conditions. But the rejection of the claim based on incorrect clause has definitely caused mental agony and harassment to the complainant, for which she is entitled to compensation. Hence, OP-1 and OP-2 are jointly and severally liable to compensate the complainant.  
21. Therefore, in the facts and circumstances of the present complaint we direct OP-1 and OP-2 to pay Rs. 50,000/- as compensation. The order be complied within 30 days from the receipt of this order, in case of non-compliance the complainant shall be entitled to interest @7% p.a. from the date of order till realization.
22. Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya) Member

(Divya Jyoti Jaipuriar)                                President