State Consumer Disputes Redressal Commission
Bawa Singh vs Religare Health Insurance Company ... on 25 March, 2022
ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
Consumer Complaint No.932 of 2019
Date of Institution : 31.12.2019
Date of Reserve : 17.03.2022
Date of Decision : 25.03.2022
Bawa Singh son of Shri Miyan Singh, aged 85 years, resident of
village Kahnuwan, Tehsil and District Gurdaspur.
.....Complainant
Versus
Religare Health Insurance Company Limited, A-3, A-4, A-5, GVS
Global, Sector 125, Noida (U.P).
Email-travelassistance@ religare.com
.....Opposite party
Consumer Complaint under Section 17
of the Consumer Protection Act, 1986.
Quorum:-
Mr. Rajinder Kumar Goyal, Presiding Member
Mrs. Kiran Sibal, Member Present:-
For the complainant : Sh. Rajeshwar Singh, Advocate For the opposite party : Sh. Shiv Bhola, Advocate for Sh. Ramdeep Partap Singh, Adv.
KIRAN SIBAL, MEMBER:-
The complainant has filed this complaint under Section 17 of the Consumer Protection Act, 1986 (in short "the Act"), against the opposite party (in short "OP") seeking following directions:-
i) to pay USD 34780.80 i.e. Rs.24,34,639/- the balance insurance claim along with interest at the rate of 15% p.a. from the date of submission of the insurance claim till the date of actual payment;Consumer Complaint No.932 of 2019 2
ii) to pay Rs.5,00,000/- as compensation, for mental tension, harassment and sufferings;
iii) to pay Rs.50,000/- as litigation expenses; and
iv) any other relief which this Commission may deem fit and proper.
2. Brief facts, as set out in the complaint, are that the son of the complainant is living in Canada and he went on visitor's Visa to his son and his family from 10th May, 2017. The stay of the complainant in Canada was for three months. Before leaving for Canada, the complainant bought an insurance policy from the OP for a sum assured of USD 50000 and paid an amount of Rs.29,872/- as insurance premium. The policy was valid w.e.f 09.05.2017 till 07.08.2017 for a total of 91 days, which covered all accident/accidental information and all other benefits including hospitalization. While in Canada, on 19.05.2017, in the morning, the complainant went to washroom for washing his hands with water. Incidentally, the tap was of single lever i.e. for hot and cold water and when he put water on his hand, bubbles were started appearing on left hand and right arm and he felt severe burning pain. Earlier the right hand of the complainant had been amputated and he was having disability certificate in this regard. He also mentioned each and every fact at the time of obtaining the insurance policy. The complainant was taken to M/s Victoria General Hospital, Winnipeg by his son Manjit Singh Bhumra for emergency check up, where he was kept for one day and was thereafter transferred to M/s Health Science Centre, Winnipeg M.B. for his treatment. The burning injury was so deep that Consumer Complaint No.932 of 2019 3 plastic surgery and skin grafting was suggested by the said hospital. The complainant remained admitted in the said hospital from 20.05.2017 to 02.06.2017 and the hospital raised a total bill for an amount of USD 66814.35 for his treatment. The complainant was entitled to full sum insured as per clause 2.7 of the insurance policy, which indicates that the total and irrecoverable loss of sight of both eyes, or actual loss by physical separation of two entire hands or two entire feet, or one entire hand or one entire foot, or loss of sight of one eye and actual loss by physical separation of one entire hand or one entire foot, constitute 100% disability and the percentage of the sum insured of the benefit payable shall be 100%. The complainant approached the OP and submitted the claim form. He also requested the OP to release the amount to the said hospital on account of his treatment. A notice was also issued by the said hospital to pay the treatment expenditure, but the OP has approved only a sum of USD 15219.20, whereas the complainant is entitled for full insured amount of USD 50000 as he suffered 100% disability. The policy provides that in case there is a loss of both hands, then the disability will be 100% and in that eventuality the OP shall pay 100% of the sum insured. A disability certificate was also issued by the medical authorities, Gurdaspur, which assessed 100% disability to the complainant. The complainant requested the OP to release the remaining amount and sent emails in this regard, but all in vain. The act and conduct of the OP Consumer Complaint No.932 of 2019 4 amounts to deficiency in service and unfair trade practice on its part, which caused great mental tension, harassment and financial loss to the complainant. Hence, the present complaint.
3. Notice of the complaint was issued to OP, who appeared through counsel. But initially written reply was not filed by the OP within the stipulated period and its defence was struck off, vide order dated 01.07.2020. Subsequently, the OP challenged the said order and the Hon'ble National Commission, by setting aside the same, directed the OP to file written reply in this Commission within 30 days. Accordingly, written reply was filed by the OP and the same was taken on record.
4. In reply to the complaint, OP stated that insurance policy bearing No.11214673 ( Explore Canada+) was issued to the complainant for the sum assured of USD 50000 subject to policy terms and conditions. The complainant approached the OP for cashless request/claim No.80118421 in respect of his hospitalization in the said hospital. The complainant was hospitalized with burn injury bilateral upper extremities. From the documents submitted by the complainant, the OP found that:-
i) That as per the discharge information sheet dated 24.05.2017, the complainant was operated for left hand and right arm debridement with split thickness skin graft.
ii) As per the microbiology report of Victoria General Hospital, the complainant was diagnosed with left hand blister on top of hand.
iii) It is nowhere mentioned that the complainant suffered left hand amputation. As per the discharge summary, his left hand was swollen and right hand skin close to stump (right wrist amputated), large vesicle left hand dorsum and volar, Distal right forearm is like superficial Consumer Complaint No.932 of 2019 5 partial burn. 2-3 % involved. Left hand ring removed with ring cutter by Paula, yellow fluid from vesicle sent for C and S. The complainant has himself stated in his complaint that his right hand was amputated 20 years ago, but the same was not disclosed to the OP. He had only disclosed his history of heart stent in the year 2016. The OP paid the claim post doing the deductions as per the policy terms and conditions. The OP approved a total of CAD 15219.20 (USD 11231.77) out of the total claimed amount i.e. CAD 66814.35 (USD 49308.99). The deductions were done/calculated as per the policy certificate read with clause 2.1.1(H)(a) of the policy terms and conditions as under:-
Sub Limit Hospital Charges Sub Limit (USD) Expenses (USD) Room Rent Ward Room CAD 64671 = 9750 (USD 750 for 13 including Charges USD 47727.19 Days) boarding 1.5% of the sum insured subject to a and lodging ICU 2 % of Emergency CAD 1038 = UAD 766.04 Sum Insured Room USD 766.04 Radiology - CAD 29.75 = USD 49 Hand, Chest USD 21.95 Elbow Radiology- CAD 19.3 = Chest USD 14.24 Portable (X2) Radiology- CAD 18.30 Abdomen (9.15 + 9.15) = USD 13.50 Ambulance Emergency 0 Medical Services Miscellaneous Out Patient CAD 1038 = USD 766.04 Expenses Clinic USD 766.04 Charges Medical Physician 0 Practitioner Professional Consumer Complaint No.932 of 2019 6 Visit Fees Services Amount CAD 66814.35= USD 11331.77 Approved USD 49308.99 Standard USD 100 = CAD 135.50 Deduction USD 100 was deducted as per the standard deductions mentioned in the policy certificate. The OP approved the claim post deducting applicable charges as per the policy terms and conditions. The complainant had the opportunity to disclose his history of amputated right hand at the time of filling of proposal form, but no such disclosure was made by him. For availing 100 % of the sum insured under clause 2.7 of the policy, physical and actual severance of hand at or above the wrist should be there but in the present case, no amputation of left hand is apparent. Hence, the OP rightly approved the claim amount in accordance with the terms and conditions of the policy. There is no deficiency in service or unfair trade practice on the part of the OP. After denying the other averments made in the complaint, OP prayed for dismissal of the complaint.
5. To prove his case, the complainant along with the complaint filed his affidavit and copies of documents Ex.C-1 to C-
9. On the other hand, OP filed written statement/evidence by way of an affidavit of Sh. Ravi Boolchandani, Legal Manager along with copies of documents Annexure R-1 to R-8.
6. We have heard learned counsel for the parties and have carefully gone through written submission filed by them and record of the case.
Consumer Complaint No.932 of 2019 7
7. The learned counsel for the complainant has vehemently contended that the complainant purchased the policy in question after paying a heavy amount of premium to the insurance company. The OP is duty bound to compensate the complainant as per his claim. The bare perusal of medical record of the complainant clearly shows that he suffered permanent disability due to burn injury on his left hand and right arm during the period of insurance. The learned counsel further argued that as per clause 2.7 of the insurance policy, the complainant is entitled for 100% of sum insured but the OP has ignored the said clause of the insurance policy and approved only an amount of USD 11231.77 instead of full sum insured USD 50000, which is on the lower side. Alleging deficiency in service on the part of the OP, the complainant prayed for acceptance of the present complaint.
8. On the other hand, the Ld. Counsel for OP argued on the similar lines as stated in the written reply, which are not required to be reproduced here for sake of brevity. In support of his contentions the learned counsel relied upon the judgment of Hon'ble Supreme Court in the case of Export Credit Guarantee corpn. of India Ltd. Vs. M/s Garg Sons International, passed on 17.01.2013 in Civil Appeal No.1557 of 2004. The learned counsel prayed for dismissal of the present complaint.
9. We have given thoughtful consideration to the contentions raised by the learned counsel for the parties. Consumer Complaint No.932 of 2019 8
10. Admitted facts of the case are that the complainant was insured with OP for the period from 09.05.2017 to 07.08.2017, vide policy bearing No.11214673, Ex. C-2, for a sum assured of USD 50000 and he has taken treatment during the currency of policy period. It is also an admitted fact that the right hand of the complainant had already been amputated before commencing of the policy and the dispute is only for claiming the amount for permanent disablement of the left hand. The complainant approached the OP and requested for availing cashless hospitalization, Annexure R-3. But the OP approved a total of CAD 15219.20 (USD 11231.77), vide letter dated 20.12.2017(Annexure R-7) out of total claimed amount of CAD 66814.35 (USD 49308.99) as per clause 2.1.1(H)(a) of the Policy Terms and Conditions, Annexure R-2. The grievance of the complainant is that the amount of CAD 15219.20 approved by the OP is on the lower side as he has entitled for full sum assured as per Clause 2.7 of the Policy Terms and Conditions. A perusal of letter for final guarantee of payment dated 20.12.2017, Annexure R-7, issued by the insurance company shows that the OP approved an amount of USD 11231.77 after policy deductible-USD 100 towards inpatient hospitalization expenses as per clause 2.1.1(H)(a) of the Policy Terms and Conditions. The relevant portion of clause 2.1.1(H)(a) is reproduced as under:-
"2.1 Benefit I : Hospitalization Expenses 2.1.1. In-Patient Care Consumer Complaint No.932 of 2019 9 (H) Conditions For In-Patient Care (Applicable only if opted by the Policyholder and specifically mentioned in the Policy certificate)
(a) The Company's maximum liability under this Benefit for In-patient Care under an admissible Claim in respect of any insured Person of Age 61 years or above (as on date of Policy Period Start Date) shall be limited in accordance with the table below:
Medical Expense Sub- Limit Room Rent including 1.5% of the sum insured subject to boarding lodging a and maximum of US $ 2,000 per day/Euro 1,500 per day ICU Charges 2% of the Sum Insured subject to a maximum of US $ 3,000 per day/Euro 2,250 per day Operation Theatre 10% of the Sum Insured subject to Charges (Incl. a maximum of US $ 20,000 per Surgeon Charges) claim/Euro 15,000 per claim Anesthesia 25% of the Surgery cost payable Ambulance Services US $ 500 per claim/Euro 375 per claim Diagnostics and US $ 1,000 per claim/Euro 750 per Radiology Services claim Medical Practitioners US $ 100 per visit/Euro 75 per visit visit fees subject to maximum of 10 visits per claim Miscellaneous US $ 1,000 per claim/Euro 750 per Expenses claim
11. Now the issue is to decide whether the complainant is entitled for claim amount as per Clause 2.1.1(H)(a) or Clause 2.7 of the Policy Terms and Conditions? To determine this issue, we have perused the entire evidence and pleadings on record. It is pertinent to mention that the OP has reimbursed the amount of hospitalization expenses only and not the claim amount for permanent disability of left hand, as per terms and conditions of the policy. The contention of learned counsel for the complainant is that the complainant is entitled for 100% of the sum assured as per Clause 2.7 of the Policy terms and conditions. The relevant Consumer Complaint No.932 of 2019 10 portion of clause 2.7 of the policy terms and conditions is reproduced as under:-
"2.7 Benefit 7 : Personal Accident
(a) If the insured Person suffers an Injury during the Period of Insurance solely and directly due to an Accident that occurs during the Period of Insurance, which directly results in:
(i) The Insured Person's death within 12 months of the occurrence of the Injury; or
ii) The Insured Person's Permanent Total Disablement within 12 months of the occurrence of the Injury such that the Insured Person is unable to resume his normal occupation or engage in similar gainful employment due to the Permanent Total Disability suffered.
The company will pay the Sum Insured in accordance with the table below:-
Sr. Event % of the
No Sum
Insured of
this Benefit
payable
1 Accidental Death 100%
2 Permanent Total Disablement
(PTD) means
A The total and
irrecoverable loss of 100%
sight of both eyes, or
actual loss by physical
separation of two entire
hands or two entire feet,
or one entire hand and
one entire foot, or loss of
sight of one eye and
actual loss by physical
separation of one entire
hand or one entire foot
B Loss of sight of one eye, 50%
or actual loss by physical
separation of one entire
hand or one entire foot
(i) For the purpose of this Benefit only, 'Physical separation of a hand or foot' means actual severance of hand at or above the wrist, and of foot at or above the ankle".
Consumer Complaint No.932 of 2019 11In support of his contention the complainant placed on record Ex. C-9 i.e. disability certificate dated 14.11.2018 issued by Medical Authority, Gurdaspur, Punjab. A perusal of the said certificate, Ex. C-9, shows that the concerned Medical Authority has certified that complainant is a case of Locomotor disability and the diagnosis in his case is B/L electric burn contracture with no grip strength and power zero. It has also been certified that complainant is 100% permanent disabled in relation to his (part of body) as per guidelines (to be specified). From the perusal of medical record, Ex. C-3, placed on record by the complainant, it is proved that the complainant suffered personal accidental burn injuries on his left hand and right arm due to which his left hand suffered permanent total disability. The complainant has relied upon disability certificate (Ex.C-9), which clearly proves that the left hand of the complainant has been rendered useless with 100% disability. Neither the OP has rebutted the said disability certificate on the record nor it has challenged the same by way of leading any cogent evidence. The onus is on the OP to prove that the complainant did not suffer from above said 100% disablement of left hand in the above said personal accident. In view of permanent disability of left hand the claim of the complainant is covered under Clause 2.7 of the policy.
12. Now the question arises as to whether the complainant is entitled for 100% sum insured or not? It is pertinent to mention here that the right hand of the complainant had already been Consumer Complaint No.932 of 2019 12 amputated prior to commencing of the insurance policy in question. In the present case, the complainant has suffered 100% permanent disability of his left hand only during the period of insurance, as such his case falls under sub-clause Sr.No. 2(B) of Clause 2.7 (Benefit 7 : Personal Accident), where under the liability of insurance company has been fixed @ 50% of the sum insured in case of permanent disability of one hand. As such, the complainant is entitled to 50% of sum insured benefit, as per above said Clause of the terms and conditions of the Policy. The standard deduction of USD 100 is not applicable under Clause 2.7 of the policy terms and conditions.
13. A sequel of our above discussion, we are of the view that the claim of the complainant has been wrongly approved as per Clause 2.1.1(H)(a), whereas the same is to be paid as per sub-clause Sr.No. 2(B) of Clause 2.7 of the Policy terms and conditions as discussed above.
14. Accordingly, we partly accept the present complaint of the complainant and direct the OP to pay 50% of the sum insured as per terms and conditions of the policy. The sum assured amount in the present case is USD 50000 and the OP shall pay 50% of the same i.e. USD 25000 minus USD 11231.77 (the amount already paid by the OP). The OP is directed to make balance payment of USD 13,768.23 (USD 25000 minus USD 11231.77) in Indian Rupees. It is made clear that the rate of USD shall be the same rate as on the date when payment of USD Consumer Complaint No.932 of 2019 13 11231.77 was made by OP. It is further directed that OP shall pay an interest at the rate of 6% p.a. on the said remaining balance amount from the date of submission of claim form by the complainant to the insurance company till its realization. The opposite party is further directed to pay lump sum amount of Rs.15000/- towards litigation expenses and compensation to the complainant. The order be complied within a period of 60 days from the date of receipt of certified copy of the same.
15. The complaint could not be decided within the stipulated period due to heavy pendency of Court cases and non- sitting of this Commission due to pandemic of Covid-19.
(RAJINDER KUMAR GOYAL) PRESIDING MEMBER (KIRAN SIBAL) MEMBER March 25th, 2022.
(dv)