ORDER

(Per: Mr. D.K. Tyagi, Member):

This is insurer’s appeal under Section 15 of the Consumer Protection Act, 1986 against the order dated 17.06.2013 passed by the District Forum, Haridwar in consumer complaint No. 205 of 2011.  By the order impugned, the District Forum has allowed the consumer complaint and directed the opposite party to pay to the complainant a sum of Rs. 50,000/- on account of medical expenses and damages, within one month from the date of order.

2.       Briefly stated the facts of the case mentioned in the consumer complaint are that the complainant-Sh. Vipin Kumar Mittal with his mother Smt. Bimla Mittal is the holder of the Medi-claim Policy No. 321905/34/09/11/00000013 for a period from 07.06.2009 to 06.06.2010 and the complainant paid Rs. 6,353/- for the premium of insurance to the opposite party-insurance company. This way, the complainant is the consumer of the opposite party.  The complainant and his mother are legally entitled to get all the treatment expenses of any kind of disease from the opposite party during the insurance coverage period.  The opposite party assured to the complainant and his mother to pay the total treatment expenses of any kind of disease immediately during the insurance coverage period.  On the assurance of the opposite party, the complainant has taken this policy from the opposite party.  In fact the complainant is the holder of the medi-claim policy since 8 years continuously.  That the mother of the complainant fall sick and she underwent the medical treatment to Caroli Cardiac Clinic at Delhi and the treatment continue from 25.12.2009 to 03.04.2010.  During course of the treatment, on the advice of the attending physician Dr. R.K. Caroli, complainant’s mother had to go under various laboratory test and investigation and based on the report she was given the necessary treatment of which vouchers and cash memo are attached herewith and the total amount of expenditure on the treatment works out to Rs. 38,905/-. The complainant lodged the claim for reimbursement with the opposite party-insurance company supported by all the relevant bill/vouchers, cash memo and the prescription. The complainant had been the subscriber to the medi-claim policy of the opposite party for the past numbers of the years regularly commencing from about twelve years back.  During this long gestation period of medi-claim policy, the complainant never took the advantage of the medi-claim policy and had been incurring the petty expenses on the treatment on his own.  In the present case, whether the complainant had to incur an expenditure of Rs. 38,905/- on the treatment of his mother, the claim was preferred with the opposite party. The opposite party deliberately with dishonest intention and without any reasonable ground repudiated the claim of the complainant on 11.06.2010 on the ground that the patient had not been admitted in any hospital and the patient had been consulting the doctor on OPD basis.  Hospitalization of a patient depends upon the nature of sickness and at the sole discretion of the attending physicians.  In the present case of the complainant, the attending physician did not feel any necessity of the hospitalization, therefore, the treatment was carried on OPD basis.  Had there been hospitalization, the amount of expenditure must have gone much more than the amount the complainant has claimed from the opposite party.  There is, therefore, no logic or justification with the opposite party for repudiating the claim on the ground that the patient was not hospitalized and received the treatment on out-door patient basis.  Furthermore, there is no such condition to which the complainant has agreed with the answering opposite party.  Still the opposite party has repudiated the claim on flimsy ground, the opposite party has no right to repudiate the claim on such ground still be doing so the opposite party has committed a deficiency in services. In these circumstances the complainant is entitled to get the compensation of services of the opposite party on account of the expenses of the treatment of his mother Rs. 38,905/- alongwith interest thereupon @ 15% per annum from the date of claim till the payment is made and compensation of mental pain and harassment Rs. 50,000/- and cost of the petition as well as fees of counsel and expenses of the proceeding amounting to Rs. 10,000/- from the opposite party in the interest of justice. The opposite party carryon business through its Branch Office at Ranipur Mod, Haridwar in the jurisdiction of District Forum, Haridwar. 

3.       The opposite party-The New India Assurance Co. Ltd. has filed its written statement before the District Forum, Haridwar and has pleaded that the contents of para No. 1 of the consumer complaint are admitted to the extent that the complainant alongwith his mother Smt. Bimla Mittal had took Hospitalization Benefit Policy/Medi-claim policy bearing No. 321905/34/09/11/00000013 for the period of one year commencing from 07.06.2009 to 06.06.2010 in consideration of net premium of Rs. 5,760/-+ Rs. 593/- as service tax, total sum of Rs. 6,353/-.  This policy was subject to medi-claim policy (2007) clause with the services of Third Party Administrator herein after to be mentioned as T.P.A. with their name, address and phone numbers, rest of the contents, as alleged, are not admitted and subject to the cogent proof.  Para Nos. 2, 3 & 4 of the consumer complaint are not admitted.  No documents of hospitalization as well as treatment have been filed by the complainant as regard to expenses worth Rs. 38,905/- spent on the treatment of her mother, with the complaint in support of his version.  There is no deficiency in service on the part of answering opposite party in deciding the captioned matter.  No cause of action has arisen to the complainant for demanding Rs. 38,950/- plus interest thereupon @ 15% and compensation of mental pain and harassment Rs. 50,000/- plus Rs. 10,000/- cost of the petition as well as fee of the counsel and expenses of proceedings as claimed in his complaint. Contents of para No. 7 of the consumer complaint are admitted to the extent that the opposite party carryon its business within the jurisdiction of District Haridwar.   In additional pleas, the answering opposite party has pleaded that the present consumer complaint is not maintainable either on facts or on legal basis.  The complainant had himself admitted in para No. 6 of the consumer complaint that his medi-claim was repudiated.  The complainant gave no intimation of the disease, if any, suffered by his mother and when he had started treatment thereof.  After the completion of the alleged treatment, the complainant has submitted alleged treatment papers to the TPA (the Manager, Universal Medi Aid Services Ltd., New Delhi).  On receiving the claim document, the TPA, Universal Medi Aid Services Ltd. after going through all the documents submitted by the complainant pertaining to the alleged treatment of complainant’s mother Smt. Bimla Mittal, the expert team of doctors examined the claim documents carefully and were of the opinion that the said sums not be paid as per terms and conditions of the policy on the ground that:

          a. the patient has not been admitted in any hospital;

          b. she has been consulting the doctor on out-door patient (OPD) basis;

          c. some test had been done. 

          Hence, the claim is repudiated as per clause of 1.0, 3.4 and 4.4.11 due to non-coverage of the disease as per terms and conditions of the Medi-claim policy.  The TPA had informed that the claim is not admissible under medi-claim policy to the complainant vide letter dated 11.06.2010 and copy of the said letter was also sent to the answering opposite party. As per repudiation letter dated 11.06.2010, it seems that no discharge summary from hospital submitted which indicates that the complainant was not admitted in any hospital for his mother’s treatment.  For the purpose of diagnosis her illness, the doctor concerned has not mentioned what had he clinically observed and nor he mentioned clinical history of the patient, that patient having what type tendency of heart and for what illness she was treated at Caroli Cardiac Clinic as OPD basis.  The petitioner knowingly and deliberately has not made party to the TPA, Universal Medi Aid Services Ltd.  The insurance company had appointed TPA for the independent assessment of claims made by the policy holders under medi-claim policy as per the direction of IRDA.  Hence, the claim petition is bad for non-joinder of necessary party to the petition.  It is clear that the insured knowingly and deliberately did not furnish true information while she was taking medi-claim policy.  Thus, the complainant had suppressed material facts within his/her knowledge.  According to the complainant in para No. 3 of the complaint, he has asserted that doctor concerned had advised her to go various investigation/pathological test to find out disease, so that the treatment could be administered, for which the complainant had pay         Rs. 38,905/- without any concurrent findings of determination of disease.  For the determination of disease or ailment, the complainant’s mother had to go under various laboratory test and investigation and on the basis of the test reports she was given necessary treatment.  But the complainant knowingly and deliberately did not furnish break-up of the amount claimed, i.e. Rs. 38,905/-, out of which what sum of amount had paid as doctor’s fee, what sum of amount he had paid for various investigation/pathological test to find out diseases and what sum of amount he had paid for medicine used in the treatment of his mother. Thus the alleged sum of amount Rs. 38,905/- as claimed as treatment expenses is not coverable under medi-claim policy as per the doctor’s opinion as such patient was not admitted in any hospital for her treatment. Therefore, the claim of the complainant was rightly repudiated.  There is no deficiency in service on the part of the answering opposite party.  The complainant has no right to file the consumer complaint on vague presumption about the medi-claim policy which provide treatment expenses. There is no provision for reimbursement for the routine check-up clinically inclusive of various tests for the determination of disease.  There is no deficiency in service on the part of the answering opposite party in deciding the captioned matter. 

4.         The District Forum, on an appreciation of the facts and circumstances of the case, has allowed the consumer complaint No. 205 of 2011 vide order dated 17.06.2013 in the above manner.  Aggrieved by the said order, the opposite party-insurance company has filed the present appeal.

5.       Smt. Savita Sethi, learned counsel for the appellant and Sh. Sanjay Yadav, learned counsel for the respondent appeared before this Commission.  We have heard learned counsel for the parties and perused the material placed on record.

6.       Learned counsel for the appellant has submitted before this Commission that the District Forum, Haridwar while passing judgment in consumer complaint No. 205 of 2011 has failed to appreciate that the complainant-respondent, who entered into a contract with opposite party-appellant for purchasing a medi-claim policy and that policy was purchased by complainant-respondent subject to certain terms, conditions and exclusions.  The District Forum has failed to appreciate that the appellant and respondent are liable to follow those terms and conditions which are the contract in which respondent and appellant have entered rather those terms and conditions are binding on both the parties. The District Forum has failed to appreciate that insurance policy on the record shows that date of issuance of first policy is 06.06.2007, but the respondent in a mood to prevail upon appellant in para No. 2 of the complaint has wrongly mentioned that the respondent is continue holder of medi-claim policy since 8 years and in para No. 5 of the complaint, he has mentioned that the respondent had been the subscriber to the medi-claim policy of the appellant for the past numbers of years regularly commencing from about 12 years back.  The District Forum has failed to appreciate that the respondent had sent an application alongwith bills etc. to Universal Medi Aid Services on 20.04.2010, who is a Third Party Administrator and who after examining the papers and consulting team of doctors opined that     Smt. Bimla Mittal (respondent’s mother) was a domiciliary treatment patient and not as hospitalization treatment patient since the patient has not been admitted in any hospital, she has been consulting the doctor on O.P.D. basis only and tests have been done on O.P.D. basis, hence, the claim is repudiated on 11.06.2010 as per clause 1.0, 3.4 and 4.4.11 of the insurance policy.  Learned counsel also argued that the District Forum has failed to appreciate that Sh. Ajay Sureka, Authorized Signatory of Universal Medi Aid Services Ltd., deposed before the District Forum that the complainant-respondent submitted documents pertaining to the alleged treatment of his mother, Smt. Bimla Mittal.  The expert team of doctors examined the claim documents carefully and were of the opinion that the said sums not to be paid as per terms and conditions of the policy on the ground that the patient has not been admitted in any hospital, she has been consulting the doctor on outdoor patient basis and some test had been done. Hence, the claim is repudiated as per clause of 1.0, 3.4 and 4.4.11 due to non-coverage of the disease as per terms and conditions of the medi-claim policy.  The Company is ready to pay and can be held liable to pay only in those cases in which terms, conditions and exclusions of the medi-claim policy are properly followed.  The District Forum has failed to appreciate that there is no cause of action to respondent to file the complaint. There was no deficiency in service on the part of the appellant-insurance company. 

7.       Learned counsel for respondent has submitted that the respondent’s mother was treated in the hospital as out-door patient and she was never admitted in the hospital for her treatment. 

8.       Learned counsel for the appellant has placed reliance on a case Deokar Exports Pvt. Ltd. vs. New India Assurance Co. Ltd.; I (2009) CPJ 6 (SC).  In this case, the Hon’ble Apex Court has held that insurance is a contract based on offer and acceptance – Proposal made by complainant accepted by insurer with modification – Complainant could have refused to accept proposal, could have accepted counter proposal or could have made counter proposal to counter proposal of insurer - Complainant did not have choice of propounding concluded contract with modification, neither proposed nor accepted.  In contract of insurance rights and obligation strictly governed by policy of insurance – No exception/relaxation can be made on ground of equity. 

9.       There is no dispute that the respondent-Sh. Vipin Kumar Mittal had purchased an insurance policy No. 321905/34/09/11/00000013 from the appellant-insurance company for the period from 07.06.2009 to 06.06.2010.  Certificate of insurance policy is filed on record (paper Nos. 43 to 44), which reveals that the respondent has taken this policy for himself alongwith his mother.   From the perusal of the insurance policy, it is evident that it is a Hospitalization Benefit Policy/Medi-claim policy (2007).  The main dispute is that whether the respondent’s mother Smt. Bimla Mittal was admitted in any hospital, or she was treated as an out-door patient and in this condition whether the respondent is entitled to take benefits from the insurance company or not. 

10.     Learned counsel for the appellant has filed Hospitalization Benefit Policy/Medi-claim Policy (2007) (paper No. 44) and its terms, conditions and exclusions (paper Nos. 48 to 62).  The respondent Sh. Vipin Kumar Mittal purchased this Hospitalization Benefit Policy/Medi-claim Policy (2007) from the appellant-insurance company on 05.06.2009 and the policy period was from 07.06.2009 to 06.06.2010, as it is clear from the perusal of this policy.  It is a hospitalization benefit policy meaning thereby insured-claimant or any other person insured through this policy is entitled to get the benefits after hospitalization in any hospital or nursing home.  Clause 1.0 of Medi-claim policy (2007) is about the terms, conditions and exclusions etc.  In this clause, the insurance company undertook that if during the period stated in the schedule or during the continuance of this policy by renewal any insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require any such insured person, upon the advice of a duly qualified Physician/Medical Specialist/Medical Surgeon to incur hospitalization expenses for treatment at a nursing home/hospital in India as an inpatient, the company will pay to the hospital/nursing home or reimburse the insured person through the Third Party Administrator.   In Clause 3.4 of the terms and conditions of the Medi-claim policy, hospitalization shall mean admission in any hospital/nursing home in India upon the written advice of a medical practitioner for a minimum period of 24 consecutive hours.  In Clause 4.4 of the terms and conditions of the Medi-claim policy there is a provision of permanent exclusion in the Medi-claim policy in which any medical expenses incurred for or arising out of diagnosis, X-ray or laboratory examination not consistent with or incidental to the diagnosis of positive existence and treatment of any ailment, sickness or injury for which confinement is required at a hospital/nursing home.  In para No. 3 of the consumer complaint, the respondent-complainant has specifically mentioned that his mother Smt. Bimla Mittal fall sick and she underwent the medical treatment to Caroli Cardiac Clinic at Delhi.  During the course of treatment, on the advice of the attending physician Dr. R.K. Caroli, the mother of the respondent had to go under various laboratory test and investigation and based on the report she was given the necessary treatment.  In para No. 6 of the consumer complaint, the respondent-complainant has stated that the appellant-insurance company repudiated his claim on the ground that the patient has not been admitted in any hospital and the patient has been consulting the doctor on OPD basis.  Hospitalization of a patient depends upon the nature of sickness and at the sole discretion of attending Physicians.  The respondent has admitted that in the present case the attending physician did not feel any necessity of the hospitalization, therefore, the treatment was carried on OPD basis.  In this way, the respondent has admitted that his mother was never hospitalized in any hospital/nursing home for her treatment rather she took treatment as out-door patient. Therefore, in terms of Hospitalization Benefit Policy/Medi-claim Policy (2007), the appellant-insurance company has rightly repudiated the claim of the respondent.  To take benefit of this policy, hospitalization of patient is necessary and treatment should be inpatient.

11.     In a case of Suraj Mal Ram Niwas Oil Mills (P) Ltd. vs. United India Insurance Co. Ltd. & Anr.; IV (2010) CPJ 38 (SC), the Hon’ble Apex Court has observed that the terms of a contract of insurance have to be strictly construed and no exception can be made on the ground of equity.  In a case of V.K. Kariyana Store vs. Oriental Insurance Co. Ltd. & Anr.; III (2014) CPJ 182 (NC), the Hon’ble National Commission has observed that the terms of the policy have to be strictly construed to determine the extent of liability of the insurer.  Therefore, the endeavor of the Court should always be to interpret the words in which the contract is expressed by the parties.  These citations are fully applicable in this case also. The terms and conditions written on the policy(s) of contract of insurance are to be seen in strict sense.  In the policy, it is specifically mentioned that it is Hospitalization Benefit Policy/Medi-claim Policy and, therefore, to take benefit of this policy, the insured should be hospitalized in any hospital/nursing home for treatment. In the present case, the respondent has provided document regarding treatment to the Third Party Administrator (Universal Medi Aid Services Ltd., New Delhi) and the team of doctors (TPA) examined the claim documents and were of the opinion that the said sums not to be paid as per terms and conditions of the policy on the ground that the patient had not been admitted in any hospital, she had been consulting the doctor on outdoor patient basis and some test had been done.  The TPA (Manager, Universal Medi Aid Services Ltd., New Delhi) had also informed the respondent that the claim is not admissible under Medi-claim policy vide letter dated 11.06.2010. 

12.     From the above discussion, we are of the view that the District Forum has not properly considered the facts and circumstances of the case and, hence, erred in allowing the consumer complaint per impugned order, which cannot legally be sustained and is liable to be set aside and the consumer complaint is also liable to be dismissed.  Resultantly, the appeal deserves to be allowed.

13.     For the reasons aforesaid, the appeal is allowed.  The impugned judgment and order dated 17.06.2013 passed by the District Forum, Haridwar is set aside and the consumer complaint No. 205 of 2011 is dismissed.  No order as to costs.