State Consumer Disputes Redressal Commission
Charanjit Kaur vs Oriental Insurance Company Ltd. on 6 February, 2017
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PUNJAB
SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.1102 of 2015
Date of Institution: 05.10.2015
Order reserved on:03.02.2017
Date of Decision : 06.02.2017
Charanjit Kaur wd/o Bhagwan Singh, r/o 20/21 East End Estate, G.T.
Road, Amritsar.
.....Appellant/complainant
Versus
1. Oriental Insurance Co. Ltd., Branch Office, Queens Road,
Amritsar through its Branch Manager, Principal Officer.
2. Medi Assist India TPA Pvt. Ltd., 47/1 Sri Krishna Arcade 1st
Main 9th Cross, Sarakki Industrial Layout, J.P. Nagar 3rd
Phase, Bangalore-560078 through its Managing
Director,/CEO/General Manager, Principal Officer.
.....Respondents/opposite parties
Appeal against order dated 24.08.2015
passed by the District Consumer
Disputes Redressal Forum, Amritsar.
Quorum:-
Shri J. S. Klar, Presiding Judicial Member.
Smt. Surinder Pal Kaur, Member Present:-
For the appellant : Sh. Anupam Bhardwaj, Advocate For respondent no.1 : None For respondent no.2 : Ex-parte ............................................ J.S KLAR, PRESIDING JUDICIAL MEMBER :-
The appellant has directed this appeal against order dated 24.08.2015 of District Consumer Disputes Redressal Forum Amritsar (in short the 'District Forum'), vide which, the complaint filed by the complainant U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs was dismissed. The respondents of this appeal are the opposite parties in the original complaint before the First Appeal No.1102 of 2015 2 District Forum and appellant of this appeal is complainant therein and they be referred as such hereinafter for the sake of convenience.
2. The complainant brought the complaint against OPs on the averments that her husband Bhagwan Singh was insured by OP no.1, vide cover note no.920699 issued on 24.12.2013 for the period 26.12.2013 to 25.12.2014 against the premium paid. The complainant and her husband earlier took policy from OP no.1 covering the period from 26.12.2012 to 25.12.2013. The complainant and her husband were, thus, insured in the earlier insurance policy since 26.12.2012 for the mediclaim. The condition of DLA Bhagwan Singh husband of complainant suddenly deteriorated and he was admitted in Fortis Escorts Hospital at Amritsar on 09.11.2014. He was provided the treatment and complainant was intimated that her husband DLA suffered cardiac arrest. Due intimation regarding the admission of DLA Bhagwan Singh therein was given to OP by the complainant for availing cashless facility. DLA Bhagwan Singh died in the evening thereat. Pre authorization permission was not granted by that time and hence expenditure of Rs.38,657/- was incurred on the treatment of insured, which was paid by the complainant from her own pocket. All the documents alongwith requisite formalities were sent to OP for reimbursement of the claim and the amount incurred on the treatment of insured Bhagwan Singh, as he was fully insured for the above period with OP. The insurance claim of the complainant was repudiated, as conveyed vide letter dated 30.12.2014 to her. The insurance claim was repudiated on the First Appeal No.1102 of 2015 3 ground that the case was not covered under the policy in view of clause 4.2(7) thereof, because insured was suffering from hypertension for specified period of two years. DLA was 76 years of age and he was insured since 26.12.2012 and he died due to cardiac arrest. The cause of death has been shown of DLA as cardio pulmonary arrest. The complainant filed complaint against OPs directing them to reimburse claim amount of Rs.38,657/- with interest @24% per annum and to pay Rs.50,000/- as compensation.
3. Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant vehemently. It was averred in preliminary objections that claim is not payable, as per exclusion clause 4.2 of the policy which reads as under:
"During the period of insurance cover, the expenses on treatment of Hypertension for specified period of two years are not payable, if contracted and/or manifested during the currency of the policy."
The claim was considered and found inadmissible by competent authority of OP no.1 on the basis of letter dated 30.12.2014 of OP no.2. There is direct nexus between hypertension ailment and cardiac arrest disease and the inception of policy was from 26.12.2012 and that was the second year of policy. As per the terms and conditions of the policy, the treatment related to hypertension is not payable and falls under exclusion of clause of 4.2 for two years. The insured Bhagwan Singh was a known case of hypertension of regular treatment and was taking medication and had history of Vertigo prior to insurance policy. The OP rightly repudiated the First Appeal No.1102 of 2015 4 insurance claim of the complainant. It was further averred in preliminary objections that complainant has no locus standi to file the complaint, as she is not the legal heir of DLA Bhagwan Singh. On merits, fact of taking the policy by life assured Bhagwan Singh was admitted. It was averred that as per exclusion clause 4.2 of the policy, the claim is not admissible. The OPs prayed for dismissal of complaint.
4. The complainant tendered in evidence affidavit and documents Ex.C-1 to C-10 and closed the evidence. As against it, OPs tendered in evidence affidavit and documents Ex.OP-1,2/1 to OP-1,2/7 and closed the evidence. On conclusion of evidence and arguments, the District Forum dismissed the complaint of the complainant. Dissatisfied with the order of the District Forum, the complainant, now appellant, has filed this appeal against the same.
5. We have heard the learned counsel for the appellant, as none appeared for respondent no.1 during the arguments of the appeal. Respondent no.2 of this appeal has been set exparte in this case. We have also examined the record of the case. The pleadings of the parties have been carefully perused by us on the record. Ex.C- 1 is the affidavit of complainant Charanjit Kaur stating that her husband Bhagwan Singh was insured with OP under above policy for the period from 26.12.2013 to 25.12.2014. She further stated that her husband also took the earlier policy from OP no.1 for the period 26.12.2012 to 25.12.2013. Bhagwan Singh DLA since diseased was, thus, insured since 26.12.2012 for the mediclaim with OPs, as deposed by her. She further stated that condition of her husband First Appeal No.1102 of 2015 5 deteriorated on 09.11.2014 which led to his admission in Fortis Escort Hospital, Amritsar, where he was given the treatment. He suffered cardiac arrest and expired thereat. She further stated that she incurred expenditure of Rs.38,657/- on her husband's treatment. Ex.C-2 is the death summary of Bhagwan Singh DLA. Ex.C-3 is letter dated 30.12.2014 by the OPs that claim does not fall within the policy's terms and conditions and it was found inadmissible for reimbursement. Ex.C-4 is provisional cover note no.920699 of Bhagwan Singh for period from 26.12.2013 to 25.12.2014. Ex.C-5 is the inpatient bill of Bhagwan Singh issued by Fortis Escorts Hospital with regard to expenses incurred on his treatment thereat. Ex.C-6 is the request for cashless hospitalization for medical insurance policy. Ex.C-7 is cancellation of pre-authorization by the Fortis Escorts Hospital Amritsar to Medi Assist India Private Ltd., Noida. We have also duly appreciated the documents Ex.C-8 to C-10 on the record. The OPs also adduced evidence of elenchus in this case. Ex.OP-1,2/1 is the letter from Medi Assist India TPA Pvt. Ltd. dated 20.02.2015 that DLA Bhagwan Singh was suffering from hypertension for the last two years and death summary is Ex.OP- 1,2/2. Ex.OP-1,2/3 is the letter dated 30.12.2014 from OPs addressed to Bhagwan Singh DLA for denial of claim. Ex.OP-1,2/5 is the affidavit of Sh. Gurdip Singh, Divisional Manager of Insurance Company on the record that claim is not admissible under the exclusion clause of the policy. The terms and conditions in detail of the policy are Ex.OP-1,2/7 on the record. Clause 4.2. of the policy is re-produced as under:
First Appeal No.1102 of 2015 6
"The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy.
If these diseases are pre-existing at the time of proposal the exclusion no 4.1 for pre-existing condition shall be applicable in such case.
i Benign ENT disorders and surgeries i.e. 1 year Tonsillectomy, Adenoidectomy, Mastoidectomy, Tympanoplasty etc. ii Polycystic ovarian diseases 1 year iii Surgery of hernia 2 years iv Surgery of hydrocele 2 years v Non infective Arthritis 2 years vi Undescendent Testes 2 years vii Cataract 2 years viii Surgery of benign prostatic hypertrophy 2 years ix Hysterectomy for menorrhagia or fibromyoma or 2 years myomectomy or prolapse of uterus.
x Fissure/Fistula in anus 2 years xi Piles 2 years xii Sinusitis and related disorders 2 years
xiii Surgery of gallbladder and bile duct excluding 2 years malignancy xiv Surgery of genitor-urinary system excluding 2 years malignancy xv Pilonidal sinus 2 years xvi Gout and Rheumatism 2 years xvii Hypertension 2 years First Appeal No.1102 of 2015 7 xviii Diabetes 2 years xix Calculus diseases 2 years xx Surgery for prolapsed inter vertebral disk unless 2 years arising from accident xxi Surgery of varicose veins and varicose ulcers 2 years xxii Joint replacement due to degenerative condition 3 years xxiii Age related osteoarthritis and Osteoporosis 3 years If the continuity of the renewal is not maintained with the company then subsequent cover shall be treated as fresh policy and clauses 4.1, 4.2 shall apply unless agreed by the company and suitable endorsement passed on the policy. Similarly, if the sum insured is enhanced subsequent to the inception of the policy, the exclusion clauses 4.1, 4.2 will apply afresh for the enhanced portion of the sum insured for the purpose of this section."
It is, thus, evident from perusal of exclusion clause 4.2 that expenses on treatment of hypertension for two years from the date of taking the policy during the currency of the policy are not payable. Clause 4.2 (7) of the policy Ex.OP-1,2/7, thus, makes the claim for hypertension inadmissible, if manifested during two years period from the date of inception of the policy. The policy was initially taken on 26.12.2012 by DLA Bhagwan Singh. He died on 09.11.2014. Two years period had not elapsed from the date of inception of the policy from 26.12.2012, which was the earlier policy period. This fact is sufficiently proved on the record that DLA was a patient of hypertension and hypertension is major contributing factor to cardiac First Appeal No.1102 of 2015 8 arrest. There is direct nexus between hypertension and the disorder of cardiac arrest. DLA died due to cardiac arrest and he being known case of hypertension was recorded in his death summary Ex.C-2, which is the document of complainant. Consequently, the claim of the complainant for the ailment of hypertension for a period of two years from the date of commencement of policy from 26.12.2012, even if second policy is tagged therewith, hence the claim is completely inadmissible as per exclusion clause 4.2(7) of the policy. The District Forum has rightly upheld the order of repudiation of the insurance claim being covered by the exclusion clause of the policy. The parties are strictly bound by the terms and conditions of the contract of insurance and they cannot back out of the same. The contract of insurance has to be interpreted sensu-stricto by us. We cannot interpolate anything in it.
6. As a result of our above discussion, we affirm the order of the District Forum Amritsar dated 24.08.2015 and consequently, the appeal filed by the appellant stands dismissed.
7. Arguments in this appeal were heard on 03.02.2017 and the order was reserved. Certified copies of the order be communicated to the parties as per rules. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR)
PRESIDING JUDICIAL MEMBER
February 06, 2017 (SURINDER PAL KAUR)
MM MEMBER