State Consumer Disputes Redressal Commission
Deepak Kumar Luthra vs Oriental Insuance Co. Ltd. on 24 September, 2012
IN THE STATE COMMISSION : DELHI (Constituted under Section 9 clause (b)of the Consumer Protection Act, 1986 ) Date of Decision: 24-09-2012 Case No. FA-09/318 (Arising from the order dated 16.3.2009 passed in CC No. 1104/2006 by the District ForumNorth, Room No. 2, Old Civil Supply Building, Tis Hazari, Delhi.) DEEPAK KUMAR LUTHRA, - APPELLANT/COMPLAINANT Son of Late Sh. R.D. Luthra R/o KD-198, Pitam Pura, Delhi. Versus M/S ORIENTAL INSUANCE CO. LTD. - RESPONDENT/OP A-25/27, Asaf Ali Road, New Delhi 110002. CORAM : JUSTICE BARKAT ALI ZAIDI - President SALMA NOOR - Member 1. Whether reporters of local newspapers be allowed to see the judgment? 2. To be referred to the Reporter or not? SALMA NOOR (ORAL) ORDER
1. This appeal has been filed by the appellant/Complainant Deepak Kumar Luthra against the order dated 16.3.2009 passed in CC No. 1104/2006 by the District Forum-North, Room No. 2, Old Civil Supply Building, Tis Hazari, Delhi. The Complainant/Appellant has come in appeal before this Commission with prayer to set aside the order of District Forum-North in the facts and circumstances of the case.
2. Complainants case before the District Forum, briefly stated, was that he had obtained a mediclaim policy No. 48/2003/104 valid upto 3.5.2003 from the OP. The complainant got sick having breathing problem and had undergone medical treatment under Dr. J.C. Suri, Head of the Department of Pulmonary, Critical Care and Sleep Medicine, Safdarjang Hospital, New Delhi and consequent upon taking various tests, it was observed that the complainant was suffering from Severe Obstructive Sleep Apnea Syndrome and the complainant was advised that he should apply Nasal CPAP at 14 CM H20 pressure every nigh during sleep and on this specific advice the complainant has purchased Devllbiss CPAP 9000 series alongwith Marg, Headgear, tubing, Carry Bag, mains Lead etc. from M/s P.K. Morgan (India) Pvt. Ltd., New Delhi for Rs. 54,000/-. It is pleaded that the equipment is indispensable and absolutely necessary for the complainant. The complainant applied for reimbursement of medical expenses of Rs. 54,000/- towards the cost of this medicine but OP refused to make the payment.
3. OP filed the written statement contesting the claim. It is pleaded by the OP that the complainant is without any cause of action and there is no deficiency in service. The complainant was asked to submit actual discharge summary of the hospital, hospitalization of the complainant was less than 24 hours and the cost of the CPA machine is not payable as per policy terms. It is admitted that a mediclaim policy was issued to the complainant on 2.5.2002 for period from 4.5.2002 to 3.5.02 subject to the terms, conditions and exclusions envisaged therein. It is pleaded that expenses on hospitalization for minimum period of 24 hours are admissible but this limit will not apply for specific treatment i.e. Dialysis Chemotherapy, Radiotherapy, Eye Surgery, Dental Surgery, Lithotripsy (kidney stone removal, Tonsillectomy, D&C taken in the Hospital/Nursing Home and the patient is discharged on the same day, the treatment will be considered to be taken under hospitalization benefit. It is pleaded that since the CPAP machine is not in the list of machines as per terms and conditions of the mediclaim policy, the claim has rightly been repudiated and there is no deficiency on that account.
4. The District Forum did not find OP deficient or negligent in repudiating the claim as it is repudiated as per terms and conditions of the policy. They find no merit in the complaint and dismissed accordingly.
5. Aggrieved against the order passed by the Ld. District Forum, the appellant/complainant filed the appeal before this Commission.
6. We have heard Mr. S.J. Salwan, Counsel for the Appellant and Sh. M.B. Agarwal, Counsel and the Respondent & perused the material on record.
7. The case of the appellant is that Clause 1 (d) of the Mediclaim Policy is broad enough to cover expenses of CPAP under similar expenses which is denied by the respondent. The District Forum has taken the view contrary to the appellants interpretation of the words similar expenses and denied his claim.
8. It is admitted fact that the complainant was suffering from severe sleep Apnea Syndrome which is a condition if not treated early and effectively may be life threatening. The use of CPAP machine is an integral part of the treatment. The cost of the CPAP machine in this case is Rs. 54,000/- approx. The respondent insurance company does not deny that the disease is life threatening and that use of CPAP is an integral part of this treatment but takes the plea that cost of CPAP is not mentioned in the clause 1(d) and the words similar expenses do not cover CPAP machine and the claim is inadmissible.
9. The policy documents generally cover diseases and treatments that are more common and the rest is covered by general terms like similar expenses. The question to be examined is whether case of CPAP machine should be considered under the category of similar expenses. The mere fact that clause 1
(d) of the terms and conditions of the policy does not specifically mentioned CPAP machine cannot be the sole ground for rejection of the claim of the appellant. It has to be examined the view of the other items mentioned in clause 1 (d), the relevant part of the clause is reproduced below:
1.0 in the event of any claim/s becoming admissible under this Scheme, the Company will pay to the insured Person the amount of such expenses as would fall under different heads mentioned below, and as are reasonably and necessarily incurred thereof by or on behalf of such insured Person, but not exceeding the Sum insured in aggregate mentioned in the schedule hereto:
A) Room,..........
B) Nursing Expenses.
C) Surgeon,........
D) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials ad X-Ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of Organs and similar expenses.
10. It is evidence from the clause 1(d), it mentions a number of heads that are life threatening and are essential part of treatment. It also mentions equipments like pacemakers which helps the heart function properly.
It also mentions artificial limbs and organs. There is no justification to deny why purchase of pacemakers which helps in functioning of heart is accepted and that of CPAP machine which helps in breathing is denied claims. Absence of both is life threatening though there may be difference of degree.
11. On the ground mentioned above, we are of the considered view that CPAP machine is covered in Clause 1 (d) of the Policy under the expression other expenses and allow the claim of the appellant.
12. The appeal is hereby allowed. The order dated 16.3.2009 passed in CC No. 1104/2006 by the District Forum-North, is hereby set aside. The respondent insurance company is directed to reimburse the cost of CPAP machine which is Rs. 54,000/- and also pay Rs. 5000/- for delay in payment, mental agony and litigation charges.
13. The above amount shall be paid by the OP insurance company to the complainant within 40 days from the date of this order failing which the OP shall be liable to pay interest on the entire awarded amount @ 9% per annum till the date of payment
14. A copy of this order as per the statutory requirements be forwarded to the parties free of charge. This file thereafter be consigned to Record Room.
15. The FDR, if any, be returned to the appellant as per rules, after completing due formalities.
(JUSTICE BARKAT ALI ZAIDI) PRESIDENT (SALMA NOOR) MEMBER rn