State Consumer Disputes Redressal Commission
Sh. Sachin Aggarwal vs The Oriental Insurance Co. Ltd. & Anr. on 2 November, 2022
FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL
COMMISSION
Date of Institution: 17.05.2019
Date of hearing:15.09.2022
Date of Decision: 02.11.2022
FIRST APPEAL NO.- 317/2019
IN THE MATTER OF:
MR. SACHIN AGGARWAL,
S/O LATE MR. VINOD KUMAR,
RESIDENT OF K-42, VIJAY VIHAR,
PHASE-II, SECTOR-4, ROHINI,
DELHI-110085
(Through: Varun Dhingra, Advocate)
.... Appellant
VERSUS
1. THE ORIENTAL INSURANCE COMPANY LTD.
2E/16, SWAMI RAM TIRATH NAGAR,
JHANDEWALAN EXTN.
NEW DELHI-110055.
(Through: Mr. Deepak Kumar Sharma, Advocate)
2. M/S PARK MEDICLAIM TPA PVT. LTD.
702, VIKRANT TOWERS, RAJENDRA PLACE,
NEW DELHI-110008.
.... Respondents
ALLOWED PAGE 1 OF 10
FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
HON'BLE MS. PINKI, MEMBER (JUDICIAL)
Present: None for the Parties.
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case necessary as per the District Commission record are:
"Instant complaint has been filed by Sh. Sachin Aggarwal (in short, the complainant) under Section 12 of the Consumer Protection Act, 1986 as amended against The Oriental Insurance Company. Ltd. (in short OP) pleading therein that he is a mediclaim policy (Happy Family Floater Policy Schedule) holder of OP1 vide policy no. 272302/48/2017/1705 valid for the period 10.02.2017 to 09.02.2017. On 22.09.2017 he suffered from a severe headache followed by transient unconsciousness and fall and he was immediately shifted to Ekansh Nursing Home, where he got admitted on advice of Dr. R. Prashar. On the next day, he informed OP2 about his hospitalization. He was discharged on 25.09.2017. He submitted his claim of Rs. 39,513/- along with original documents to OP2 who thereafter raised a query on 16.10.2017 which was duly replied by him on 23.10.2017. Thereafter he did not receive any response from the OP. Hence, the instant complaint was filed seeking direction to OP to pay to the complainant a sum of Rs. 39,513/- towards the insured amount along with interest @ 12% per annum, Rs. 25,000/- as compensation for causing mental agony and Rs. 25,000/- towards litigation expenses. price."
2. The District Forum after taking into consideration the material available on record passed the judgment dated 11.04.2019, whereby it held as under:
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"Our attention is drawn to condition no. 2.1 of the policy contract which reads as follows:
"2.DEFINATIONS: 2.1 HOSPITAL/NURSING HOME:
means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.
OR
b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under
i. It should have at least 15 in-patient medical beds in case of Metro cities A Class cities & B class cities or 10 in-patient medical beds in case of C class cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time.
ii. Should have fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e. Pathological test and X-ray, ECG etc. for the care and treatment of injured or sick persons as in-patient."
Copy of registration certificate issued by Directorate General of Health Services Government of NCT of Delhi is placed on record bearing registration no. DGHS/NH/657 dated 07.06.2017 which reads as under:
"It is certified that Ekansh Nursing Home 122-123, Shahbad, Daulat Pur, Delhi-110042 with -10- beds is being run by Mr. Manish Gupta has been registered under Delhi Nursing Homes Registration Act, 1953 and is authorized to carry out ALLOWED PAGE 3 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 permitted nursing home activities at the above said premises."
As per condition no. 2.1 of the policy, hospital/nursing home in metro cities should have at least 15 in-patient beds. Delhi is a metro city. Therefore, the above said nursing home does not meet the requirement of having at least 15 in-patient beds.
5. In ICICI Prudential Life Insurance vs. Anil Kumar Jain First Appeal No. FA-09/27 vide its order dated 01.02.2010 our State Commission observed that "the complainant had a severe Chest Pain and the doctor attending him diagnosed Coronary Artery Disease (Unstable Angina III B), and placed an Stent inside his Right Coronary Artery (2.75 x 23 mm axxion) on 12.11.07, and his was a case of known type II Diabetes Mellitus and Hypertension.
10. The insurance company refused to pay the compensation on the ground that the disease suffered by the insured did not fulfill the conditions as mentioned in the Insurance Cover Note.
12. ......It is manifest that the Respondent suffered a serious Heart Ailment and an arterie was found blocked and a stent was placed. It was a very serious condition and if such a Heart Ailment is not compensable, what other disease, will be required for grant of reimbursement. It is not open to the Insurance Company to place conditions which are unlikely to be fulfilled with a view to create a device to escape payment of compensation. It amounts to defrauding and cheating the customer. It is not open to Insurance Company to provide such particulars and details of the disease which quite often do not appear and which may provide a ground to the Insurance Company to avoid Payment of Compensation. Symptoms appearing in all kinds of Heart Ailment cannot ALLOWED PAGE 4 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 always be the same, and merely because all symptoms are not 100% the same, the Insurance Company cannot avoid compensation. The ailment suffered by the Respondent was highly serious and life threatening and the spirit and purport of the agreement must be assumed to be such, as to provide for such serious disease of Heart."
State Commission accordingly held that insurer was not justified to withhold reimbursement of treatment charges and the compensation on the grounds enumerated in the Cover Note.
Insurance Company preferred Revision Petition No. 1234 of 2010 against the said order of the State Commission and vide its order dated 01.03.2017, National Commission observed that:
"Learned State Commission had no authority to rewrite terms & conditions of the policy as held by Hon'ble Apex Court in II (2013) CPJ 1(SC)- Export Credit Guarantee Corpn. Of India Ltd. Vs. Garg Sons International; and in such circumstances, merely because opposite party has placed certain conditions which are unlikely to be fulfilled, insured cannot get benefits of the policy when his treatment is not covered by the policy."
6. Hon'ble Supreme Court in United India Insurance Company Limited v. M/s. Harchand Rai Chandan Lal reported in JT 2004 (8) SC 8 has held that:
"The insurance policy has to be construed having reference only to the stipulations contained in it and no artificial farfetched meaning could be given to the words appearing in it....
In Oriental Insurance Co.Ltd. Vs. Sony Cheriyan reported ALLOWED PAGE 5 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 in (1999) 6 SCC 451 Apex Court observed:
"The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy."
Similarly in General Assurance Society Ltd. Vs. Chandumull Jain and Anr. (1966) 3 SCR 500 the Constitution Bench observed that the policy document being a contract has to be read strictly. It was observed, " In interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties, because it is not for the court to make a new contract, however reasonable, if the parties have not made it themselves."
7. As per the aforesaid judgments of Apex Court, policy documents have to be read strictly. Complainant having got treatment from Ekansh Nursing Home which was not recognized under the policy his claim was rightly repudiated. The complaint is dismissed. Copy of this order be sent to the parties as statutorily required. File be consigned to record room."
3. Aggrieved by the aforesaid judgment of the District Commission, the Appellant/Complainant has preferred the present appeal contending that the District Commission has erred in dismissing the complaint of the appellant by not considering the terms and condition of the said policy. The counsel for Appellant further contented that the District Commission had wrongly interpreted the Clause 2.1 of the insurance ALLOWED PAGE 6 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 policy as Ekansh Nursing Home was duly registered by the Directorate General of Health services, Government of NCT of Delhi.
4. The Respondent, on the other hand, denied all the allegations of the Appellant and submitted that there is no error in the impugned judgment as the entire material available on record was properly scrutinized before passing the said order.
5. We have perused the Appeal, District Commission Record and the Impugned judgment dated 11.04.2019.
6. The question for consideration before us is whether District Commission has erred in dismissing the complaint of the appellant by holding that Ekansh Nursing Home is not covered under the policy in question.
7. At this stage we deem it appropriate to refer clause 2.1 of the said policy:
2.DEFINATIONS: 2.1 HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either
a) Is duly licensed and registered as a hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner.
OR
b) In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home and should comply with minimum criteria as under
ALLOWED PAGE 7 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 i. It should have at least 15 in-patient medical beds in case of Metro cities A Class cities & B class cities or 10 in-patient medical beds in case of C class cities. Classification of cities shall be as per Govt of India Notifications issued in this respect from time to time.
ii. Should have fully equipped and engaged in providing Medical and Surgical facilities along with Diagnostic facilities i.e., Pathological test and X-ray, ECG etc. for the care and treatment of injured or sick persons as in- patient."
8. After carefully reading the aforesaid clause 2.1 of the said policy, it is clear that the hospital/nursing home would be covered by the said policy if the hospital/nursing home is duly licenced and registered by the appropriate authority and supervised by a certified and qualified medical professional OR if licensing and registration facilities are not available, then it must meet the minimal requirements outlined in the said clause. Therefore, in order to cover the said nursing facility in the said policy, it must satisfy either one of the two requirements stated above.
9. On perusal of record, it is noted that the Directorate General of Health Services, Government of NCT of Delhi had actually registered the Ekansh Nursing Home with registration number DGHS/NH/657 (Annexure on page 54 of the complaint). Therefore, we hold that the Ekansh Nursing Home is duly recognized as per the policy in question.
10. In view of the aforesaid discussion, we further hold that Respondent no. 1 was deficient in providing its services to the Appellant as they had wrongly interpreted the terms and ALLOWED PAGE 8 OF 10 FA/317/2019 MR. SACHIN AGGARWAL VS. THE ORIENTAL INSURANCE COMPANY LTD. & ANR. DOD.: 02.11.2022 conditions of the policy in question and repudiated the genuine claim of the Appellant for an amount of Rs. 39,513/-. It is not in dispute that the appellant due to severe headache got admitted to Ekansh Nursing Home on 23.09.2017 and was discharged on 25.09.2017 and the said fact was duly intimated to Respondent no. 1 vide email dated 23.09.2017.
11. In these circumstances, we hold that the District Forum was wrong in dismissing the complaint of the Appellant on the ground that Ekansh Nursing Home was not recognized under the policy in question. Consequently, the present appeal is allowed and the impugned judgment dated 11.04.2019 passed by District Commission (Central) in CC No. 283/2017 is set aside
12. Keeping in view the facts of the present case, we direct the Respondent no. 1 to pay Rs. 39,513/- along with interest as per the following arrangement:
A. An interest @ 6% p.a. calculated from 13.12.2017 (date of Final reminder cum closure letter sent by the Respondent no. 1) till 02.11.2022 (being the date of the present judgment);
B. The rate of interest payable as per the aforesaid clause (A) is subject to the condition that the Respondent no. 1 pays the entire amount on or before 01.01.2023; C. Being guided by the principles as discussed above, in case the Respondent no. 1 fails to refund the amount as per the aforesaid clause (A) on or before 01.01.2023, the entire amount is to be refunded along with an interest @ 9% p.a. calculated from 13.12.2017 till the actual realization of the amount.
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13. In addition to the aforesaid and taking into consideration the facts of the present case, the Respondent no. 1 is directed to pay a sum of:
A. Rs. 1,00,000/- as cost for mental agony and harassment to the Appellant; and B. The litigation cost to the extent of Rs. 50,000/-.
14. Application(s) pending, if any, stand disposed of in terms of the aforesaid judgment.
15. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
16. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) (JUDICIAL MEMBER) Pronounced On:
02.11.2022 ALLOWED PAGE 10 OF 10