State Consumer Disputes Redressal Commission
Oriental Insu. Co. Ltd. & Ors. vs Sh. Mohindar Khanna on 23 July, 2013
IN THE STATE COMMISSION : DELHI (Constituted under Section 9 clause (b)of the Consumer Protection Act, 1986 ) Date of Decision: 23.07.2013 Case No. FA-544/11 (Arising from the order dated 15.06.2011 passed in Complaint Case No. 232/07 by the District Consumer Forum-II, Udyog Sadan, C-22 & 23 Institutional Area (Behind Qutub Hotel) New Delhi-16.) 1. SR. DIVISIONAL MANAGER - APPELLANT ORIENTAL INSURANCE CO. LTD. UGF-8, 11 & 13, Arunachal Building Barakhamba Road, New Delhi. 2. MR. ANUJ RAIZADA M/s Union Insurance Broking Services Pvt. Ltd. F-13, Tara Apartment, Alakanda, Kalkaji, New Delhi 110019. Versus SHRI MOHINDAR KHANNA - RESPONDENT C-57, South Extention-II New Delhi. CORAM : S.A. SIDDIQUI - MEMBER (JUDICIAL) S.C. JAIN - MEMBER 1. Whether reporters of local newspapers be allowed to see the judgment? 2. To be referred to the Reporter or not? S.A. SIDDIQUI (ORAL) JUDGEMENT
1. This appeal has been filed by the appellant/OP-1, Oriental Insurance Company Ltd. against judgment and order dated 15.06.2011 passed by DCDRF-II, Udyog Sadan, C-22 & 23 Institutional Area (Behind Qutub Hotel) New Delhi-16 in Complaint Case No.232/07 Mohindar Khanna Vs. The Divisional Manager, Oriental Insurance Company Ltd.
2. Complainant/Respondent, Mohindar Khanna obtained a Mediclaim Insurance Policy No. 2006/416 from OP-1/appellant for himself and his wife for a period w.e.f. 04.06.2005 to 03.06.2006. In this medi-claim policy, all types of risk/diseases/injuries except the disease specifically excluded in the insurance cover note were covered. The complainant/respondent had regularly paid the amount of premium. During the month of February, 2006, complainant/respondent visited Mumbai.
Unfortunately, he fell ill with a complaint of chest congestion/discomfort and high blood pressure. During the night time, House doctor was called at the Hotel itself for medical treatment. However, due to emergency, complainant/respondent was taken to Bombay Hospital and Medical Research Centre, Mumbai on 26.2.2006 where he was admitted in the Intensive Care Unit. The complainant/respondent had to go for a complete medical check up including ECG and after getting his treatment, he was discharged from the Hospital on 26.2.2006 itself. At the time of discharge from the Hospital, he had to pay a sum of Rs. 17,454/- towards Hospital expenses for the treatment. Thereafter, he preferred insurance claim for reimbursement of the aforesaid amount by the OP-1/appellant. Along with insurance claim, he sent all necessary papers and medical certificates but the OP-1/appellant did not settle his claim.
It was alleged that the settlement of the claim was deliberately delayed and denied, therefore, he was compelled to file a consumer complaint seeking directions to the OP-1 for payment of the insurance claim along with interest. Compensation and cost of litigation were also claimed.
3. OP-1/appellant contested the claim. The OP-1/appellant in their written statement admitted to have issued the mediclaim policy No. 2006/416. Rest of the allegations were denied. In Para 8 of the written submissions, it was stated that the insurance claim was rejected by the OP-1/appellant through letter dated 5.7.2006 addressed to Mr. M.M. Khanna, complainant/respondent. The contents of the letter were:
We refer to the above claim. On scrutinizing the claim papers, it is observed that your claim does not fall under the terms and conditions of the policy as your hospitalization is less than 24 hours.
Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. However, this time limit will not apply to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney stone removal), Tonsillectomy, D&C, taken in the Hospital/Nursing Home where the insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalization Benefit.
This condition will also not apply in case of stay in hospital of less than 24 hours provided a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals and b) due to technological advances hospitalization is required for less than 24 hours only.
4. It was submitted by OP-1/appellant that the complainant/respondent was not suffering from any disease mentioned above, hospitalization of less than 24 hours does not attract any deficiency on the part of the Insurance Company. Hence the same deserved dismissal with heavy cost. Through affidavit filed by the way of evidence, refusal of the claim was justified on the ground that the claim of the respondent/complainant fell under the condition No. 2.2 of the Policy and the same was not maintainable. In condition No. 2.2, it has been clearly mentioned that expenses on a hospitalization are admissible only if it is for a minimum period of 24 hours, except in cases of specialized treatment, which was not the case of the respondent/complainant.
5. Through rejoinder, complainant/respondent refuted the plea taken by the OP-1 in its written statement.
6. Parties led evidence by way of affidavit and file documentary evidence.
7. Ld. District Forum through its impugned order dated 15.6.2011 decreed the claim with the following observations, in our opinion, the condition mentioned in the policy, as mentioned under Rule 2.2 is not applicable in the present case, rather the case of the complainant comes under this exclusion clause whereas extension of hospitalization are admissible even if the hospitalization is for a minimum period of 24 hours and therefore, this complaint was allowed and it was observed that the OP-1/appellant were found guilty of deficiency of service.
8. Insurance Company felt aggrieved by this finding and preferred this appeal interalia on the following main grounds besides the others:
(a) That the Impugned order dated 15.06.2011 passed by the Ld. District Forum was perverse and devoid of any merit.
(b) Ld. District Forum failed to appreciate the fact that complainant was admitted for the treatment of Accelerated HTN and discharged on the same day i.e. 26.2.2006 itself and therefore, the claim of the complainant was not maintainable and that it was rightly rejected.
(c ) The claim was falling under the specific clause of the policy which excluded a claim for hospitalization less than 24 hours.
(d) Ld. District Forum failed to appreciate the fact that expenses on hospitalization were admissible only if it was for a minimum period of 24 hours. But this time limit will not be applicable to specific treatments i.e. dialysis, chemotherapy, radiotherapy, eye surgery, dental surgery, lithotripsy (kidney stone removal), tonsillectomy, D&C, taken in the hospital/nursing home where insured was discharged on the same day. In the present case, the complainant was not suffering from any disease mentioned above hence hospitalization for a period less than 24 hours does not attract any deficiency on the part of the OP/appellant and the finding recorded by Ld. District Forum was illegal besides being perverse.
(e ) That Ld. District Forum failed to consider the fact that there was no contract between the parties regarding payment of interest. Award of interest @ 9% was unjust and illegal besides a disproportionate compensation was also awarded. The claim was only for Rs. 17,454/- and award of Rs. 25,000/- as compensation was not only disproportionate but totally uncalled for and unjust.
(f) The appeal is, therefore liable to be allowed for the aforesaid reasons.
9. The complainant/respondent filed reply and maintained that impugned order dated 15.6.2011 passed by Ld. District Forum was totally legal, just and based on evidence available on record. On 25.2.2006, when complainant was staying in Mumbai Hotel, he felt chest congestion and due to emergency, he was advised by the attending doctor to get himself admitted in Bombay Hospital and Medical Research Center. He was, therefore, taken to the hospital on 26.2.2006 where he was admitted in ICU.
The complainant/respondent had to undergo the procedure of ICU including a complete check up, ECG and monitoring etc., which could have been done in the hospital only. The medical certificate along with discharge summary was filed as Annexure R-3.
10. It is further mentioned that Rule 2.2 of the policy was not applicable in the present case rather the case comes under this exclusion clause whereby extension of hospitalization was admissible even if the hospitalization for a minimum period of 24 hours. He fell ill due to chest congestion, which was a sign of heart attack and in such cases, proper treatment was necessary. It is true that hospitalization was less than 24 hours but the treatment certainly fell in the category of specialized treatments for which minimum hospitalization of 24 hours can be waived off and hence the claim is definitely payable under the mediclaim policy issued to the respondent/complainant and there was no illegality or irregularity of any kind in the impugned order dtd. 15.6.2011.
11. We have heard Sh. Pradeep Gaur, Counsel for the appellant as well as Sh. Chetan, Counsel for the respondent. We have also perused the record.
12. The claim of the respondent/complainant was rejected through letter dated 5.7.2006 sent by Divisional Manager, Oriental Insurance Company to Mr. M.M. Khanna, complainant/respondent. Letter dated 5.7.2006 provided: On scrutinizing the claim papers, it is observed that your claim does not fall under the terms and conditions of the policy as your hospitalization is less than 24 hours.
Expenses on Hospitalization are admissible only if hospitalization is for a minimum period of 24 hours. However, this time limit will not apply to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney stone removal), Tonsillectomy, D&C, taken in the Hospital/Nursing Home where the insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalization Benefit.
This condition will also not apply in case of stay in hospital of less than 24 hours provided a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals and b) due to technological advances hospitalization is required for less than 24 hours only.
13. A plain reading of the aforesaid letter goes to suggest that expenses on hospitalization are admissible only if it is for a minimum period of 24 hours but there are two exception to this general rule:
(a) However, this time limit will not apply to specific treatments i.e. Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (Kidney stone removal), Tonsillectomy, D&C, taken in the Hospital/Nursing Home where the insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalization Benefit.
(b) This condition will also not apply in case of stay in hospital of less than 24 hours provided a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in hospitals and b) due to technological advances hospitalization is required for less than 24 hours only.
14. It is the case of the complainant/respondent that while staying in the Mumbai Hostel on 25.2.2006, complainant fell ill due to congestion/heaviness in the heart and the House Doctor of the Hotel was called who found that there was emergency as it was a sign of heart attack and on his advice, complainant/respondent was hospitalized in Bombay Hospital and Medical Research Centre on 26.2.2006 and after necessary treatment, he was discharged from the hospital on the same day. Since chest congestion was a sign of heart attack and therefore, in such a situation, hospitalization was necessary facility of treatment for such an ailment was available only in the well equipped hospital. Therefore, the condition mentioned in Rule 2.2 of the insurance policy was not applicable in the present case but the case of the complainant is covered under second exception of the letter dated 5.7.2006 issued by the Divisional Manager, Oriental Insurance Company Ltd. The ailment of the complainant un-doubtly necessitated hospitalization where specialized infrastructural facilities were available and due to technological advances required treatment was possible within less than 24 hours.
15. In view of the above facts we are of the firm opinion that Ld. District Forum did not commit any illegality or irregularity in decreeing the complaint. However, we are also of the opinion that award of compensation was towards higher side as the insurance claim was just for an amount of Rs. 17,454/-; therefore, it was not just and proper to have allowed a sum of Rs. 25,000/- towards compensation for mental pain, agony and harassment. Therefore, the amount of compensation is reduced to a sum of Rs. 15,000/- only.
ORDER Accordingly, the appeal is partly allowed. The appellant/OP-1, Oriental Insurance Company Ltd. is directed to pay a sum of Rs. 17,454/- along with interest @ 9% p.a. from the date of hospitalisation till the date of realisation. The appellant/OP-1 is also directed to pay a sum of Rs. 15,000/- towards compensation for mental agony, pain and harassment. To this extent, the impugned Order dated 15.06.2011 passed by District Consumer Redressal Forum-II in Complaint Case No. 232/07 is modified.
16. A copy of this judgement and order as per the statutory requirement be provided to the parties free of charge and one copy be sent to the District Consumer Redressal Forum-II to place it on the record of the Complaint Case No. 232/07 and for compliance, thereafter the file be consigned to Record Room.
17. The FDR, if any, deposited by the appellant at the time of filing of the appeal shall be refunded as per rule.
(S.A. SIDDIQUI) MEMBER (JUDICIAL) (S.C. JAIN) MEMBER rn