State Consumer Disputes Redressal Commission
Shishir Chawada vs Oriental Insurance Co. Ltd on 23 December, 2017
M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PLOT NO. 76, ARERA HILLS, BHOPAL (M.P.)
FIRST APPEAL No.2084 /2016.
DECIDED ON : 23 -12-2017.
Shishir Chawada,
S/o Shri Balkrishna Chawada,
R/o 12, Kanungo Bakhal,
Indore (M.P.).
.... Appellant.
Versus
1. Branch Manager,
Oriental Insurance Co. Ltd.,
City Branch Office,
5, Sheeba Complex,
562, M. G. Road,
Regal Square, Indore.
2. Vipul Medicorp T.P.A. Pvt. Ltd.,
515, Udyog Vihar, Phase - 5,
Gurgaon, Haryana - 122 016.
.... Respondents.
BEFORE:
HON'BLE SHRI S. D. AGARWAL, PRESIDING MEMBER
HON'BLE DR. (SMT) MONIKA MALIK, MEMBER
COUNSEL APPEARING FOR THE PARTIES :
SHRI K. P. MAHESHWARI, LEARNED COUNSEL FOR APPELLANT.
SHRI V. K. SAXENA, LEARNED COUNSEL FOR RESPONDENT NO.1.
NONE FOR RESPONDENT NO.2.
ORDER
The following order of the Commission was delivered by Dr. (Smt) Monika Malik, Member :
1. This is an appeal by the complainant against the order passed by District Forum, Indore in CC No.419/2015 whereby the complaint filed by him has been dismissed.
- 2-
2. Briefly stated, facts of the case are that the complainant had obtained an insurance policy from opposite party under which he and four other members of his family were insured. Under this insurance policy every one individually and totally put together were insured for sum insured of Rs.1.5 lacs. The complainant got the aforesaid policy renewed on 15.5.2013 for enhanced sum insured of Rs.2.5 lacs. During the policy cover period, one of the insured, Master Naksh suddenly fell ill and was admitted for treatment in 'Narayana Institute of Cardiac Sciences', Bangalore on 11.1.2014, regarding which the complainant sought approval for cashless policy, which was denied by the opposite party and the complainant was told to make payment on his own and later on submit his claim for reimbursement. The complainant, therefore submitted his claim form for reimbursement of Rs.2,62,799/- from the opposite party, which was repudiated by the latter, stating that the treatment was sought for a disease under the category of 'Congenital Internal Disease' which, falls under the Clause 4.8 of the policy and is excluded from the insurance coverage. The complainant stated that he was uninformed about the policy terms and conditions and therefore the repudiation of claim by the opposite party is unjustified.
3. The defence put-up by the opposite party is that the insured was treated for a disease which falls under the category of 'Congenital Internal Disease' i.e. the disease existed since the time of birth of the insured. Therefore since the disease falls under the exclusion Clause 4.8 of the policy, the claim is not payable.
- 3-
4. The District Forum after appreciating the evidence on record dismissed the complaint filed by the complainant.
5. Heard the counsels for the parties. Perused the record.
6. As we observe 'operation note' (Ex. P-11) of Baby Naksh Chawada ( 1 year / male), his diagnosis is indicated - Tetralogy of fallot with small sized pulmonary arteries, PDA. 'Surgical discharge summary' of Baby Naksh indicates the procedure performed as - Intra Cardiac Repair with short transannular pericardial patch. The claim form (Ex. P-5) of Baby Naksh, mentions that the insured was diagnosed with 'Tetralogy of Fallot' & was treated for the same.
7. The repudiation letter (Ex. P-7) issued by the respondent dated 31.3.2014, states that as per policy Exclusion Clause 4.8 the claim is not payable, which is reproduced hereunder :
"4. EXCLUSION : 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 ;
4.8 Convalescence, general debility, rundown condition or rest cure, congential external and internal diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, veneral diseases, intentional self injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and / or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc."
- 4-
8. It's a well known medical fact that 'Tetralogy of fallot' is a Congenital heart defect i.e. present at birth, which is technically treated in the first year of life.
9. Learned counsel for the appellant in his complaint, appeal memo, as well as during arguments before us has categorically stated that he was not aware of the policy terms and conditions, under which his claim has been repudiated. Learned counsel for the respondent has stated that, as has been mentioned in the policy terms and conditions the claim is not payable. Learned counsel for the respondent during arguments before us has given reference of Hon'ble National Commssion judgement rendered in Aman Kapoor Versus National Insurance Co. Ltd. & Others, 2017 (2) CLT 372.
10. As we carefully go through the policy placed on record by the appellant, we observe that on the second page of 'Happy Family Floater Policy Schedule', it is mentioned that "the insurance under this policy is subject to conditions, clauses, warranties, endorsements as per forms attached." Therefore the plea of the learned counsel for the appellant is not acceptable as this remains unexplained that why did the appellant not ask for full documents of terms and conditions of policy, if he had not received the same, even when it is categorically stated in the policy itself, that the insurance claim is subject to terms and conditions. The judgement rendered in Aman Kapoor, supra is applicable in the instant matter. In para 24 the National Commission has observed as under :
- 5-
"Another plea has been taken by the
petitioner/complainant that he was not aware of the terms and conditions of the policy as the same had never been supplied to him. This too has been taken into account by the State Commission which has found itself unable to accept this plea on the ground that there seems to have been no effort on the part of the petitioner/complainant to obtain a copy of the terms and conditions. We are inclined to also agree with this view. We further contend that it is incumbent upon the consumer to be an informed and responsible consumer in order to be able to avail of relief under the Consumer Protect Act, 1986. Ignorance of terms and conditions of the policy is no excuse and provides no shelter to the petitioner complainant."
11. Therefore, in view of the above, we reach a conclusion that since the treatment was received by the insured for a defect / disease which falls under the category of exclusion clause 4.8 of the insurance policy, the treatment expenses incurred were not payable by the respondent. Considering the facts and circumstances of the matter, we find no illegality in the order passed by the District Forum, Indore. The order is affirmed and the appeal is dismissed. No order as to costs.
(S.D. AGARWAL) (DR.MONIKA MALIK) Presiding Member Member