State Consumer Disputes Redressal Commission
The Oriental Insurance Co. Ltd. vs Roseleen Sidhu on 15 January, 2016
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH First Appeal No. : 22 of 2016 Date of Institution : 13.01.2016 Date of Decision : 15.01.2016 The Oriental Insurance Company Limited, through its Regional Head, Regional Office, SCO No.109-110-111, Sector 17D, Chandigarh. Oriental Insurance Company Limited, through its Chairman/Managing Director, Regd. & Head Office A-25/27, Asaf Ali Road, New Delhi 110002. Now both through authorized signatory of Regional Office, SCO No.109-110-111, Sector 17-D, Chandigarh. ......Appellants/Opposite Parties. V e r s u s Roseleen Sidhu wife of Sh. Navneet Singh Hundal, now aged 39 years, resident of House No.4540, Darshan Vihar, Sector 68, Mohali. ....Respondent/Complainant Appeal under Section 15 of the Consumer Protection Act, 1986. BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT. MR. DEV RAJ, MEMBER.
MRS. PADMA PANDEY, MEMBER.
Argued by:Sh.R.C. Gupta, Advocate for the appellants.
PER JUSTICE JASBIR SINGH (RETD.), PRESIDENT This appeal is directed against an order dated 26.11.2015, rendered by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (hereinafter to be called as the Forum only), vide which, it accepted a complaint, filed by the complainant (now respondent).
As per admitted facts on record, in the year 2005, the respondent had purchased a Mediclaim Insurance Policy, from the appellants, and, thereafter, she continued to renew the same, year after year, till 06.08.2013. In October 2012, it was diagnosed that she was suffering from Hepatitis C. She was treated in the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh. She was given injection (interferon a 2b 80 mcg), per week, staring from October 2012 till December 2013, on regular basis. In all, she was given 60 injections, costing Rs.11,500/- each. She put up a claim with the appellants, to reimburse her, the amount of Rs.6,90,000/-, spent by her, on her treatment. However, her claim was rejected by the Company. Aggrieved of the same, the respondent went to the Insurance Ombudsmen, against the said rejection, but it also, vide letter dated 04.08.2014, rejected her claim, on the ground that she had taken only "Day Care" treatment, without mandatory indoor hospitalization for 24 hours. Above act of the appellants forced the respondent, to file a consumer complaint, before the Forum.
Upon notice, reply was filed by the appellants. An objection was taken qua territorial jurisdiction of the Forum. Purchase of Mediclaim Insurance Policy, by the respondent, for a sum of Rs.2 lacs, upto 06.08.2013 was admitted. It was stated that claim of the respondent was rejected, as she did not remain admitted in the hospital and also did not receive indoor treatment for a minimum period of 24 hours there. It was further on record that the matter even went before the Insurance Ombudsmen, Chandigarh, however, claim of the respondent was rejected. The remaining averments, were denied being wrong.
In her rejoinder filed, the respondent reiterated all the averments contained in the complaint, and repudiated those contained in the written version of the appellants.
The parties led evidence, in support of their case.
After hearing the respondent in person, Counsel for the appellants, and, on going through the evidence, and record of the case, the Forum, accepted the complaint, and granted following relief to the respondent:-
"For the reasons recorded above, we find merit in the complaint and the same is partly allowed. The OPs are directed :-
(i) To make payment of an amount of Rs.2.00 lakhs to the complainant alongwith interest @ 9% per annum from the date of filing of the claim till realization.
(ii) To also make payment of an amount of Rs.11,000/- to the complainant towards litigation expenses.
This order be complied with by OPs within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amount mentioned at Sr.No.(i) above, with interest @ 12% per annum from the date of filing of the present complaint till realization, apart from compliance of direction at Sr.No.(ii) above."
Feeling aggrieved, the instant appeal, has been filed by the appellants/opposite parties, alongwith application for condonation of delay, of 05 days, in filing the same (appeal).
We have heard Counsel for the appellants, on the application for condonation of delay aforesaid, as also in the main appeal, at the preliminary stage, and, have gone through the evidence, and record of the case, carefully.
By making reference to the terms and conditions of the Mediclaim Insurance Policy, it is stated by Counsel for the appellants, that to claim reimbursement of medical expenses, it is mandatory that the insured gets indoor treatment, in any hospital for a minimum period of 24 hours. To say so, reliance was placed on condition no.2.3 of the Policy. The said condition reads thus:-
"2.3 HOSPITALISATION PERIOD: Expenses on Hospitalisation are admissible only if hospitalisation is for a minimum period of 24 hours. However, (A) This time limit will not apply to following specific treatments taken in the Network Hospital/Nursing Home where the Insured is discharged on the same day. Such treatment will be considered to be taken under Hospitalisation Benefit.
i. Haemo Dialysis, ii. Parentral Chemotherapy, iii.Radiotherapy, iv.Eye Surgery, v. Lithotripsy (kidney stone removal), vi.Tonsillectomy, vii. D & C, viii. Dental surgery following an accident ix. Hysterectomy x. Coronary Angioplasty xi. Coronary Angiography xii. Surgery of Gall bladder, Pancreas and bile duct xiii. Surgery of Hernia xiv. Surgery of Hydrocele.
xv. Surgery of Prostrate.
xvi. Gastrointestinal Surgery.
xvii. Genital Surgery.
xviii. Surgery of Nose.
xix. Surgery of throat.
xx. Surgery of Appendix.
xxi. Surgery of Urinary System.
xxii.Treatment of fractures/dislocation excluding hair line fracture, Contracture releases and minor reconstructive procedures of limbs which otherwise require hospitalisation.
xxiii. Arthroscopic Knee surgery.
xxiv. Laproscopic therapeutic surgeries.
xxv. Any surgery under General Anaesthesia.
xxvi. Or any such disease/procedure agreed by TPA/Company before treatment.
(B) Further if the treatment/procedure/ surgeries of above diseases are carried out, in Networked specialised Day Care Centre which is fully equipped with advanced technology and specialised infrastructure where the insured is discharged on the same day, the requirement of minimum beds will be overlooked provided following conditions are met.
i. The operation theatre is fully equipped for the surgical operation required in respect of sickness/ailment/injury covered under the policy.
ii. Day Care nursing staff is fully qualified.
iii. The doctor performing the surgery or procedure as well as post operative attending doctors are also fully qualified for the specific surgery/procedure.
(C) This condition of minimum 24 hours Hospitalisation will also not apply provided i. The treatment is such that it necessitates hospitalisation and the procedure involves specialised infrastructural facilities available only in hospitals, BUT ii. Due to technological advances hospitalisation is required for less than 24 hours.
AND / OR iii. Surgical procedure involved has to be done under General Anaesthesia".
The Forum also noted the above condition and it rejected argument raised, while observing as under:-
"10. The learned counsel for the OPs has contended that the claim of the complainant falls within the purview of exception clause 2.3 (c) of the policy (Annexure R-1), the relevant portion of which is extracted as below :-
"(C) This condition of minimum 24 hours Hospitalisation will also not apply provided, medical treatment, and/or surgical procedure is:
i. undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hours because of technological advancement, and ii. which would have otherwise required a hospitalization of more than 24 hours."
The learned counsel for the OPs has contended that the complainant got the injections administered as an OPD patient at PGI, Chandigarh. Further, the injections administered to her never required any general or local anesthesia in hospital, therefore, the Insurance Ombudsman rightly observed in his order (Annexure C-5) that the insurance company's decision to reject the claim on the ground of 'day care' treatment without mandatory indoor hospitalization for 24 hours and treatment does not fall in the approved 'day care' procedure. The learned counsel for the OPs has strenuously argued that the order passed by the Insurance Ombudsman is a well-reasoned order and after considering all the contentions/submissions of the complainant, her claim was rightly rejected by the OPs and the Insurance Ombudsman.
11. We have given our careful consideration to the above arguments. At the outset, it is important to note that the exception clause mentioned in the terms and conditions (Annexure R-1) and reproduced in the written statement of the OPs pertains to mediclaim insurance policy (group) whereas the complainant is an individual and she has produced the correct copy of the mediclaim insurance policy (individuals) alongwith her rejoinder. According to the correct terms and conditions, clause 2.3 (c) i.e. the exception clause reads as under :-
"(c) This condition of minimum 24 hours Hospitalisation will also not apply provided I) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in hospitals.
BUT II) Due to technological advances hospitalization is required for less than 24 hours.
AND/OR III) Surgical procedure involved has to be done under General Anaesthesia."
We are of the view that the OPs have not come with clean hands in the matter and have rejected the claim on the basis of the terms and conditions of the mediclaim insurance policy (group) which are not applicable to the complainant.
12. The complainant has specifically pleaded in para 4 of the complaint as under :-
"xxx xxx xxx It is important to state here that in the year 2002, people in India started suffering from a particular ailment, which on treatment was found as Hepatitis C. The patient of this treatment was used to be treated as indoor patient, which practice remain in operation till the year 2006-2007. As the medical science progressed and advanced, there was technological advancement in respect to this treatment and the indoor treatment was converted to outdoor treatment."
Significantly, the above said plea of the complainant has not been specifically denied by the OPs in their written reply. Thus, it is established that earlier patients like complainant were used to be treated by injecting hepatitis C as indoor patient. However, due to advancement in the technology and further research, now the patient is administered such injections as an out door patient and the patient need not to remain admitted even for 24 hours. The certificate dated 19.1.2015 (Annexure C-6) of Dr. R.K. Dhiman of Department of Hepatology, PGI, Chandigarh shows that the complainant has been cured from chronic hepatitis C. She received peg interferon 2b 80 mcg per week + ribavirin (800-1000 mg/day) for the 60 weeks w.e.f. October 2012 to December 2013. At PGI, Chandigarh giving IFN injection is an OPD procedure and patient need not be admitted as hospitals are overflowing with more serious patients. Today due to technological advancement, it is an OPD treatment.
13. Evidently, the complainant has been visiting the PGI, Chandigarh for getting administered the above said injections and due to technological advances, hospitalization is required for less than 24 hours. The objection raised by the learned counsel for the OPs that the complainant never required any general or local anesthesia in hospital is devoid of any force because as per the exception clause mentioned above, the condition of minimum 24 hours hospitalization does not apply where the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available only in the hospitals, but, due to technological advances, hospitalization is required for less than 24 hours. The words "and/or" mentioned in the condition relating to surgical procedure are quite significant and show that surgical procedure under general anesthesia is not mandatory under the exception clause. In our opinion, had the word been "and" only, then the surgical procedure under general anesthesia would have been necessary. Consequently, the complainant is entitled to the reimbursement of the amount spent on injections which were administered to her as an outdoor patient in PGI, Chandigarh."
It was observed by the Forum that by not disclosing contents of condition no.2.3 of the Policy correctly, an attempt has been made to mislead the Forum. Taking note of the above condition, the Forum rightly came to the conclusion that claim of the respondent was wrongly rejected. It was noticed that as per Clause (C) of condition no.2.3, the condition of minimum period of 24 hours was not needed, where, due to technological advancement, hospitalisation is required for less than 24 hours. It was a positive case of the respondent, that to the Hepatitis C patients, upto the years 2006-2007, treatment was being given as indoor patients. However, on account of technological advancement, the indoor treatment was converted into outdoor treatment. It is not disputed that the respondent had been visiting PGIMER, every month, for the period of 60 weeks.
An argument was also raised by Counsel for the appellants that benefit can be extended to the respondent, for outdoor treatment, only if she had been suffering qua diseases mentioned in Clause (A) of condition no.2.3. We are not convinced with this argument. Clause (C) of the said condition, gives an independent right to an insurer to claim benefit, if his/her case is covered under the said provision. In Clause (B) of condition no.2.3, it is specifically stated that benefit is available to the insurer, under the conditions said therein qua diseases (above diseases), mentioned in Clause (A). In Clause (C) it is not so mentioned. The Forum was right in awarding claim to the respondent.
The Forum was further right in holding that it had territorial jurisdiction to entertain and decide the complaint. It is on record that the amount of premium to purchase Mediclaim Insurance Policy was paid by the respondent, from his account, maintained at a Bank in Chandigarh. To say so, reliance has been placed on copies of statement of accounts. It has also come on record that an Official of the appellants had approached the respondent, to purchase Mediclaim Insurance Policy, at her Office, in Chandigarh. It is also on record that the grievance raised by the respondent qua rejection of her claim by the Company, was rejected by the Insurance Ombudsman, at Chandigarh, on 04.08.2014. The claim granted has rightly been calculated by the Forum, till the date of expiry of the Mediclaim Insurance Policy i.e. 06.08.2013. As such, no ground, whatsoever has been made out, by the appellants, to reverse the findings of the Forum.
No other point, was urged, by Counsel for the appellants.
In view of the above discussion, it is held that the order passed by the Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the Forum is upheld.
Since the appeal filed by the appellants has been dismissed, at the preliminary stage, as such, the application filed by them, for condonation of delay aforesaid, is also dismissed, being rendered infructuous. The application stands disposed off, accordingly.
Certified copies of this order, be sent to the parties, free of charge.
The file be consigned to Record Room, after completion Pronounced.
15.01.2016 Sd/-
[JUSTICE JASBIR SINGH (RETD.)] PRESIDENT Sd/-
(DEV RAJ) MEMBER Sd/-
(PADMA PANDEY) MEMBER Rg