State Consumer Disputes Redressal Commission
National Insurance Co. Ltd vs Pratibha Jain on 14 November, 2006
IN THE STATE COMMISSION:DELHI IN THE STATE COMMISSION:DELHI (Constituted under Section 9 of The Consumer Protection Act, 1986) Date of Decision: 14-11-2006 F.A. No. 516/ 2006 (Arising out of Order dated 27-02-2006 passed by the District Consumer Forum (North), in Complaint Case No. 305/2005) National Insurance Company Ltd. EMCA House, Ansari Road, 23/23B, Daryaganj, Delhi. . . . Appellant Versus Mrs. Pratibha Jain, W/o. Shri Rajiv Jain, R/o. E-157, Greater Kailash-I, New Delhi 110033 . . . Respondent In person CORAM: Justice J.D. Kapoor, President Ms. Rumnita Mittal, Member
1. Whether Reporters of local newspapers be allowed to see the judgment?
2. To be referred to the Reporter or not?
Justice J.D. Kapoor (Oral)
1. In the instant appeal, the respondent has appeared in person and argued the matter. The appeal is being decided on merits.
2. The short question involved for determination in this appeal arising from the Order dated 27-02-2006 passed by the District Forum is whether Clause 4.3 of mediclaim insurance policy was applicable in respect of the disease the respondent was alleged to be suffering from.
3. Admittedly, the respondent was insured for Rs. 1,00,000/- for the period 26-10-04 to 25-10-05. According to her she was suffering from heavy and continuous bleeding P/V (per vaginum) since December, 2004 and visited Mata Gujri Medical Centre on 29-12-2004 and when the bleeding did not stop even thereafter, she visited Dr. Indrani Ganguli on 03-01-2005. The bleeding had continued for 17 days and she was advised to undergo operation D&C/Hysteroscopy by Dr. Ganguli. The respondent underwent said operation in Sir Ganga Ram Hospital on 4-1-2005 and she was advised to take the prescribed medicines. The respondent preferred the claim with the OP Insurance company for a sum of Rs. 18,745/- on 12-1-2005 for reimbursement. The respondent received a letter from the appellant requiring certificate regarding the continuation of the policy and previous claim history. Vide letter dated 25-2-2005 the appellant repudiated the claim on the ground that for the 1 years as stated in the Discharge Summary she was having irregular bleeding and since this disease was not covered in the first year of policy, she was not entitled for any claim in view of exclusion clause 4.3. Feeling aggrieved the respondent filed the instant complaint.
4. While repelling the ground of repudiation, the District Forum, directed the appellant to pay Rs. 18,745/- to the respondent with 9% interest from the date of repudiation of the claim till the date of actual payment and Rs. 5000/- as compensation and Rs. 1000/- as cost of litigation.
5. Clause 4.3 of the policy provides as under:-
The Company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of the expenses on treatment incurred on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhoea or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in Anus, Piles, Sinusitis and related disorders during the first year of the operation of insurance cover. If these diseases are pre-existing at the time of the proposal they will not be covered even during subsequent period of renewal too.
6. As is apparent from the aforesaid clause, the problem of the respondent was assessed by the appellant as Menorrhoea, i.e. excessive vaginal bleeding during periods.
7. The technical terms of the disease is such which is tongue twisting and cannot be understood by a layman who takes the medi-claim insurance policy. Even if we go by the definition of this disease as excessive bleeding still the doctor who had treated the respondent at Ganga Ram Hospital has nowhere given the indication that the problem of the respondent fell within the disease known as Menorrhoea.
The certificate given by Dr. Indrani Ganguli in this regard is relevant which is as under:-
This is to certify that Smt. Pratibha Jain has been examined by me on 3rd January, 2005. She came with the complaint of bleeding P/V which resulted in Hb.7.8gm.
Her Ultrasound examination showed endometrial thickness as 18.3m. D&C, Hysteroscopy done on 04-01-2005. However, in July, irregular period mentioned in my record is quite common in pre-menopausal ladies. I again ascertained that D&C was necessary to stop the bleeding and diagnosed the condition which was a recent development of 17 days.
The aforesaid report of the doctor clearly states that aforesaid condition was a pre-menopausal problem and not Menorrhoea.
8. Time and again we have deprecated the practice of the insurance companies to repudiate the claim of consumers on flimsy grounds. We have also taken the view that unless and until the main clause, which operates adversely to the interest of consumer, is made part and parcel of the proposal form or insurance cover. Insurance company cannot take advantage of the said clause as every consumer at the time of contract is supposed to be told or informed that he will not be entitled for a claim for a particular disease in the first year.
9. By dispatching the lengthy and micro-printed terms and conditions of the terms of the policy subsequently, the consumer cannot know that this single clause, which is normally clause-4 and 4.1 or 4.3 out of a hundred clauses, would repudiate his claim and that too by picking up stray references from the discharge summary of the hospital where the consumer received treatment. Such type of contracts are voidable as these are unilateral and not bilateral;
firstly, not being signed by the party; and secondly, the terms of the contract having not been explained to the party who is a layman. At the time of accepting the proposal and issuing the cover note the consumer should be informed that in the first year he will not be entitled for the diseases mentioned therein.
10. In the instant case, the onus was on the appellant to prove by medical evidence and record that the condition the respondent was suffering from was clearly covered within the disease termed as Menorrhea.
11. In respect of mediclaim insurance policy insurance companies are liable to indemnify the consumer as to the expenses incurred by him on hospitalization or operation. To go into the nitty gritties and hair splitting of the physical condition and of the problem that landed the consumer in the hospital is neither the object nor the aim of the mediclaim policy.
12. It is universal rule of interpretation of a statute or a contract that it contract should be read as a whole and every term should be interpreted in a manner that should always be in consonance with the aims and objects of the statute or contract. Any interpretation straying away from the aims and objects of the contract is not permissible. Otherwise, the very purpose of the contract would be defeated and the contract itself will be rendered nugatory and tautologous.
13. In our view, the appellant should not have preferred the appeal in such a case because the interest of the consumer should always be kept in mind and the consumer should not be harassed unnecessarily. Such an attitude of the insurance company is neither consumer friendly nor as per perception and understanding of the contract of a layman.
14. In the instant case, the approach of the appellant insurance company was highly pedantic and reprehensible. We do not find any merit in the appeal and dismiss the same. Payment shall be made within one month from the receipt of this order.
15. A copy of the order as per statutory requirement be forwarded to the parties free of cost and the concerned District Forum and thereafter the file be consigned to record. FDR / Bank Guarantee, if any, be released forthwith under proper receipt.
16. Copy be sent to Presidents of all the District Fora.
(Justice J.D. Kapoor) President (Rumnita Mittal) Member HK