State Consumer Disputes Redressal Commission
Satvir Singh Sidhu vs Religare Health Insurance Company ... on 22 February, 2022
ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
Consumer Complaint No.578 of 2019
Date of Institution : 30.07.2019
Date of Reserve : 15.02.2022
Date of Decision : 22.02.2022
Satvir Singh Sidhu, aged about 35 years, son of Shri Baldev
Singh, resident of Near Kalgidhar Gurudwara, village Fatehgarh
Korotana, Tehsil Dharamkot, District Moga.
.....Complainant
Versus
1. Religare Health Insurance Company Limited, Vipul Tech.
Square Tower-C, 3rd Floor, Sector 43, Golf Road, Gurugram
through its Incharge. Email. Travel Assistance @
Religare.com.
2. Religare Health Insurance Company Limited, Vipul Tech.
Square Tower-C, Registered office at 5th Floor, 19 Chawla,
Nehru Place, New Delhi through its Incharge.
3. Guru Kirpa Enterprises, Amritsar Road, Near Punjab
National Bank, Authorized Officer of concerned office
namely Vicky Ahluwalia and Lucky Ahluwalia (Mobile
No.95928-70000)
.....Opposite parties
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. S.P.Singh, Advocate For Opposite party No.1 &2 : Sh. P.M. Goyal, Advocate For Opposite Party No.3 : Exparte Consumer Complaint No.578 of 2019 2 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 parties (in short "OPs") seeking following directions:-
i) The OPs be directed to pay a sum of Rs.57,36,084/-
along with interest @ 18% p.a. till the date of payment.
ii) Rs.5,00,000/- as compensation on account of mental harassment and deficiency in service.
iii) Rs.25,000/- as litigation expenses.
iv) Not to cancel the policy in question or to restore the same if already cancelled.
2. Brief facts, as set out in the complaint, are that the complainant purchased a health insurance policy bearing No.12382426 for the sum assured of $65000 (American Dollars) from OPs No.1 & 2 through OP No.3. The policy was valid w.e.f 13.04.2018 to 04.10.2018. After obtaining the policy in question, the complainant went to Winnipeg (Canada) and in the month of August 2018, he suffered from vomiting with bleeding and was admitted at 'St.Boniface Hospital, Winnipeg MB R2H 2A6 Canada' and 'J. Arm Strong Health Information Management Professional Medical Legal Health Information Concordia Hospital-1095, Concordia Avenue Winnipeg Manitoba R2K 3S8 Canada'. The complainant informed and contacted the insurance company through OP No.3 and the concerned officials of OPs No.1 & 2 assured that the insurance company would compensate him for his proper medical treatment and other expenses. The bare perusal of medical record of the complainant shows that ECG, CT Consumer Complaint No.578 of 2019 3 Scan and many other tests were conducted by the Health Centre at Canada and the following observation was made by the doctor:-
"hemoptysis- sudden onset, ? IL total bleeding, hypoxic, CXR normal,? Source, ? PE R/O PE".
The complainant has spent a total sum of $1,08,228.50 on his treatment and he approached the OPs a number of times regarding his claim but the OPs put off the matter on one pretext or the other. The OPs are duty bound to compensate the complainant as per his claim of Rs.57,36,084/-. The complainant also served a legal notice dated 23.04.2019 through his counsel upon the OPs but they illegally and arbitrarily rejected his genuine claim. This act and conduct of the OPs amounts to deficiency in service on their part. Hence the present complaint.
3. Notice of the complaint was issued to the OPs and OPs No.1 & 2 appeared through counsel and contested the complaint. But OP No.3 has not appeared despite service and was proceeded against exparte, vide order dated 21.12.2020, passed by this Commission.
4. In its joint reply to the complaint, OPs No.1 & 2 stated that the complainant was issued a Health Insurance Policy namely "Explore-Canada+" bearing No.12382426 covering the complainant for the sum insured of USD 50,000 subject to policy terms and conditions. The OPs received a request for availing cashless facility from the hospital on behalf of the complainant. The OPs raised a query via mail dated 18.09.2018 and asked to provide the following documents:
Consumer Complaint No.578 of 2019 4
• Medical records/day care/referral/discharge summary with diagnosis and details of the treatment done in Concordia Health in Winnipeg and Discharge Summary with diagnosis and details of the treatment done in Health Science Centre in Winnipeg.
• Is there any past medical history/past surgical history of any disease? If yes, please provide the details of the treatment with records for the same.
• Reports of investigation done.
• Also provide treatment details for the treatment taken in Saint Boniface Hospital with inpatient records, summary if discharged from this hospital.
The OPs received a reply from the complainant via mail dated 19.09.2018. As per pre-authorization form, the insured was admitted on 17.08.2018 at 'Health Science Centre, Winnipeg' and was diagnosed with "Ebstein's heart anomaly/biventricular cardiac shunt". On the basis of documents received with the pre-
authorization form, the Insurance company denied the cashless request of the complainant vide denial letter dated 07.12.2018 for the following reason:
Clause 2.1.3(vii): "Any claim in respect of any insured person for, arising out of directly or indirectly due to treatment of any congenital Anomaly or illness of defects or anomalies or treatment relating to birth defects shall not be admissible under the policy".
As per the Discharge Summary dated 29.08.2018 of St. Boniface Hospital, the complainant was found to be a case of "Ebstein's Anomaly and Congenital Heart Anomaly". As the treatment of any congenital anomaly or anomalies are not admissible as per policy terms and conditions, the claim of the complainant was rightly rejected by Insurance Company. After denying the other averments made in the complaint, OPs No.1 & 2 prayed for dismissal of the complaint.Consumer Complaint No.578 of 2019 5
5. To prove his case, the complainant along with the complaint filed his affidavit and copies of documents Ex.C-1 to C-
4. On the other hand, OP No.1&2 filed on record affidavit of Tejinder Singh along with copies of documents Annexure OP-1 to OP-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.
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 OPs are duty bound to compensate the complainant as per his claim. The bare perusal of medical record of the complainant clearly shows that ECG, CT Scan and many other tests were conducted by the Health Centre at Canada and the following observation was made by the doctor:-
"hemoptysis- sudden onset, ? IL total bleeding, hypoxic, CXR normal,? Source, ? PE R/O PE".
But the OPs rejected the genuine claim of the complainant, vide letter dated 07.12.2018 illegally and arbitrarily. Alleging deficiency in service on the part of the OPs, the complainant prayed for acceptance of the present complaint.
8. On the other hand, the Ld. Counsel for OPs No.1 & 2 argued that on receiving request for availing cashless facility from the hospital on behalf of the complainant, the OPs raised a query via mail dated 18.09.2018 and asked to provide certain Consumer Complaint No.578 of 2019 6 documents. On the basis of documents received with the pre- authorization form, the Insurance company denied the cashless request of the complainant vide denial letter dated 07.12.2018 on the ground that the case of the complainant fell under Execution Clause of the policy terms and conditions. The learned counsel further argued that the OPs rightly rejected the claim of the complainant as the Discharge summary of 'M/s St.Boniface Hospital' dated 26.08.2018 shows that the complainant is a known case of Ebstein's anomaly and congenital heart anomaly and as per Exclusion clause 2.1.3(vii) of the policy any claim related to Ebstein's anomaly and congenital heart anomaly are not covered under the policy benefit. In support of his contention 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.
10. Admitted facts of the case are that the complainant has been insured with OP No.1 & 2 for the period from 23.04.2018 to 04.10.2018, vide policy bearing No.12382426, Ex. C-1. It is also not in dispute that the complainant has taken treatment during the currency of policy period. The request for availing cashless facility was rejected vide letter dated 07.12.2018, annexure OP-5, on the ground that cashless settlement for hospitalization cannot be Consumer Complaint No.578 of 2019 7 approved as per Clause 2.1.3 (vii) of the policy terms and conditions. The grievance of the complainant is that OP No.1 & 2 repudiated his genuine claim. A perusal of repudiation letter dated 07.12.2018, issued by insurance company, Annexure OP-5, shows that the insurance company repudiated the claim on the ground, which is reproduced as under:-
"We have reviewed your request, and hereby inform you that the cashless settlement for hospitalization cannot be approved as per the Policy Terms & Conditions. For ease of your perusal, we have reproduced the reason below:
Clause 2.1.3(vii): Any claim in respect of any insured person for, arising out of directly or indirectly due to Treatment of any congenital Anomaly or illness of defects or anomalies or treatment relating to birth defects shall not be admissible under the policy".
.
11. Now the issue is to decide whether the repudiation of claim by the insurance company, on the basis of Exclusion Clause 2.1.3(vii), is justified or not? To determine this issue, we have perused the entire evidence and pleadings on record. A perusal of policy document, Annexure OP-1, shows that as per Execution Clause 2.1.3(vii) of terms and condition under the head Exclusions Applicable to Benefit I: "Any claim in respect of any insured person for, arising out of or directly or indirectly due to treatment of any Congenital Anomaly or illness or defects or anomalies or treatment relating to birth defects, shall not be admissible under this benefit unless expressly stated to the contrary elsewhere in the policy terms and conditions". The contention of Ld. Counsel for the complainant is that from the bare perusal of medical record of the complainant, it Consumer Complaint No.578 of 2019 8 clearly shows that ECG, CT Scan and many other tests were conducted by the Health Centre at Canada and the following observation was made by the doctor:-
"hemoptysis- sudden onset, ? IL total bleeding, hypoxic, CXR normal,? Source, ? PE R/O PE".
On the other hand, the contention of the learned counsel for the OPs No.1 & 2 is that the Discharge summary of 'St.Boniface Hospital' dated 26.08.2018 shows that the complainant is a known case of Ebstein's anomaly and congenital heart anomaly. A perusal of discharge summary of St-Boniface Hospital, Annexure OP-6, shows that the complainant was admitted in the said hospital on 19.08.2018 and discharged on 26.08.2018. The relevant portion of the discharge summary is reproduced as under:-
"Admission Findings:-
"34 year old M admitted Aug.19th with massive hemoptysis and hypoxemia resulting in admission to ICMS, work up for this resulted in new diagnosis of congenital heart disease (Ebstein + secundum ASD) ...........
..............
Summary of Diagnoses Main CLINICAL REASON:
• Ebstein's anomaly • Congenital heart anomaly"
12. From the above discharge summary, it is clearly proved that the complainant was diagnosed with Ebstein's anomaly and congenital heart anomaly. Moreover, the request for Cashless Hospitalization for Medical Insurance Policy, Annexure OP-2, also shows that the complainant was diagnosed "Ebstein's Consumer Complaint No.578 of 2019 9 Heart anomaly/Biventricular (R7L dominant) Cardiac shunt". As per medical abstract Ebstein's anomaly is a rare heart defect that's present at birth (congenital). Therefore, the treatment of said disease fall under the exclusion clause 2.1.3(vii) (Supra). Accordingly, we find force in the contention of learned counsel for OPs No.1 & 2.
13. It is not the case of the complainant that he was not aware of the terms and conditions of the policy.
14. The Insurance is a contract between the parties and is governed by its policy terms and conditions. As per law laid down by the Hon'ble Supreme Court in the case titled as "Export Credit Guarantee Corporation of India Vs. M/s Garg Sons International" reported in 2013(1) CPC 192, held that;
"Courts are excepted to given paramount importance to the terms of insurance contract into between the parties - terms of insurance policy must be strictly construed in order to determine the extent of liability of the insurer"
Further in case titled "Vikram Greentech (I) Ltd. and another Vs. New India Assurance Co. Ltd. 2009(4) CLT 313" and further in case titled "Deokar Exports Pvt. Ltd. Vs. New India Assurance Co. Ltd. 2009(2) CLT 15" held that "In a contract of insurance, rights and obligations are strictly governed by the policies of insurance-No exception of relaxation can be made on the ground of equity.
The Hon'ble National Commission in case titled "LIC of India and others Vs. Mahendra Singh" reported as 2011(4) CLT 39, also held that, Consumer Complaint No.578 of 2019 10 "The terms of policy are in the nature of a contract and their interpretation has to be made in accordance with the strict construction of the contract - Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitute."
Accordingly, we are of the view that the repudiation of the claim by opposite parties No.1 & 2 is justified.
15. Sequel to the above discussion, the complaint is hereby dismissed being devoid of merits.
16. 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 February 22nd, 2022.
(dv)