State Consumer Disputes Redressal Commission
National Insurance Company Limited vs Gian Chand on 1 July, 2008
IN THE STATE COMMISSION: DELHI IN THE STATE COMMISSION: DELHI (Constituted under section 9 clause (b) of the Consumer Protection Act, 1986.) Date of decision :01.07.2008 Appeal No. A-281/04 (Arising from order dated 29.3.2005 passed by the District Forum-VII, Sheikh Sarai-II, Delhi in complaint case No. 2/05 National Insurance Company Ltd. Through its Divisional Manager, DO XXIII, 105, Palika Bhawan, R.K. Puram, Sector 13, New Delhi - 110007 ..Appellant Through Sh. Kamaldeep, Advocate Versus Mr. Gian Chand A/C Mrs. Santosh Mendiratta, 17/A/22, W.E.A. Karol Bagh, New Delhi 110005 ..Respondent Through Sh. Gian Chand, Advocate CORAM Justice J.D. Kapoor President Ms. Rumnita Mittal Member1
Whether reporters of local newspapers be allowed to see the Judgement.
2. To be referred to the Reporter or not.
Justice J.D. Kapoor (Oral)
1. Question arising in this appeal is whether expenditure incurred on C-PAP (Continuos Positive Airway Pressure) Machine is reimbursable against the mediclaim insurance policy or not as the claim of the respondent was rejected on the ground that under the policy the appellant was not liable to reimburse the cost of the machine which was an external aid and was excluded under clause 1 of the policy.
2. We have already decided few cases involving the same controversy whereby we had held that in absence of the C-PAP respondent cannot survive long and as such this system is a part of the treatment of the disease irrespective of the fact whether it is embedded in the body like pace maker because if the patient does not use it he risks his life as there is risk of cardiac failure.
3. Any beneficial legislation or for that purpose beneficial contract like the insurance contract has to be provided and receive a beneficial interpretation and if there are more than one interpretation available the interpretation which goes in favour of the consumer has to be accepted . Our detailed reasons in this regard given in identical cases are in appeal No. 700/02 decided on 22nd March 2007 titled The New India Assurance Co. Ltd. Vs. Sh. Shiv Kumar Rupramka wherein we had discussed the meaning and interpretation of the clause 1 and 3 are as under:-
Now the next contention of the counsel for the appellant that calls for determination is whether expenses incurred upon the machine known as C-PAP which is a life saving machine to control the disease in question was reimbursable or not. In this regard clauses 3.2 and 1.00 of the policy are relevant and are as under:
3.2 POST-HOSPITALISATION Relevant medical expenses incurred during period upto 60 days after Hospitalization on disease/illness/injury sustained will be considered as part of claim as mentioned under item 1.0 above.
Clause 1.00 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 scheduled hereto:
A) Room, boarding expenses as provided by the Hospital/Nursing Home.
B) Nursing Expenses C) Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialists fees.
D) Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical appliances, Medicines and Drugs, Diagnostic, Maternal and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of organs and similar expenses.
This clause 1.00 does not specifically refer to the device of the type one in question namely C-PAP but it specifically makes clear that nursing expenses and expenses for the disease Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical appliances, Medicines and Drugs, Diagnostic, Maternal and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of pacemaker, Artificial Limbs and cost of organs and similar expenses, are admissible.
As is apparent from this clause even those equipments are reimbursable which are essential for treatment of the disease and necessary for saving life, for instance pace maker and artificial limbs. So far as C-PAP is concerned any patient having the disease the respondent was having cannot survive long if such system is not used. Rather he can die any moment if such a device is not used. Rather he can die any moment if such a device is not used. This system has to be used at all times and is therefore part of the treatment of the disease and if patient does not use this device he puts himself at risk of death or repeated problem of cardiac failure. Thus the meaningful interpretation of the aforesaid clause has to be provided keeping in view the nature of the disease and the curing and remedy for the same. The disease and the treatment on hospitalization should have nexus with each other. Survival after receiving treatment for the disease in question without use of C-PAP system is always at risk.
Thus from any aspect we may examine the matter, C-PAP system is an equipment like pace-maker or any other such equipment without which there is no cure or any relief from the disease respondent was suffering from.
It is universal rule of interpretation that the contract or the statue should be read as a whole and not in isolation and every clause of the contract and every section of statute should be provided meaning which should be in consonance with the aim and object of the contract and the statute. It should serve its purpose and promote its object. Applying this rule we do not find any escape from the conclusion that the C-PAP system prescribed by the doctor was such instrument which was essential for if not curing the disease as some disease are not curable but controlling it to such an extent that without which the life of the insured is always at risk. The disease in question is such a disease, which kills a person in sleep and if C-PAP system is not considered as an essential part of the treatment of the disease then we do know what else shall be considered.
4. Foregoing reasons persuade us to hold that the respondent was entitled for re-imbursement of the expenses incurred by him towards the purchase of this equipment. However, interest awarded by the District Forum by way of compensation was in our view not awardable, because there was no equitable ground though lump sum compensation could have been awarded for the mental agony and harassment suffered by the respondent. Wherever the nature of dispute is of adjudicatory nature and involves more than two or three interpretations it does not form basis for awarding interest by way of compensation which is always awarded on the ground of equity, good conscious and justice. Otherwise consumer should be awarded an amount as compensation as per Section 14(1)(d) of the Consumer Protection Act 1986, as to the actual loss or injury suffered b him as well as mental injury suffered by him.
5. In view of the aforesaid reasons we partly allow the appeal by maintaining the direction of payment of a sum of Rs.87,000/- besides lump sum compensation of Rs.20,000/- which shall include the cost of litigation and set aside the rest of the order. The payment shall be made within one month from the date of receipt of this order.
6. The FDR, if any deposited by the appellant, be returned forthwith.
7. A copy of this order as per statutory requirements be forwarded to the parties free of costs and also the concerned District Forum and thereafter the file be consigned to Record Room.
Announced on Ist day of July, 2008.
(Justice J.D. Kapoor) President (Rumnita Mittal) Member rk