Chandigarh

DF-I

CC/170/2020

Ravinder Singh Bhalla - Complainant(s)

Versus

The Oriental Insurance Co. Ltd. - Opp.Party(s)

D.P Sharma & Rajinder Pandey

01 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/170/2020
Date of Institution	:	08/06/2020
Date of Decision	:	01/12/2022

Ravinder Singh Bhalla (since deceased) through his legal heirs :-

1. Mrs. Randeep Kaur w/o late Shri Ravinder Singh Bhalla, #241, Sector 46-A, Chandigarh 160047 (wife of the complainant).
2. Mrs. Tripti Arora w/o Shri Gagandeep Singh, #241, Sector 46-A, Chandigarh 160047 (daughter of the complainant).
3. Mrs. Rajni w/o Shri Deekshant Bhatia, House No.1113, New Housing Board, Karnal, Haryana – 132001 (daughter of the complainant).
4. Shri Baldeep Singh Bhalla s/o late Shri Ravinder Singh Bhalla, #241, Sector 46-A, Chandigarh 160047 (son of the complainant).

… Complainant

V E R S U S

1. The Oriental Insurance Company Limited, SCO 48-49, Sector 17-A, Chandigarh 160017.
2. The Senior Divisional Manager, The Oriental Insurance Company Limited, SCO 48-49, Sector 17-A, Chandigarh 160017.
3. M/s Raksha Health Insurance, SCO 39, Sector 26, Chandigarh 160026 (through its Manager).

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Rajinder Pandey, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh.Ravinder Singh Bhalla, complainant against the opposite parties (hereinafter referred to as the OPs). The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant, who has been maintaining his saving account with Punjab National Bank, Sector 27, Chandigarh, had obtained a PNB-Oriental Mediclaim Policy (hereinafter referred to as the “Mediclaim Policy”) from OP-1 effective from 31.7.2019 to 30.7.2020 for a sum insured of ₹5.00 lacs. The said policy covered hospitalization expenses for medical/surgical treatment at any nursing home/ hospital in India as an in-patient for the complainant or his spouse. The complainant had paid premium of ₹10,230/- inclusive of GST which was accepted by the OPs who had accordingly issued receipt for the same on 30.5.2019 and later on issued the insurance policy containing three pages only. As per the said policy, complainant himself or his spouse were entitled to claim compensation to the extent of ₹5.00 lacs from the OPs for the hospitalization expenses etc. and either or both of them were entitled for the reimbursement of the sum insured in case of their medical treatment or on account of hospitalization expenses.  On 5.12.2019, complainant had pain and heaviness in the left side of his chest which caused slight difficulty in breathing and sweating and on this the complainant visited the hospital where he was attended upon by Dr.Chandandeep Singh Sandhu, Consultant Physician.  On check-up and finding critical condition of the complainant, the said doctor advised for his admission in the hospital for thorough check up and treatment.  During thorough check up, complainant was diagnosed with “Coronary Artery Disease – Triple Vessel Disease”.  On this, complainant was treated by the doctor with medicines under observation in the initial 48 hours and also advised treatment using latest advanced non surgical modalities instead of bypass surgery or angioplasty.  The complainant was treated with 35 sittings of Enhanced External Counter Pulsation (hereafter referred to as “EECP”) which is USFDA approved machine based treatment used for non surgical revascularization, EECP treatment was given as an out patient treatment following 48 hours hospitalization from 5.12.2019 to 7.12.2019.  The complainant had undergone 35 sittings of EECP from 7.12.2019 to 13.1.2020 as an out patient.  On account of his treatment, complainant had paid an amount of ₹1,91,000/- to Chandan Hospital, Mohali.  Thereafter the complainant filed his claim alongwith complete medical record, payment receipts in original with OP-1 on 31.1.2020 through TPA (OP-3) and OPs were requested to reimburse the aforesaid amount. However, OP-1 vide letter dated 11.3.2020 (Annexure C-10) has repudiated the claim of the complainant on the ground that the said treatment of the complainant does not cover under the policy (Annexure C-1) as the same is excluded by the exclusion clause 4.19 which was also communicated to the complainant. The policy (Annexure C-1) itself shows that the aforesaid exclusion clause was never a part of the policy document issued to the complainant. Hence, repudiation of the genuine claim of the complainant amounts to deficiency in service on the part of the OPs. Even in the earlier consumer complaint filed by the complainant, OPs had resisted the claim of the complainant, but, the said complaint was allowed and the OPs were directed to pay an amount of ₹5.00 lacs alongwith compensation to the complainant.  OPs were requested several times to admit the claim of the complainant, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written reply, inter alia, denying that the claim of the complainant was wrongly repudiated by the OPs by admitting that the policy in question was issued to the complainant by the OPs by receiving an amount of ₹10,230/- as premium.  The sum insured of ₹5.00 lacs is also admitted.  It is, however, alleged that all the terms and conditions of the policy were within the full knowledge of the complainant.  It is denied that the terms and conditions of the policy were not issued to the complainant. It is further admitted that the complainant has been getting the insurance policy from the OPs since 2012 and has been getting the same renewed every year for the sum insured of ₹5.00 lacs.  Since the TPA scrutinized the document and sent a letter dated 12.2.2020 (Ex.OP 1-3/2) to OP-1 recommending repudiation of the claim as per exclusion clause 4.19 of the insurance policy as the treatment which was taken by the complainant from the hospital  is not covered under the policy, the claim of the complainant was accordingly repudiated.  It is further alleged that it has been held by the Hon’ble Apex Court in several judgments that an insurance contract is a species of commercial transaction and must be construed like any other contract to its own terms and by itself.  As the complainant was knowing about the exclusion clause of the policy which was duly given to him, the present consumer complaint of the complainant being not maintainable is liable to be dismissed. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted his claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
4. Close scrutiny of the entire evidence on record of the case file, coupled with the rival contentions of the learned counsel for the parties, are discussed as under:-

1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant has been taking the Mediclaim Policy (Annexure C-1) from the OPs since the year 2012 and at the relevant time when the complainant got treatment for his heart related ailment as an indoor patient for 48 hours w.e.f. 5.12.2019 to 7.12.2019 and at that time he was having the Mediclaim Policy (Annexure C-1) which was valid w.e.f. 31.7.2019 to 30.7.2020, the case is reduced to a narrow compass as it is to be determined if the OPs were not justified in repudiating the claim of the complainant and complainant is entitled for the reliefs, as prayed for, as is the case of the complainant or if the OPs have repudiated the claim of the complainant as per terms and conditions of the policy, as is the defence of the OPs.
2. In the case in hand, complainant has come with a specific plea that only three pages of the Mediclaim Policy (Annexure C-1) were issued to him after getting premium of ₹10,230/- inclusive of GST by the OPs and in the said policy the sum assured was ₹5.00 lacs for the hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in-patient for the complainant or his spouse and as the terms and conditions of the policy contained from pages 1 to 24 of Ex.OP 1-3/1, which includes clause 4.19 having been relied upon by the OPs, have never been given to the complainant, repudiation of the genuine claim of the complainant by the OPs is not justified. On the other hand, OPs have come with the plea that as heart related ailment is covered under the policy of which the complainant has taken the treatment through EECP which comes under exclusion clause of the policy (Ex. OP 1-3/1) vide clause 4.19, claim of the complainant was repudiated in terms of the policy.  In this manner, the treatment taken by the complainant from the Chandan Hospital, Mohali as well as the terms and conditions of the policy which were received by him at the time of issuance of the policy are required to be scanned carefully.
3. Ex.C-9 is the medical record/discharge summary which (at internal page 6) reveals that the complainant was diagnosed with “Coronary Artery Disease – Triple Vessel Disease”.  It further shows the treatment given to the complainant by the Hospital, which is reproduced as under for convenience :-

TREATMENT

In view of the increased risk due to presence of co morbidities and age of the patient, it was decided to manage the patient conservatively with medicines under observation for the initial 48 hours, and then subsequently advised treatment using latest and advanced non surgical modalities instead of Bypass Surgery or Angioplasty. He was treated with 35 sittings of EECP (Enhanced External Counter Pulsation), which is a USFDA Approved machine based treatment used for non-surgical revascularization. EECP Treatment was given as an Out Patient Treatment following 48 hours of hospitalization.

DISCHARGE SUMMARY

The patient underwent 35 sittings of EECP (Enhanced External Counter Pulsation) from 07 December, 2019 to 13 January, 2020 as an out patient basis. A pre treatment Myocardial Viability Scan was performed on a Gamma Camera to assess Cardiac Viability post treatment on 07 December, 2019; which revealed negligible uptake in LV myocardium Indicating poor viability of the myocardium. The same scan was repeated after the treatment which showed increased perfusion. As compared to pre treatment 2D Echocardiography, the LVEF showed a marked increase from ~18% to 29%. He was asymptomatic, reported no complaints of Angina or Dyspnea along with increased exercise tolerance and was advised to follow up on an OPD basis after 6 weeks.”

 

                Thus, one thing is clear from the discharge summary that the complainant was diagnosed with Coronary Artery Disease – Triple Vessel Disease, which is admittedly covered under the policy in question and does not fall under the category of exclusion clause.  It is also evident from the discharge summary that the complainant remained as indoor patient for 48 hours and thereafter had undergone 35 sittings of EECP from 7.12.2019 to 13.1.2020 as an out patient basis.

4. The claim of the complainant has been resisted by the OPs on the ground that complete policy, including its terms and conditions, was received by the complainant and he was having knowledge about exclusion clause and since the treatment taken by the complainant for the aforesaid disease is hit by the exclusion clause i.e. 4.19 of the policy (Ex.OP 1-3/1), the claim of the complainant was rightly repudiated.  In order to determine this fact if the claim of the complainant is hit by the exclusion clause of the Policy, the relevant clause is reproduced as under for convenience :-

“4.       GENERAL EXCLUSIONS: The Company shall not be liable to make any payment under this policy in respect of any expense whatsoever incurred by any Insured Person in connection with or in respect of :

4.19    Treatment for age Related Macular Degeneration (ARMD), treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.”

 

5. However, this defence of the OPs is countered by the complainant on two grounds – firstly that the terms and conditions of the policy i.e. from page 15 to 34 were never given to him by the OPs, rather the complainant was only given with three pages of the Policy (Annexure C-1) and the said terms and conditions of exclusion (Ex.OP 1-3/2), if any, have no effect on the rights of the complainant so far as the claim is concerned.  Perusal of Ex.C-1 clearly indicates that the same contains only three pages which was admittedly received by the complainant.  On the other hand, so far as the terms and conditions of the Policy (Ex.OP 1-3/1) containing pages 15 to 34 are concerned, nothing has come on record that the same were duly received by the complainant or the same were sent to him by the OPs.  Here we are strengthened by the judgment of the Hon’ble Apex Court in the case of M/s Modern Insulators Ltd. Vs. The Oriental Insurance Co. Ltd. decided on 22.2.2000 in which it was held as under :-

“In view of the above settled position of law we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, respondent cannot claim the benefit of the said exclusion clause.”

 

6. Secondly, as per clause 4.16 of the Policy, alleged to have been issued by the OPs, the same otherwise seems to be included just to repudiate the claim of the policy holder especially when the Policy (Annexure C-1) at page 2 clearly provides that the Policy shall pay for hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in-patient defined in the Policy. The insurance company cannot dictate one sided terms without explaining to the insured that the particular treatment by way of EECP cannot be taken by the patient. Moreover, this term says that unless the patient goes for bypass surgery or angioplasty, insured is not entitled for the claim. Even EECP is the treatment being given to the patient by using latest and advanced non surgical modalities instead of bypass surgery or angioplasty, as has also been opined in the discharge summary and also the complainant has recovered from his heart related ailment through the aforesaid treatment, making further clear that there is deficiency in service on the part of OPs while repudiating the genuine claim of the complainant.

5. In view of the foregoing discussion and the ratio of law as discussed in the aforesaid case, the present consumer complaint deserves to succeed and the OPs are liable to reimburse the claim of the complainant alongwith suitable compensation for the harassment suffered by him.

Relief

6. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is accordingly partly allowed and OPs are directed as under :-

1. to pay ₹1,91,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e.11.3.2020 till realization of the same.
2. to pay an amount of ₹30,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

7. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/12/2022 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member