State Consumer Disputes Redressal Commission
Reameshwar Lal vs National Ins. Co.Ltd. on 27 March, 2017
IN THE STATE COMMISSION: DELHI
(Constituted under section 9 of the Consumer Protection Act, 1986)
Date of Decision: 27.03.2017
First Appeal-67/2013
(Arising out of the order dated 27.12.2012 passed by the District Forum, Janakpuri, New Delhi in
complaint case No. 1049/09)
In the Matter of:
Sh. Rameshwar Lal
S/o Sh. Raje Lal
R/o A-25, Kamla Nagar
Delhi-110007 ....... Appellant
Versus
1. National Insurance Co. Ltd.
Through its Branch Manager
201, Harsha House
Milan Complex, Karampura
New Delhi-110015
2. M/s Alankit Healthcare Ltd.
2E/21, Jhandewalan Extension,
New Delhi-110055 .......Respondents
CORAM
Justice Veena Birbal, President
Ms. Salma Noor, Member
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
Ms. Salma Noor, Member
1. This is an appeal u/s 15 of the Consumer Protection Act against the order dated 27.12.2012 passed by the Consumer Disputes Redressal Forum, Janakpuri, New Delhi in Complaint Case No. 1049/09.
2. Brief facts of the case are that the appellant/complainant was the holder of the mediclaim policy of the respondent company having policy No. 360303/48/9/8500000020. He was undergoing treatment from AIIMS where he was advised the use of CPAP (auto adjustment type with all standard accessories). It was alleged by the appellant/complainant that he wrote a letter to respondent/OP requesting to provide him the machine or pay him Rs. 80,000/- to Rs. 90,000/- towards the costs of the machine. Again a reminder was sent on 20.08.2009 but no response was received from the respondent/OP. He served a legal notice on the respondent/OP on 11.09.2009 asking the respondent/OP to provide the machine or to pay him a sum of Rs. 80,000/- to 90,000/-. That notice was also not replied by the respondent/OP. The appellant/complainant was having restless night sleep which was causing irritation, memory lapse and loud snoring. He purchased a machine on 25.09.2009 from Breath Well Medicare India Pvt. Ltd. for a sum of Rs. 74,880/-. The appellant/complainant sent a bill of the CPAP machine along with doctor's advice to the respondent/OP and also informed the respondent/OP that in similar matters State Commission and National Commission had ordered to pay the amount of the machine to the Consumers. It is the grievance of the appellant/complainant that respondent/OP had not at all bothered to reply his letters dated 29.07.2009, 08.10.2009, legal notice dated 11.09.2009 and reminder dated 10.11.2009. As appellant/OP was not getting the response to his letters, he filed a complaint before the Ld. District Forum for reimbursement of the amount of CPAP machine along with interest and compensation.
3. Notice was issued to the respondent/OP who appeared and contested the case on various grounds. The preliminary objection was raised by the respondent/OP that appellant/complainant never submitted any bill to the respondent for reimbursement of the amount of CPAP machine and no claim was ever lodged with respondent/complainant. Moreover, it was also pointed out by the respondent/OP that CPAP machine was not payable as per the exclusion clause 4.16 of the mediclaim policy issued to the respondent/complainant.
4. Appellant/complainant had filed rejoinder reiterating the same facts which he had averred in the complaint. Both the parties led their evidence in the form of affidavits.
5. After hearing both the parties, the Ld. District Forum held as under:
"The claim alleged to have been filed by the complainant was not rejected or repudiated by the respondent because according to the respondent no formal claim was ever filed with them and requests for paying the cost of the machine was not considered as the machine intended to be purchased by the complainant was hit by exclusion clause 4.16. We have perused the first letter written by the complainant which is dated 29th July, 2009 wherein the complainant wrote that he had been admitted to AIIMS for the treatment. On advice he had to purchase CPAP machine with accessories for the treatment and made a request for permission to purchase the machine and to issue a claim form. On 20th August, 2009 again a request was made for permission to purchase the machine. On 11.09.2009 a notice through advocate was served upon the respondent in para 4 of the notice, it was written "in case you failed to provide the machine or the amount required my client shall purchase the same at your risk, cost and --- and you shall be liable to pay the cost of the machine which my client shall purchase from the market and in that event you shall have no grievance regarding the cost or expenses incurred as required. "Again a letter was written on 08.09.2009 which was received in the office of the insurance company on 09.10.2009 Again in this letter a request was made reimbursement of the sum of Rs. 74,880/- alongwith interest at the rate of 18%. This letter contained 3 enclosures- policy claim form, copy of the bill amount of Rs. 74,880/- copy of the AIIMS tests and related papers with letter dated 29th July, 2009. We have carefully perused all the documents placed on record. There is no document on record showing that complainant was ever admitted in the hospital. The original bill of purchasing the machine and the prescription was never submitted by the complainant. Photocopy of one OPD card dated 29th June, 2009 is only placed on record. No record of admission in the hospital in December, 2008 is filed with the complaint. Photocopies of the documents placed on record show that on 02.12.2008 he was referred to AIIMS by Dr. Ravi Prakash. On 24.12.2008 certain tests were conducted with regard to his sleep pattern and on 29 th June, 2009 he visited the hospital second time in the OPD. The only observation made by the doctor in his OPD Card was "this patient had tried to use CPAP machine provided on trial basis from AIIMS with which there is objective and subjective benefit to the complainant. This treatment is essential for the complainant.
On the basis of this note only he applied to the respondent for payment of the cost of the machine, the claim alongwith the original documents and cash memos alongwith a certificate in original from the doctor was never lodged by him. Hence, to that extent, respondent's defence was genuine that the complaint was filed without any cause of action there being no formal claim lodged with the respondent. As already 3 years have passed since the filing of this complaint, we hereby order that complainant shall lodge the formal claim with the respondent No. 1 within 30 days from the receipt of the copy of this order and the claim shall be considered on merits by the insurance company within next 30 days. With these observations complaint stands disposed off with no order as to compensation or cost".
6. Aggrieved by the aforesaid order of the Ld. District Forum the appellant/complainant has filed the appeal for setting aside the impugned order stating that he had already lodged a claim with respondent/OP prior to filing of the complaint before the Ld. District Forum. He also admitted that at the time of filing of the complaint before the Ld. District Forum the respondent/OP had not repudiated his claim. Ld. District Forum has rightly directed the complainant to lodge a formal claim with respondent-1 i.e. National Insurance Co. Ltd. within 30 days from the receipt of the copy of the order and directed insurance company to consider the claim of the appellant/complainant on merits thereafter within 30 days. The appellant/complainant instead of filing of the claim before the insurance company filed this appeal before this Commission for setting aside the impugned order passed by the Ld. District Forum.
7. On this appeal notice was issued to respondent i.e. NIC Ltd. who appeared and filed reply to the appeal reiterating the facts which were stated before the Ld. District Forum. It is alleged that the appellant/complainant never provided any document to the respondent/OP showing his admission at AIIMS on 24.12.2008. The respondent/OP stated its inability to reimburse the cost of the CPAP machine as it is alleged that same comes under the exclusion clause 4.16 of the terms and conditions of the policy. It is also admitted by the respondent/OP that during the pendency of the appeal the respondent/OP repudiated the claim of the appellant/complainant.
8. We have heard counsel for the parties and also requisitioned the record of the Ld. District Forum. We have carefully gone through the same. While passing the impugned order the Ld. District Forum observed that appellant/complainant did not file original bill of purchasing of CPAP machine neither any proof of admission in AIIMS on 24.12.2008. This observation of the Ld. District Forum is wrong as it is evident from the record of the Ld. District Forum that appellant/complainant has placed on record document at page 24 of his complaint which shows that the appellant/complainant was admitted in the All India Institute of Medical Science on 24.12.2008 wherein requisite test was done. Paper of his admission in All India Institute of Medical Science is reproduced as below:
"All India Institute of Medical Sciences Ansari Nagar, New Delhi- 110029 POLYSOMNOGRAPHY REPORT (template: General_ PSG_5.2. rt) Patient : Lal, Rameshwar Date of Test: 12/24/08 DOB: 3/10/53 Height: 164 cm File code: 532 Weight: 82 kg.
Sex: Male Age: 55 yrs
Habitual snoring: Yes BMI (kg/m2) : 30.50
Epworth Sleepiness Scale(ESS) 13 Technician: Jitender Sharma
Prof-in charge: Dr. S.K. Sharma, Faculty-in-charge: Dr. Vinay Gupta
Sleep Summary:
Bedtime: 22:00:57 % SPT WASO
Risetime: 6:18:57 REM 10.4%
Total Recording Time: 498 Min 18.0%
Total Sleep Time: 446 Min
Sleep efficiency: 89.6% Stage 4 Stage 1
Sleep Onset Latency: 0 Min 10.1%
REM Onset Latency: 86 Min
Total Wake Time: 52 Min Stage 3
Wake during sleep: 52 Min 11.3%
Total Awakenings: 25 Stage 2
Sleep Stage Summary
Stage Latency duration % SPT
(min) (min)
WASO 1 52 10.4
Stage1 7 47 9.4
Stage2 0 199.5 40.1
Stage3 0.5 56.5 11.3
Stage4 36 50.5 10.1
Stage 3 & 4 0.5 107 21.5
Total NREM - 353.5 71.0
REM 86 89.5 18.0
The appellant/complainant supplied document along with his claim to the respondent-1 i.e. insurance co. He also produced the bills of the CPAP machine which is annexed at page 17 in his complaint that was also supplied to the respondent/OP. Hence observation of the Ld. District Forum that no document ever been produced by the appellant/complainant about his admission in AIIMS admission on 24.12.2008 and receipt of CPAP machine was ever produced before the Ld. District Forum is wrong.
9. Now the next controversy between the parties that calls for determination is whether expense incurred upon the machine known as CPAP which is life saving machine to control the disease in question was reimbursable or not according to the terms and conditions of the insurance papers. In this regard clause 3.2 and 1.00 of the policy are relevant and is 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, Anesthetists, Medical Practitioner,
Consultants, Specialists fees.
D) Anesthesia, 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."
10. 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 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.
11. As is apparent from his 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. 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.
12. 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.
13. 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.
14. As discussed above, we are of the considered view that the appellant/complainant is entled for re-imbursement of the expenses incurred by him towards the purchase of this equipment."
15. In view of the aforesaid discussion, we allow the appeal and set aside the impugned order and direct the respondent/OP to pay Rs. 74.880/- towards cost of the CPAP machine along with 6% interest from the date of purchasing of CPAP machine. The payment shall be made within one month from the date of receipt of this order.
A copy of the order be sent to the parties as well as to the Ld. District Forum for necessary information. The record of the Ld. District Forum be also sent back forthwith. Thereafter, the file be consigned to record room.
(Justice Veena Birbal)) President (Salma Noor) Member Rakeeba