National Consumer Disputes Redressal
Ram Avtar Gupta vs National Insurance Co. Ltd. on 19 January, 2017
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2312 OF 2011 (Against the Order dated 11/03/2011 in Appeal No. 2155/2008 of the State Commission None) 1. RAM AVTAR GUPTA S/o Late Sh Ram Bhaj, R/o House No.796A, Ward No. 23, DLF Colony, Civil Lines Rohtak Haryana ...........Petitioner(s) Versus 1. NATIONAL INSURANCE CO. LTD. Through it Divisional Manager, Divisional Office No.II, Naraina Complex, Civil road, Rohtak Haryana ...........Respondent(s)
BEFORE: HON'BLE DR. B.C. GUPTA,PRESIDING MEMBER HON'BLE MR. PREM NARAIN,MEMBER For the Petitioner : Mr. Abhishek Verma, Advocate For the Respondent : Ms. Nanita Sharma, Advocate Dated : 19 Jan 2017 ORDER
1. This revision petition No.2312 of 2011 has been filed by Ram Avtar Gupta, petitioner against the order dated 11.03.2011 of the State Consumer Disputes Redressal Commission, Haryana (in short 'the State Commission') passed in Appeal No.2155 of 2008.
2. The brief facts of the case are that the petitioner, his wife and daughter had obtained mediclaim policy from the respondent which was valid from 29.03.2005 to 28.3.2006. The petitioner was insured for Rs.2.00 lacs. On 21.04.2005, the petitioner suffered heart attack and he was admitted to Escorts Heart Institute and Research Centre, New Delhi and he remained there from 21.4.2005 to 25.4.2005. In the month of April, 2005, the petitioner spent Rs.2,95,000/- on his aforesaid treatment towards hospital charges and Rs.15,000/- towards medicines. In the month of April-May, 2005, the petitioner raised a claim of Rs.2.00 lacs upon the respondent for remittance against the said policy. On 12.07.2005, vide letter dated 12.7.2005, the respondent repudiated the claim of the petitioner on the ground that the claim was not payable as the policy was in the first month. In September, 2005, the petitioner suffered severe chest pain and was again admitted to same hospital from 25.09.2005 to 30.09.2005. The petitioner underwent CART on 28.9.2005 and he spent Rs.3,12,358/- on his treatment. The petitioner again lodged this claim with the respondent company. On 07.02.2006, the respondent company repudiated this claim on the following ground:-
"Since the disease/ailment contracted in the first year from the commencement date of Insurance i.e. 29th March, 2005, as is evident from the papers that the treatment is taken from 25th September, 2005, the same is not covered under the first year exclusion clause 4.3."
3. Challenging the repudiation of his claim the complainant invoked the jurisdiction of the District Consumer Disputes Redressal Forum, Rohtak, (in short "the District Forum") by filing complaint No.327 dated 5.9.2005 with respect to the first claim and complaint No.144 dated 20.03.2006 with respect to second claim, which on being contested by the opposite party on the grounds stated above, were accepted by the District forum vide separate orders dated 11.11.2008 by granting following relief:-
"Accordingly we hereby allow the present complaint with direction to the opposite party to pay the insured amount of Rs.200000/- (Rupees two lacs only) alongwith interest @ 9% p.a. from the date of filing the present complaint till its realization and Rs.2000/- (Rupees two thousand only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the amount of award shall carry interest @ 12% p.a. from dated 11.12.08 onwards till its realization."
4. Aggrieved with the order dated 11.11.2008 of the District Consumer Disputes Redressal Forum, Rohtak, the opposite party/respondent filed two appeals No.2155 and 2156 of 2008 before the State Commission and State Commission decided these appeals vide its order dated11.03.2011as under:-
"As a sequel to our aforesaid discussion, it is established that the complainant is entitled to compensation for the expenses incurred by him on his treatment during the period w.e.f. 25.09.2005 to 30.09.2005 from Escorts Heart Institute and Research Centre, Okhla Road, New Delhi and the Insurance Company is not liable to pay any compensation with respect to the treatment taken by the complainant from Escorts Heart Institute and Research Centre, Okhla Road, New Delhi w.e.f. 21.4.2005 to 25.4.2005.
Accordingly, appeal No.2155/2008 is accepted, impugned order passed by the District Forum is set aside and complaint No.327/2005 is dismissed.
AND Appeal No.2156/2008 is without any merit and upholding the order passed by the District Forum in complaint No.144/2006, this appeal stands dismissed."
5. Hence the revision petition against the order dated 11.03.2011 passed in Appeal No.2155/2008.
6. Heard the learned counsel for the parties and perused the record.
7. The learned counsel for the petitioner stated that the terms and conditions of the policy were not supplied to the petitioner before the treatment taken in the Escorts Heart Institute and Research Centre and therefore, he was not aware of the fact that there is any condition that treatment taken within 30 days of the inception of the policy will not be considered for the reimbursement under the policy. In a way, this is unfair trade practice as the Insurance Company is taking premium for full 12 months, but providing actual insurance for 11 months only. The learned counsel further argued that the order impugned is liable to be set aside in as much as the Ld. State Commission has failed to appreciate that the terms and conditions of the Insurance Policy were not disclosed to the petitioner herein. It was further submitted that the policy document was never given to the petitioner herein. In absence of the same, the insurance company i.e. the respondent herein is estopped from relying upon or taking benefit of the terms and conditions contained in the Insurance Policy. The order impugned is liable to be set aside as the respondent has failed to prove on record that the terms and conditions of the aforesaid policy were described and explained properly to the petitioner or that the relevant policy document containing the aforesaid terms and conditions was ever supplied to the petitioner. The respondent herein has further failed to prove that the petitioner had undergone any kind of treatment regarding the disease from which he suffered on 21.04.2005, prior to taking the aforesaid policy in question. As such the Ld. District Forum had rightly appreciated the aforesaid correct facts and allowed the complaint. The order impugned is liable to be set aside in as much as the aforesaid exclusion clause i.e. clause 4.2, on which much reliance has been placed by the respondent herein is absolutely illegal, arbitrary and is against the public policy. A bare perusal of the aforesaid exclusion clause reveals that each and every disease is excluded from any claim within 30 days from the date of commencement of the policy. It impliedly means that the policy is for eleven months and not for complete one year, whereas as per the admitted case of the respondent herein, the policy issued was for complete one year and admittedly respondent had taken full premium for complete one year. It was further submitted by the learned counsel that even as per the said clause, it is further stipulated that if in the opinion of panel of medical practitioners constituted by the company for the purpose, the insured person could not have known of the existence of the disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company, the said exclusion shall not apply. It was submitted that admittedly the petitioner had no such pre-existing disease or any symptoms or complaints thereof at the time of making the proposal for insurance to the company. Though duty bound, the respondent did not even try to ascertain the aforesaid fact, in terms of the procedure contained in clause 4.2, thereby itself breaching the terms of the policy. Admittedly no document or material, whatsoever has been placed on record by the respondent, even remotely suggesting that petitioner had any such pre-existing disease or even complaint thereof. On the other hand, the doctors who treated the petitioner at Escorts Hospital duly certified that the petitioner did not have any such complaint prior to his admission in the aforesaid hospital on 21.04.2005 and in view thereof, the Ld. State Commission gravely erred in accepting the appeal of the respondent and setting aside the order passed by the Ld. District Forum.
8. Learned counsel for the respondent stated that the terms and conditions of the policy are part of the policy. Hon'ble Supreme Court has laid down the law that the policy will have to be interpreted in terms of the actual wordings of its terms and conditions. The State Commission has rightly appreciated the fact that no claim is admissible under Exclusion Clause 4.2 of the policy for treatment taken within 30 days from the inception of the policy. The learned counsel further mentioned that there was another claim under the same policy, which was also allowed by the District Forum and appeal filed by the opposite party was dismissed by the State Commission and the opposite party has not filed any revision petition against that order.
9. We have gone through the material available on record and have considered the arguments of both the learned counsel. Though, the order dated 11.11.2008 passed in other complaint No.144 dated 20.03.2006 for the second claim is not available on record, but the order of the State Commission mentions the following:-
"It is material to mention here that similar relief was granted in both the complaints with respect to the separate claims."
10. In the instant complaint case No.327/2005, the District Forum has awarded Rs.2,00,000/- as payment of treatment. Going by the above observation of the State Commission, it is clear that a claim of Rs.2,00,000/- was also approved by the District Forum in the second complaint, which has also been upheld by the State Commission. We have perused the policy and the policy amount is Rs.2,00,000/- only in respect of the complainant. The mediclaim policy in question mentions that Company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect thereof by or on behalf of such insured person but not exceeding the sum insured in aggregate in any one period of insurance stated in the schedule hereto. There is also a note at the end of this Section, which states that Company's liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per person mentioned in the schedule.
11. Both the episodes of treatment have happened in one year only during the currency of the mediclaim policy, which was valid from 29.03.2005 to 28.03.2006. The first episode happened on 21.04.2005. The second episode happened on 25.09.2005. Thus, if one claim of Rs.2,00,000/- has already been settled with the complainant/insured and the total policy was also of Rs.2,00,000/- only, as per conditions of the policy mentioned above, no further sum remains against which any claim can be allowed. None of the counsel of the parties argued on this aspect. However, based on this condition of the policy, we are of the view that no further claim is admissible as the sum insured has already been exhausted. Therefore, we feel no need to go into details of the case any further.
12. Based on the above discussion, we do not find any illegality, material irregularity or jurisdictional error in the order dated 11.03.2011 of the State Commission, which calls for any interference from this Commission. Accordingly, Revision Petition No.2312 of 2011 is dismissed. Parties to bear their own costs.
...................... DR. B.C. GUPTA PRESIDING MEMBER ...................... PREM NARAIN MEMBER