State Consumer Disputes Redressal Commission
Reliance Life Insurance Company Ltd. vs Varun Katyal on 18 June, 2015
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 100 of 2015 Date of Institution : 05.05.2015 Date of Decision : 18.06.2015 Reliance Life Insurance Company Limited, Regd. Office H Block 1st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai - 400710 (Maharashtra). Reliance Life Insurance Company Limited, SCO 141-142, Sector 8-C, Chandigarh. Both through their Authorized Signatory Mr. Rupesh Mohindra, Senior Territory Manager, Reliance Life Insurance available at SCO 141-142, Sector 8-C, Chandigarh. ......Appellants/Opposite Parties No.1 and 2 V e r s u s Varun Katyal s/o Sh. O.P. Katyal, R/o H.No.812, Sector 17, Panchkula (Haryana) ....Respondent No.1/Complainant Medicare T.P.A. Services Pvt. Limited, Flat No.10, Paul Mansions 6B, Bishop Lefroy Road, Kolkata - 700020, through its Managing Director. ....Respondent No.2/Opposite Party No.4 Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE SHAM SUNDER (RETD.), PRESIDENT. MR. DEV RAJ, MEMBER.
MRS. PADMA PANDEY, MEMBER Argued by:Sh. Gaurav Bhardwaj, Advocate for the appellants.
Sh. Varun Katyal (Advocate) respondent No.1 in person. Respondent No.2 exparte. PER JUSTICE SHAM SUNDER (RETD.), PRESIDENT
This appeal is directed against the order dated 26.03.2015, rendered by the District Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which, it accepted the complaint, filed by the complainant (now respondent No.1) and directed Opposite Parties No.1, 2 and 4 (now two of which are appellants No.1 and 2 and one is respondent No.2) as under:-
"In the light of above observations, we are of the concerted view that the Opposite Parties No.1, 2 & 4 are found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties No.1, 2 & 4, and the same is allowed, qua them. The Opposite Parties No.1, 2 & 4 are directed, jointly and severally, to:-
[a] To pay Rs.118751/- towards hospitalization charges;
[b] To pay Rs.10,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant;
[c] To pay Rs.7,000/- as cost of litigation;
The above said order shall be complied within 30 days of its receipt by the Opposite Parties No.1, 2 & 4; thereafter, they shall be liable for an interest @ 9% per annum on the amount mentioned in sub-para [a] & [b] above, apart from cost of litigation mentioned in sub-para [c] above, from the date of institution of this complaint, till it is paid."
The facts, in brief, are that the complainant purchased Medi Claim Policy i.e. Reliance Life Care For You Plan (Non Linked, Non- Participating, Regular Premium, Hospitalization Benefit Plan) - cashless, on 13.01.2012, through Opposite Party No.3, for the sum assured to the tune of Rs.2 lacs, for which he was required to pay premium of Rs.3,868.22Ps., per year. The term of the said Policy was 03 years, commencing from 13.01.2012 and the date of benefit expiry was 20.01.2015. It was stated that the complainant had made payment of all the installments, as per the terms and conditions of the said Policy.
It was further stated that on 08.02.2013, the complainant accidently fell in his bathroom, due to which he had been in pain and experienced some difficulty in walking. He was taking pain killer and applying ointment, due to which he was feeling some relief. On 22.02.2013, when the complainant was in District Courts, Chandigarh, he again accidently fell down in the parking. He was rushed to the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, where he was advised Laminectomy L4 Discectomy, as is evident from OPD Card Annexure C-3. It was further stated that, thereafter MRI of the complainant was got done, on 24.02.2013, on payment of Rs.2500/-. It was further stated that the complainant was admitted in Silver Oaks Hospital, Mohali, on 04.03.2013, where he underwent Laminectomy L4 Discectomy, on 05.03.2013 and was, thereafter, discharged on 09.03.2013. It was further stated that since the complainant was having cashless Policy for hospitalization, his case was referred to Opposite Party No.1, which referred the same to Opposite Party No.4. It was further stated that, Opposite Party No.4, vide e-mail dated 05.03.2013, rejected the case of the complainant, on the ground that the disease, for which he underwent treatment in the said Hospital, had got 04 years waiting period, as provided under Clause 5.6 of the Insurance Policy.
It was further stated that, as such, the complainant had to pay Rs.1,18,751/- to Silver Oaks Hospital, Mohali, on 09.03.2013, on his own. It was further stated that, thereafter, legal notice dated 24.01.2014 (Annexure C-10), was served upon Opposite Party No.1, to reimburse the amount, referred to above, incurred by the complainant, on the treatment aforesaid, but to no avail.
It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Parties, to reimburse the amounts of Rs.1,18,751/-, Rs.2500/- and Rs.1595/- spent towards the treatment, tests and medicines, aforesaid; and compensation to the tune of Rs.1 lac, for mental agony and physical harassment.
Opposite Parties No.1 and 2 in their joint written version, admitted that the complainant purchased Medi Claim Policy i.e. Reliance Life Care For You Plan (Non Linked, Non- Participating, Regular Premium, Hospitalization Benefit Plan) - cashless, on 13.01.2012, through Opposite Party No.3, from them, for the sum assured to the tune of Rs.2 lacs, for which he was required to pay premium of Rs.3,868.22Ps., per year. It was also admitted that the term of the said Policy was 03 years, commencing from 13.01.2012 and the date of benefit expiry was 20.01.2015. It was also admitted that the complainant had made payment of all the installments, as per the terms and conditions of the said Policy. It was, however, stated that as per Clause 5.6 of the Insurance Policy, there was a four years waiting period, in case of treatment taken for discectomy. It was further stated that on 05.03.2013 Opposite Party No.4, received a request from the complainant for cashless hospitalization, for the treatment of discectomy, underwent by him, but the same was denied by it (Opposite Party No.4) as per clause 5.6 of the Policy. The rejection letter was immediately sent to the hospital. It was further stated that neither there was any deficiency, in rendering service, on the part of Opposite Parties No.1 and 2, nor they indulged into unfair trade practice. The remaining averments, were denied, being wrong.
In view of the endorsement made by the complainant, on the complaint itself, the name of Opposite Party No.3 was deleted from the array of the Opposite Parties, vide order dated 01.08.2014.
Despite deemed service, none put in appearance, on behalf of Opposite Party No.4, as a result whereof, it was proceeded against ex-parte, vide order dated 06.05.2014.
The complainant, Opposite Parties No.1 and 2, led evidence, in support of their case.
After hearing the complainant, in person, Counsel for Opposite Parties No.1 and 2, and on going through the evidence, and record of the case, the District Forum, accepted the complaint, in the manner, referred to, in the opening para of the instant order.
Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties No.1 and 2.
We have heard the Counsel for the appellants, complainant/respondent No.1, in person, and, have gone through the evidence, and record of the case, carefully.
The Counsel for the appellants, submitted that no doubt, respondent No.1/complainant, purchased Medi Claim Policy i.e. Reliance Life Care For You Plan (Non Linked, Non- Participating, Regular Premium, Hospitalization Benefit Plan) - cashless, on 13.01.2012, for the sum assured to the tune of Rs.2 lacs, for the period of three years, commencing from 13.01.2012 and expiring on 20.01.2015, on payment of premium. He further submitted that admittedly the complainant took treatment for discectomy. He further submitted that as per Clause 5.6 of the Insurance Policy, there was a four year waiting period, in case of treatment taken for discectomy. He further submitted that since the parties were governed by the terms and conditions of the Insurance Policy, and the treatment for the aforesaid disease, was taken by the complainant, in the second year of inception of the same (Policy), his claim was not covered according to the said Clause. He further submitted that, no doubt, according to the complainant, he accidently fell in the bathroom and, thereafter, in the parking of the District Courts, Chandigarh and was having some pain in his back and difficulty in walking, as a result whereof, the treatment for discectomy was taken by him and medical expenses were incurred. He further submitted that the medical record did not speak of his any such accidental fall, in the bathroom and the parking of the District Courts. He further submitted that the story set up by the complainant, regarding fall, therefore, could not be believed. He further submitted that the District Forum was wrong, in coming to the conclusion, that the complainant was entitled to the claim and the repudiation thereof, was illegal. He further submitted that the District Forum illegally awarded cost of litigation, to the tune of Rs.7,000/-, though no relief in regard thereto was sought by the complainant. He further submitted that the order of the District Forum, being illegal and invalid, is liable to be set aside.
Respondent No.1/complainant, however, submitted that since he was hospitalized and incurred expenses for Laminectomy L4 discectomy surgery on account of accidental falls in the bathroom and the parking of the District Courts, his claim was covered under the Policy and waiting period of 4 years under Clause 5.6 of the same (Policy) was not applicable to such an eventuality. He further submitted that his claim was illegally and arbitrarily repudiated by the Opposite Parties. He further submitted that the order of the District Forum, being legal and valid, is liable to be upheld.
After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the appellants, respondent No.1/complainant and the evidence, on record, we are of the considered opinion, that the appeal is liable to be partly accepted, for the reasons, to be recorded hereinafter. Admittedly, respondent No.1/complainant purchased Medi Claim Policy i.e. Reliance Life Care For You Plan (Non Linked, Non- Participating, Regular Premium, Hospitalization Benefit Plan) - cashless, on 13.01.2012, for the sum assured to the tune of Rs.2 lacs, for the period of three years, commencing from 13.01.2012 and expiring on 20.01.2015, on payment of premium. There is also, no dispute, with regard to the factum that the parties are governed by the terms and conditions of the Insurance Policy, which constitutes a concluded contract between them. The first question, that falls for consideration, is, as whether, hospitalization of the complainant for discectomy was on account of his accidental fall, in the bathroom and in the parking of the District Courts, Chandigarh and that he incurred medical expenditure, on account of that reason, or not. The complainant, in paragraph No.5 of the complaint, in clear-cut terms stated that on 08.02.2013, he accidental fell in the bathroom and was having some pain in the back and difficulty in walking, due to such fall. It was further stated by the complainant, in this paragraph that he was taking pain killer and applying ointment, due to which he was feeling some relief. This averment of the complainant was duly supported by him, by way of his affidavit, submitted in the shape of evidence. No doubt, in reply to paragraph No.5, it was stated by Opposite Parties No.1 and 2, that the complainant had concocted this false story. However, no cogent and convincing evidence was produced by Opposite Parties No.1 and 2 that such a version set up by the complainant, in paragraph No.5 was a concocted and false. Even in paragraph No.6 of the complaint, it was stated by the complainant that on 22.02.2013, when he was in the District Courts, Chandigarh, he again unfortunately fell down, in the parking area and was rushed to the PGIMER, Chandigarh, in emergency OPD, where he was examined by the Doctors. He was referred to the Neurology Department of PGIMER, where he was given appointment for 24.02.2014. After conducting tests etc., the complainant was advised Laminectomy L4 discectomy. Copy of the outpatient card is Annexure C-3. This version set up by the complainant, in the complaint, in paragraph No.6, is also duly supported by his affidavit, submitted by him, in the shape of evidence. No doubt, in Annexure C-3, copy of the outpatient card of the complainant, issued by the PGIMER, Chandigarh, nothing was mentioned, with regard to his fall, yet that does not mean that the version set up by him (complainant), in the complaint was, in any way wrong. In case, the complainant had been suffering from the disease, in question, earlier to the taking of the Insurance Policy, then some medical record, with regard to the same could be produced by Opposite Parties No.1 and 2, to prove that factum. However, no medical record of the complainant, that he was suffering from the aforesaid disease, earlier to the taking of the Insurance Policy, was produced by Opposite Parties No.1 and 2. Ultimately, the complainant had to undergo Laminectomy L4 discectomy surgery, in Silver Oaks Hospital, and had to spend a sum of Rs.1,18,751/-. It is, therefore, held that the complainant suffered discectomy, on account of falls, in the bathroom and in the parking area of District Courts, Chandigarh, on different dates on account whereof he had to undergo Laminectomy L4 discectomy surgery. The complainant was, thus, hospitalized, underwent surgery and incurred medical expenses for the same, due to accidental falls. The submission of the Counsel for the appellants, to the contrary, being devoid of merit, is rejected.
The second question, that falls for consideration, is, as to whether, Clause 5.6 of the Insurance Policy Annexure C-1, excluded treatment/surgery for discectomy for the period of four years, from the date of inception of the same, or not. With a view to determine this controversy, reference to Clause 5.6 of the Policy is necessary, which reads as under:-
"5.6 Completion of One year from the first term renewal or Four years waiting Period:- Total knee Replacement, Total Hip Replacement, Discectomy, Arthroscopy, unless post Accident, for each of these treatments/surgeries/ procedures, Pelvic inflammatory Diseases, Varicose Veins, Diabetes and its complications, high blood pressure and its complications, Chronic Renal Failure, no matter when detected.
The Waiting Periods, will not apply for Hospitalization or Medical Expenses incurred due to Accident".
It is evident from the afore-extracted Clause 5.6 of the Policy Annexure C-1, which was taken by the complainant, that Total knee Replacement, Total Hip Replacement, Discectomy and Arthroscopy, were excluded for four years, from the date of inception of the same (Policy). In other words, the same were not payable by the Insurance Company for 4 years. However, it is further evident, from the afore-extracted Clause 5.6 of the Policy, that, in case, Total knee Replacement, Total Hip Replacement, Discectomy and Arthroscopy, were due to post-accident, then the waiting period shall not apply for hospitalization or medical expenditure incurred due to the said accident. Medical expenses incurred by the insured for discectomy and other ailments, mentioned above, due to accident could be claimed, even if four years had not expired, from the date of inception of the Policy. In other words, waiting period of four years, for such treatment and hospitalization was not applicable, if it was on account of some accident. Under these circumstances, the District Forum was right, in coming to the conclusion, that in the peculiar facts and circumstances of the case, the provisions of Clause 5.6 extracted above of the Policy, were not applicable to the instant case. The District Forum was also right, in holding that the claim of the complainant was illegally and arbitrarily repudiated by Opposite Parties No.1 and 2. The District Forum was also right, in holding that repudiation of the claim being illegal, Opposite Parties No.1 and 2 were deficient, in rendering service.
However, it is evident from the contents of the complaint, and also the prayer clause thereof, that the complainant did not seek the relief of award of litigation cost, as he was pursuing the same (complaint) himself, being a lawyer. The District Forum, without considering the prayer made by the complainant, seeking certain reliefs also granted litigation costs, to the tune of Rs.7,000/-, which relief was never sought by him. It is settled principle of law, that the Consumer Foras, cannot grant relief, beyond the one, which has been sought by the consumer, in the complaint. The District Forum is required to confine itself, with regard to the reliefs sought for, by the complainant. The District Forum, therefore, while granting a sum of Rs.7,000/- as cost of litigation, exceeded its Jurisdiction. The complainant was not entitled to litigation costs, as he did not seek relief, in respect thereof. Accordingly the order of the District Forum needs modification.
No other point was raised by the Counsel for the appellants and respondent No.1.
For the reasons recorded above, the appeal is partly accepted, with no order as to costs. The order of the District Forum is modified, and Opposite Parties No.1, 2 and 4 jointly and severally are directed as under:-
To pay a sum of Rs.1,18,751/- to the complainant, incurred by him towards the treatment/hospitalization aforesaid, as awarded by the District Forum.
To pay Rs.10,000/- to the complainant, on account of deficiency in rendering service and causing mental agony and physical harassment to him, as awarded by the District Forum.
The direction regarding payment of Rs.7,000/- as cost of litigation, to the complainant, given by the District Forum, is set aside.
The other reliefs granted and directions given by the District Forum, in the order impugned, subject to the modification aforesaid, regarding litigation costs, shall remain intact.
Certified copies of this order, be sent to the parties, free of charge.
The file be consigned to Record Room, after completion.
Pronounced.
18.06.2015 Sd/-
[JUSTICE SHAM SUNDER (RETD.)] PRESIDENT Sd/-
(DEV RAJ) MEMBER Sd/-
(PADMA PANDEY) MEMBER Rg