State Consumer Disputes Redressal Commission
United India Insurance Co.Ltd. & ... vs Rohit Sabharwal & Another on 28 January, 2022
ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.247 of 2020
Date of Institution : 28.08.2020
Date of Reserve : 09.12.2021
Date of Decision : 28.01.2022
1. United India Insurance Company Ltd., Registered Office, 24,
Whites Road, Chennai 600014 through its regional office i.e.
United India Insurance Co., 136, Feroze Gandhi Market,
Ludhiana through Pankaj Mehra, Assistant Manager (Legal).
2. United India Insurance Co. Ltd., Branch Office 57, Railway
Link Road, Amritsar through its regional office i.e. United
India Insurance Co., 136, Feroze Gandhi Market, Ludhiana
through Pankaj Mehra A.M. (legal).
......Appellant/Opposite Parties No.1 & 2
Versus
1. Rohit Sabharwal S/o Sh.Rajeev Kumar Sabharwal R/o 58,
Anand Avenue, Amritsar.
......Respondent/Complainant
2. M/s Vipul Medcorp Insurance TPA private Ltd., SCO No.98,
1st Floor, Industrial Area, Phase-2, Chandigarh-160002
through its Branch Head/Manager/Principal Officer.
.......Respondent/opposite party No.3
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 04.02.2020 of the District
Consumer Disputes Redressal Forum, (now
'Commission'), Amritsar.
Quorum:-
Mr. Rajinder Kumar Goyal, Presiding Member
Mrs.Kiran Sibal, Member First Appeal No. 247 of 2020 2 Present:-
For the appellant : Sh.Lalit Garg, Advocate For respondent No.1 : Sh.Shubham Mehta, Advocate For respondent No.2 : Deleted vide order dt.11.09.2020 RAJINDER KUMAR GOYAL, PRESIDING MEMBER The appellants/opposite parties No.1 & 2 have filed the present appeal under Section 41 of the Consumer Protection Act, 2019 for setting aside of the order dated 04.02.2020 passed by the District Commission, Amritsar whereby the complaint filed by the complainant was allowed and opposite party No.1 was directed to pay Rs.4,58,600/- along with interest at the rate 9% per annum from the date of filing of the complaint till payment. Opposite parties were further directed to pay litigation expenses of Rs.10,000/-.
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission.
2. As per the complaint, the complainant obtained a medical insurance policy from opposite parties vide policy No.2002012817P116933346 under the plan "Individual Health Policy" along with Super Top Up Medi Care Policy for a sum assured of Rs.5,00,000/- for the period 05.03.2018 to 04.03.2019 and a sum of Rs.18,919/- was paid by the complainant as premium. Further averred that the complainant took first medic claim in 2002. Unfortunately, the complainant remained hospitalized w.e.f. 18.04.2018 to 24.04.2018 in Escorts Heart Institute & Research Centre, New Delhi for the treatment of Paroxysmal & Tachyacardia diseases. The complainant thereafter First Appeal No. 247 of 2020 3 lodged a Medi Claim with the opposite parties on 10.05.2018 and supplied all the requisite documents through opposite party No.3, but the claim of the complainant was not settled. Thereafter, a legal notice dated 05.03.2019 was served upon the opposite parties, however, the opposite parties issued the repudiation letter on 18.03.2019. The opposite parties declined a genuine claim of the complainant on the basis of Artial Septal Defect which is a heart defect that is presented at birth. Alleging deficiency in service on the part of the opposite parties, the complainant filed the complaint before the District Commission and sought the following directions against the opposite parties:
i) to settle the claim and to pay a sum of Rs.4,58,600/- to the complainant along with interest at the rate of 18% per annum as per settled law;
ii) to pay Rs.2,00,000/- as compensation on account of mental agony and pain suffered by the complainant;
iii) to pay Rs.11,000/- as litigation expenses; and
iv) to pay interest at the rate of 18% per annum on the award amount;
3. Upon notice, opposite parties appeared and filed their joint reply taking preliminary objections that as per exclusion clause 4.1, the claim is not payable. Further submitted that as per opinion of opposite party No.3, the patient was diagnosed as a case of ASD with SVT (Atrial Septal Defect with Supraventricular Tachycardia) First Appeal No. 247 of 2020 4 and underwent Heart Port ASD Closure. As per medical abstract, Atrial Septal Defect is a Heart Defect that is present at birth and thus congenital in nature and policy clause 4.1 excludes such diseases. The complainant was informed vide letter dated 18.03.2019 that the claim was repudiated as per clause 4.1 of the policy.. The complainant is estopped by his own act and conduct from filing the complaint. The complainant was duly provided the terms and conditions of the Insurance Policy, in question and both the parties are strictly bound by the same and are strictly governed by the said terms and conditions of the policy. The claim of the complainant was repudiated on merits in view of the terms and conditions of the policy. On merits, it was submitted that contract of insurance is a bilateral agreement in which both the parties i.e. insured and insurer are strictly governed by the terms and conditions of the policy, in question and bound by the same. It was submitted that there is no deficiency in service or unfair trade practice on the part of the opposite parties. Rest all the averments as averred by the complainant in his complaint were denied and prayed for dismissal of the complaint.
4. The complainant filed replication to the reply filed by opposite parties denying all the allegations made in the reply and reiterated the averments made in the consumer complaint.
5. The parties led their evidence in support of their respective contentions before the District Commission and after hearing the First Appeal No. 247 of 2020 5 learned counsel for the parties, the complaint was allowed, vide impugned order dated 04.02.2020.
6. Aggrieved by the said order, present appeal has been filed by the appellants/opposite parties No.1 & 2 for setting aside the impugned order and to allow the appeal.
7. Notice of the appeal was issued to the respondent No.1/complainant through registered post on 15.09.2020 who appeared through his counsel, whereas the name of respondent No.2 was deleted vide order dated 11.09.2020 on the statement suffered by the appellants at bar.
8. We have heard the learned counsel for the parties and have also carefully gone through the record as well as written arguments filed by the parties.
9. Learned counsel for the appellants argued that the District Commission allowed the complaint without taking into consideration that the claim of the complainant does not lie within the framework of the conditions of the Insurance Policy. The claim of the complainant is not payable as per exclusion clause 4.1 of the terms and conditions of the Insurance Policy. The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of Congenital diseases (Internal and External). The District Commission has grossly erred while travelling beyond the terms and conditions of the Insurance Policy. The complainant in his complaint has not even mentioned a single First Appeal No. 247 of 2020 6 word that he was not aware in respect of the benefit provided under the terms and conditions of the policy. The claim of the complainant was rightly repudiated as per the terms and conditions of the policy. There is no deficiency in service or unfair trade practice on the part of the appellants/opposite parties No.1&2. Finally, it is prayed to allow the appeal by setting aside the impugned order passed by the District Commission.
10. On the other hand, learned counsel for the respondent argued that the medi-claim of the complainant/respondent No.1 was wrongly and erroneously rejected by the appellant/Insurance Company. As per the medical record, the complainant/respondent No.1 was diagnosed with ASD (Artrial Septal Defect) with SVT (supraventricular tachy cardia). It was clearly established on record that prior to 18.04.2018, when the complainant was admitted for treatment, there was no evidence with the insurance company to even remotely suggest that the complainant had taken any prior treatment for the said disease, which as per Insurance Company was congenital in nature. It is a settled law that repudiation of medi-claim by relying upon the exclusion clause related to genetic disorders is bad in the eyes of law. The District Commission passed the order after thoroughly gone through the evidence and hearing learned counsel for both the sides at length. The order passed by the District Commission is a well reasoned order. There is no need of interference in it. Finally, it is prayed to dismiss the appeal being devoid of merits.
First Appeal No. 247 of 2020 7
11. We have given our thoughtful consideration to the contentions raised by the learned counsel for the parties and have carefully gone through the record of the case.
12. Brief facts as per the complaint are that the respondent/complainant obtained an Individual Health Policy bearing No.2002012817P116933346 along with Super Top Up Medical Policy bearing No.2002012817P116934562 for the period 05.03.2018 to 04.03.2019, vide Ex.C-2 & Ex.C-3 from the appellants/opposite parties and paid a premium of Rs.14,435/- and Rs.4,464/- respectively. The sum insured was Rs.5,00,000/- each for the complainant, his wife and daughter. On 18.04.2018, the complainant was admitted to Escorts Heart Institute & Research Centre, New Delhi, where the complainant was diagnosed with ASD (Atrial Septal Defect) with SVT (Supraventricular Tachycardia) and Heart Port ASD Closure Surgery was done on 18.04.2018. The respondent/complainant remained in the hospital and was discharged on 24.04.2018. An expenditure of Rs.4,58,600/- was incurred by the respondent/complainant on his treatment, vide Hospital Final Bill Ex.C-27. A claim was lodged with the respondent/ opposite party No.3 vide Ex.C-30 dated 01.05.2018. The respondent/opposite party No.3 sent a query letter Ex.C-37 dated 13.06.2018 with the following observations:
i) Please provide investigation report to support the diagnosis dully signed by Pathologist/ Radiologist.
ii) Please dully filled Consent Form.
First Appeal No. 247 of 2020 8
iii) Please provide exact duration of presenting complaint
certified by treating doctor.
iv) Treating doctor kindly confirm the ASD is genetic in
nature or not.
v) As per the policy T&C, documents are to be submitted
within 7 days from the date of discharge but the documents have been submitted on 10.05.2018 after discharge on 24.04.2018. Please provide the reason for delay submission.
13. The above querries were replied by the respondent/ complainant vide letter dated 29.09.2018, Ex.C-16. The appellant/opposite party-Insurance Company repudiated the claim vide Ex.C-40 dated 18.03.2016 with the observations:
"We thank you for choosing "United India" as your insurer for the above Health Policy. Against this policy you have lodged a claim and submitted the supporting documents. While going through the papers, it is observed that the patient is diagnosed with ASD with SVT undergone heart port ASD closure. As per Medical abstract, Atrial Septal defect is a heart Defect that is presented at birth. Hence all congenital disease (internal or external) fall under the permanent exclusion of the policy. Hence, the claim can be repudiated as per Clause 4.1 of the policy."
14. Now the issue is to decide whether the repudiation of claim by the appellants/opposite parties is justified or not?
As per discharge summary, Ex.C-31 dated 24.04.2018, the respondent/complainant was diagnosed with ASD with SVT & Heart Port ASD Closure Surgery was done on 18.04.2018. As per First Appeal No. 247 of 2020 9 medical abstract, ASD is a heart defect that is present at birth and thus congenital in nature and policy clause 4.1 excludes such disease which reads as under:
"4. Exclusions The company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured Person in connection with or in respect of; 4.1 Congenital Diseases (Internal and External)"
Clause 3.6 on Congenital Anomaly also is placed in verbatim:
"3.6 CONGENITAL ANOMALY Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.
i) Internal Congenital Anomaly Which is not in the visible and accessible parts of the body.
ii) External Congenital Anomaly Which is in the visible and accessible parts of the body."
15. The District Commission allowed the claim while relying upon the judgment of the Hon'ble Delhi High Court in the case of United India Versus Jai Parkash Tayal in RFA No.610 of 2016 & CM Nos.45832 of 2017 decided on 26.02.2018, which refers to genetic disorders and not to the congenital disorder. Therefore, the First Appeal No. 247 of 2020 10 facts of the judgment are distinguished from the present case and as such, cannot be applied in the present case.
16. The counsel for the respondent/complainant presented a copy of guidelines on standardization of exclusions in Health Insurance Contracts issued by IRDA vide Circular No.IRDAI/HLT/REG/CIR/117/09/2019 dated 27th September, 2019. As per Chapter II Clause I of these guidelines exclusions not allowed in Health Insurance Policies in case of Internal Congenital diseases, generic diseases or disorders. However, these guidelines are applicable in all Health Insurance Products w.e.f. 01.10.2019. As the present case is prior to the date of applicability of the said guidelines as such cannot be applied.
17. It is not the case of the respondent/complainant that he was not aware of the terms and conditions of the policy.
18. 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" and 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 First Appeal No. 247 of 2020 11 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 "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."
In view of the above, in our view, the repudiation of claim by the appellants/opposite parties is in order.
19. Sequel to the above discussions, we find merit in the appeal. Accordingly, the appeal is allowed and the order passed by the District Commission is set aside as well as the complaint filed by the complainant before the District Commission is dismissed being devoid of merits.
20. The appellants/opposite parties had deposited a sum of Rs.2,64,861/- at the time of filing of the appeal. They deposited another sum of Rs.2,60,279/- vide receipt No.2837110 dated 21.09.2020 in compliance of the order 11.09.2020. Both these sums along with interest accrued thereon, if any, shall be remitted by the Registry to the appellants/opposite parties, after the expiry First Appeal No. 247 of 2020 12 of 45 days of the sending of certified copy of the order to them in accordance with law.
21. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(RAJINDER KUMAR GOYAL) PRESIDING MEMBER (KIRAN SIBAL) MEMBER January 28th ,2022 parmod