BEFORE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
FATEHABAD.
Complaint Case No.: 217 of 2016.
Date of Institution: 17.08.2016
Date of order: 27.04.2017.
Smt.Sushila Devi Bansal wife of Shri Atam Parkash Bansal son of Chhabil Dass resident of C/o Vijay Laxmi Cotton Industry, Tehsil & District, Fatehabad.
….. Complainant.
Versus
United India Insurance Company Limited (E-Meditek) Corporate Office: Plot No.577, Udyog Vihar Phase V, Gurgaon-122016 through its authorized signatory.
United India Insurance Company Limited shop No.75, Anaj Mandi, Fatehabad Tehsil & District Fatehabad through its Branch Manager.
….Opposite parties.
Complaint U/s 12 of the Consumer Protection Act
BEFORE: Sh.Raghbir Singh, President.
Smt.Ansuya Bishnoi, Member. Sh.R.S.Panghal, Member.
Present: Shri Devi Lal, Advocate for the complainant.
Shri N.D.Mittal, Advocate for the OPs.
ORDER:
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against the opposite parties (hereinafter to be referred as OPs).
2. In short, the case of the complainant is that the husband of the complainant namely Atam Parkash had obtained a Family Medicare insurance policy 2014 bearing No.1119032815P113791686 UIN No.IRDA/NL-HLT/UIL/P-H/V.II/231-13-14 which was valid upto from 18.02.2016 to 17.02.2017 for a sum of Rs.5,00,000/- from OP No.2 and the name of the complainant has been mentioned at Sr.No.2 as one of the insured. It has been further averred that the complainant felt ill and got treatment from Mohak Hi-Tech Specialty Hospital, SAIMS Campus, Indore-Ujjain State Highway, MR-10 Crossing, Indore (M.P.) by spending a sum of Rs.2,92,487.77/-. Thereafter the complainant had submitted all the bills to the OPs and requested for settlement of the claim but the OPs wrongly and illegally repudiated the claim vide letter dated 31.05.2016 on the ground that she was admitted in Mohak Hi-Tech Specialty Hospital, Gastric Bypass for the treatment of obesity, therefore, the claim was not entertainable. The act and conduct of the Ops clearly amounts to deficiency in service. Hence, this complaint. In evidence, the complainant has tendered her affidavit as Annexure C1, affidavit of Sh.Atam Parkash as Annexure C2 besides documents Annexure C3 to Annexure C22.
3. Upon notice, OPs appeared through their counsel and resisted the complaint by filing joint reply. It has been further submitted that the present complaint is not maintainable and the complainant is estopped from filing the present complaint because she got the treatment for Obesity. It has been further submitted that the weight of the complainant was 116.5 Kgs. and her height was 142 cms and she had undergone treatment for Laparoscopic Mini Gastric Bypass for obesity, therefore, as per exclusion clause 4 & 4.9 of the Family Medicare Insurance Policy, the company would not be liable to make any payment under this policy qua the expenses whatsoever incurred in respect of obesity treatment. The claim of the complainant has rightly been repudiated. It has been further submitted that in the operative part of Clause 2 of the policy it has been mentioned that the liability of the insurance company shall be subject to the terms, definitions, exclusions and conditions contained therein. Other pleas made in the complaint have been controverated and prayer for dismissal of the complaint has been made. In evidence, the Ops have tendered affidavit of Sh.K.R.Jain, as Annexure R1 and documents Annexure R2 and Annexure R3.
4. We have heard learned counsel for the parties and have perused the case file carefully. In his arguments the counsel for the complainant has reiterated the submissions made in the complaint. On the other hand the counsel for the OPs rebutted the above said arguments of the counsel for the complainant and further in support of his contention has relied upon the judgment titled as Suraj Mal Ram Niwas Oil Mills P. Limited Vs. United India Insurance Company & Anr. Iv (2010) CPJ 38 (SC).
5. The OPs have resisted the claim of the complainant solely on the ground that as per exclusion clause 4.9 of the terms and conditions of the policy, the complainant is not entitled for any claim. Relevant 4.9 of the terms and conditions of the policy (Annexure R3) is as under:
“4.9 Convalescence, general debility, run-down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxication drugs/alcohol”.
6. Learned counsel for the complainant has taken a plea that terms and conditions were not supplied to the complainant at the time of issuing of insurance policy but this plea is not tenable because there is nothing on the file to show that the above terms and conditions of the policy (Annexure R3) wherein the exclusion clause on which the OPs have relied upon was included, were neither a part of the contract of insurance nor disclosed to the complainant. Had it been so, the complainant could have rebutted this plea by filing rejoinder to the reply filed by the Ops but it has not done by the complainant, therefore, at this point she cannot raise this plea that she was ignorant about the terms and conditions of the policy and the same were not supplied to her. Undisputedly, the complainant had obtained a medi-claim policy, therefore, it is necessary to mention the scope of cover of the medi-claim policy, which runs as under:
Scope of Cover
The policy is meant to cover only the unexpected Hospitalization Expenses and the policy is liable only to meet the expenses that are necessarily and reasonably incurred for treatment of the ailment.
In the present case, the complainant was not treated for any unexpected ailment/injury rather she herself has opted for the treatment of obesity which is evident from Annexure R2 wherein it has been clearly mentioned that the complainant was diagnosed for Morbid Obesity, therefore, she is ceased to claim for the expenses allegedly incurred on her treatment as per exclusion clause 4.9 of the Family Medicare Insurance Policy (Annexure R3). The present complaint deserves dismissal being not maintainable. Accordingly, we dismiss the present complaint leaving the parties to bear their own costs. A copy of this order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced in open Forum.
Dated: 27.04.2017
(Raghbir Singh)
President
(R.S.Panghal) (Ansuya Bishnoi) Distt.Consumer Disputes
Member Member Redressal Forum, Fatehabad.
