State Consumer Disputes Redressal Commission
The New India Assurance Co. Ltd vs Nitin Jain on 7 May, 2024
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UP C-1 Vikrant Khand 1 (Near Shaheed Path), Gomti Nagar Lucknow-226010 First Appeal No. A/1236/2019 ( Date of Filing : 18 Oct 2019 ) (Arisen out of Order Dated 16/09/2019 in Case No. C/115/2017 of District Meerut) 1. The New India Assurance Co. Ltd Through Manager Legal Cell M.G. Marg Hazratganj Lucknow ...........Appellant(s) Versus 1. Nitin Jain S/O Shri Naresh Kur Jain R/O 27/28 Rangsaaj Mohalla Sadar Meerut Cantt ...........Respondent(s) BEFORE: HON'ABLE MR. JUSTICE PRESIDENT PRESIDENT HON'BLE MR. JUSTICE ASHOK KUMAR PRESIDENT PRESENT: Dated : 07 May 2024 Final Order / Judgement STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UTTAR PRADESH, LUCKNOW APPEAL NO. 1236 OF 2019 (Against the order dated 16-09-2019 in Complaint Case No.115/2017 of the District Consumer Commission, Meerut The New India Assurance Company Limited Through Manager Legal Cell M. G. Marg, Hazratganj Lucknow ...Appellant Vs. Nitin Jain S/o Sri Naresh Kumar Jain R/o 27/28, Rangsaaj Mohalla Sadar, Meerut Cantt. ...Respondent BEFORE: HON'BLE MR. JUSTICE ASHOK KUMAR, PRESIDENT For the Appellant : Sri Jitendra Narain Mishra, Advocate. For the Respondent : Sri Veer Raghav Chaubey, Advocate. Dated :07-05-2024 JUDGMENT
PER MR. JUSTICE ASHOK KUMAR, PRESIDENT The instant appeal has been filed under Section 41 of the Consumer Protection Act 2019 against the judgment and order of the District Consumer Commission, Meerut dated 16-09-2019 passed in Complaint Case No. 115/2017 by which the complaint has been allowed and the following order has been passed.
"प्रश्नगत मेडिक्लेम बीमा पालिसी के सम्बन्ध में प्रतिपक्षी न्यू इण्डिया एश्योरेंस कम्पनी लिमिटेड के विरूद्ध, परिवाद पत्र की अनुतोष कण्डिका में मांगे गये अनुतोष हेतु, परिवादी नितिन कुमार पुत्र श्री नरेश कुमार जैन का यह उपभोक्ता परिवाद आंशिक रूप से स्वीकार किया जाता है।:2:
प्रतिपक्षी न्यू इण्डिया एश्योरेंस कम्पनी लिमिटेड का प्रश्नगत बीमा क्लेम निरस्तीकरण आदेश दिनांकित 23.8.2016 तदनुसार निरस्त किया जाता है तथा प्रतिपक्षी न्यू इण्डिया एश्योरेंस कम्पनी लिमिटेड को आदेशित किया जाता है कि वह इस निर्णय दिनांकके तीस दिन के अन्दर प्रश्नगत मेडिक्लेम बीमा पालिसी से सम्बन्धित अंकन-1,10,298/-रूपये (एक लाख दस हजार दो सौ अट्ठानवे रूपये) की राशि परिवादी नितिन जैन को अदा कर दे।
परिवाद संस्थित किये जाने की दिनांक से पूर्ण एवं वास्तविक अदायगी की दिनांक तक अंकन-1,10,298/-रूपये (एक लाख दस हजार दो सौ अट्ठानवे रूपये) की इस धनराशि पर 6 प्रतिशत साधारण वार्षिक ब्याज की दर से ब्याज राशि भी प्रतिपक्षी बीमा कम्पनी द्वारा परिवादी को देय होगी।
इसके अतिरिक्त, प्रतिपक्षी बीमा कम्पनी के इस उपेक्षित व्यवहार के कारण स्वयं को पहुंची मानसिक वेदना एवं शारीरिक कष्ट की प्रतिपूर्ति मद में अंकन-10,000/-रूपये (दस हजार रूपये) एवं वाद व्यय प्रतिपूर्ति मद में अंकन-5,000/-रूपये (पांच हजार रूपये) की धनराशि भी प्रतिपक्षी बीमा कम्पनी से प्राप्त करने का परिवादी अधिकारी होगा।
Being aggrieved with the impugned judgment and order the opposite party The New India Assurance Company Limited has come up in appeal.
Facts of the case stated in brief are that the complainant has obtained a Medi-claim policy from the opposite party The New India Assurance Company Limited after paying premium ofRs.9,962/-. The policy was valid from 16-02-2016 to 15-02-2017. In the said policy the complainant and his family including his spouse Smt. Prachi Jain was covered. The complainant has been obtaining medi-claim policy in the name of himself and his wife for last several years from the opposite party.:3:
The complainant's wife Smt. Prachi Jain has made complaints of maculonodular skin lesion with ulceration over lower half of both legs since December, 2015 and as per advice of the consulting doctor Smt. Prachi Jain was admitted for Rituximab infusion on 10-05-2016 in Indraprasth Apollo Hospital, New Delhi. She was discharged on the next day i.e. on 11-05-2016 and she remained in the hospital for a period of more than 24 hours.
Smt. Prachi Jain was again admitted in the same hospital on 24-05-2016 for the purpose of administration/treatment of Rituximab infusion. Dr. S J Gupta, Senior Consultant Rheumatologist has given a certificate on 22-08-2016 wherein it has been mentioned that "It is further certified that Rituximab infusion has to be given in hospital with prior medication and under observation for at least 24 hours as there is a significant risk of anaphylaxis/reaction to this medication." The complainant has lodged a claim for Rs.98,735/- and Rs.11,563/- for treatment in Apollo Hospital from 10-05-2016 to 11-05-2016 and thereafter on 24-05-2016 with the opposite party. The opposite party vide letter dated 23-08-2016 had stated that the claim is not maintainable as per policy condition no. 2.15 as the hospitalization of 24 consecutive hours are not required for injecting injunction of Rituximab.
Thereafter the complainant had made the representation to the opposite party on 04-09-2016 and thereafter on 01-10-2016 which was also rejected by the opposite party vide letter dated 14-10-2016 on this ground that M/s Vipul Medcorptpa Private Limited has denied the admissibility of claim vide their email dated 14-10-2016. The rejection/repudiation of the claim by theopposite party is wrong, erroneous and illegal. The opposite party has committed deficiency in rendering the services to the complainant and the complainant has suffered a mental and physical agony on account of refusal of the complainant's claim.:4:
The complainant has sent the legal notice to the opposite party on 27-11-2016 which was erroneously replied by the opposite party through their Counsel on 24-12-2016. The said reply is not admitted to the complainant being erroneous, vague and misconceived.
The opposite party has filed its written statement before the learned District Consumer Commission and has denied the allegations made by the complainant in his complaint.
Sri Jitendra Narain Mishra, learned Counsel for the appellant appeared.
Sri Veer Raghav Chaubey, learned Counsel for the respondent appeared.
Heard learned Counsel for the parties and perused the record. .
It has been argued by the learned Counsel for the appellant that the order passed by learned District Consumer Commission is illegal, arbitrary and unjust in the eyes of law.
It has been argued by the learned Counsel for the appellant that the impugned judgment and order has been passed by the District Consumer Commission without considering the facts and circumstances of the case. The entire approach of the District Consumer Commission in deciding the complaint is erroneous and suffers from manifest error of both facts and law.
It has been further argued by the learned Counsel for the appellant that the impugned order so passed by the District Consumer Commission is erroneous and bad in the eyes of law in as much as the same has been passed without application of mind and assailing the records.
It has been contended by the learned Counsel for the appellant that the impugned order suffers from illegality and material irregularity and is also contrary to the facts and evidence available on record and the same is therefore, liable to be quashed and set aside.:5:
It has been further contended by learned Counsel for the appellant that the claim of the respondent was repudiated strictly in accordance with the terms and conditions of the insurance policy and as such the appellant could not be legally held liable to indemnify the respondent.
Learned Counsel for the appellant has argued that the appellant repudiated the claim vide letter dated 23-08-2016 since none of the two claims were covered under the scope of the insurance policy, in as much as, neither the treatment taken by the respondent's wife was covered under Day Care as per policy condition no.2.10, nor was the treatment covered under policy condition no. 2.10. Clause 2.10 of the policy condition reads as under:-
"2.10 DAY CARE TREATMENT: Day Care treatment refers to medical treatment or Surgery which are:
-Undertaken under General or Local Anesthesia in a Hospital/Day Care Centre in less than 24 hours because of technological advancement, and
-which would have otherwise required a Hospitalization of more than 24 hours.
Treatment normally taken on an out-patient basis is not included in the scope of this definition."
It has been argued by the learned Counsel for the appellant that the appellant did not commit any deficiency in repudiating the claim, since claim/hospitalization not being covered in the insurance policy, it was stated that the claim did not relate to necessary and required hospitalization of 24 consecutive hours and also does not pertain to the list of treatment/surgical procedures where such admission could be for a period of less than 24 consecutive hours.
Learned Counsel for the respondent has argued that the order passed by the learned District Consumer Commission is perfectly :6: correct and the learned District Consumer Commission has committed no illegality in passing the impugned judgment and order.
Learned Counsel for the respondent/complainant has further argued that the District Consumer Commission has jurisdiction to entertain and adjudicate the complaint and cause of action accrued to the complainant to file the complaint before the learned District Consumer Commission.
Learned Counsel for the respondent/complainant has argued that the learned District Consumer Commission has applied its judicial mind to all the facts, circumstances and evidence and on judicious consideration of all the materials available on the record, passed the impugned judgment and order, which is perfectly legal and sustainable and allegations made by the appellant contrary to this are baseless and fit to be rejected and the appeal filed by the appellant is fit to be dismissed with exemplary cost to the complainant.
It has been further contended by the learned Counsel for the respondent that as per advice of the consulting doctor Smt. Prachi Jain was admitted for Rituximab infusion on 10-05-2016 in the hospital and she was discharged on the next day i.e. on 11-05-2016 and she remained in the hospital for a period of more than 24 hours. Thereafter Smt. Prachi Jain was again admitted on 24-05-2016 for the purpose of administration of Rituximab infusion.
Learned Counsel for the respondent has referred the Annexure No.01 the certificate issued by Dr. S. J Gupta, Senior Consultant Rheumatologist which reads as under:-
"To |Whom It May Concern:
Attention : New India Assurance Company Re: Mrs. Prachi Jain Diagnosis: Beheet's Disease:
This is to certify that Mrs. Prachi Jain was admitted under my care at Apollo Indraprastha Hospital, on 10th May 2016 and 24th May 2016, for the purpose of administration of Rituximab infusion. It :7: is further certified that Rituximab infusion has to be given in hospital, with prior pre-medication and under observation for atleast 24 hrs, as there is a significant risk of anaphylaxis/reaction to this medication.
Dr. S J Gupta, FRCP Senior Consultant Rheumatologist "
Learned Counsel for the respondent has argued that neither the Insurance Company nor their T.P.A. M/s Vipul Medcorptpa Private Limited has got any knowledge of the disease which the complainant's wife Smt. Prachi Jain had. The Senior Consultant Dr. S J Gupta of Indraprastha Apollo Hospital is a renowned Doctor of Rheumatology. It is a well settled law that about the patient only the consulting doctor may tell about his/her disease. Except him no doctor can tell about the exact illness of the patient.
It has been further contended by learned Counsel for the respondent that the opposite party has committed deficiency in rendering the services to the complainant and the complainant has suffered a mental and physical agony on account of refusal of the complainant's claim.
I have perused the impugned judgment and order passed by the learned District Consumer Commission.
The District Consumer Commission has recorded a categorical finding in its judgment which is reproduced hereinbelow:-
"पत्रावली पर उपलब्ध साक्ष्य के आधार पर यह तथ्य भलीभांति सिद्धहै कि अपने कथित इलाज के सम्बन्ध में श्रीमती प्राची जैन दिनांक 10.5.2016 समय 10.48.11 से दिनांक 11.5.2016 समय 11.28.39 बजे तक इन्द्र प्रस्थ अपोलो अस्पताल नई दिल्ली Rheumatology विभाग के वरिष्ठ Rheumatologist चिकित्सक एस.जे. गुप्ता के परामर्श एवं निर्देशानुसार ही अस्पताल में भती रही हैं। अत: ऐसी स्थिति में प्रतिपक्षी बीमा कंपनी का यह प्रतिवाद अभिकथन फिर :8: बेमानी हो जाता है कि Rituximab इन्जेक्शन लगवाये जानेहेतु दिनांक 10.5.2016 से दिनांक 11.5.2016 तक 24 घण्टे से अधिक श्रीमतीप्राची जैन अनावश्यक रूप से अपनी मर्जी से ही अस्पताल में भर्ती बनी रहीं, एवं इस प्रकार उसके द्वारा मेडिक्लेम पालिसी की शर्त संख्या-2.15 का उल्लंघन किया गया।
यह तथ्य सिद्ध है कि अपने कथित इलाज के सम्बन्ध में परिवादी की पत्नी श्रीमती प्राची जैन द्वारा जानबूझकर, प्रश्नगत मेडिक्लेम बीमा पालिसी की शर्त संख्या-2.15 का कोई उल्लंघन नहीं किया गया है। अत: ऐसी स्थिति में जैसा कि न्याय दृष्टान्त Apollo munich health Insu. Co. Ltd. V. Hemant Thakur (1)CPJ 2019 SCDRC Chandigarh Page 199 एवं न्याय दृष्टान्त National Insurance Co. Ltd. V. Vineet Mahajan (2) CPJ 2019SCDRC Delhi Page 253 के अन्तर्गत यह स्पष्ट रूप से प्रतिपादित किया गया है कि यदि प्रकरण Exclusion Clause के अन्तर्गत नहीं आता है, तो ऐसी स्थिति में सम्बन्धित बीमा कम्पनी द्वारा पारित किया गया बीमा क्लेम निरस्तीकरण आदेश फिर उचित नहीं ठहराया जा सकता।
इस प्रकार, साक्ष्य एवं विधि की उपर्युक्त विवेचना के आधार पर यह तथ्य भलीभांति सिद्ध है कि अपने इलाज हेतु श्रीमती प्राची जैन इन्द्र प्रस्थ अपोलो अस्पताल नई दिल्ली के Rheumatology विभाग के वरिष्ठ एवं योग्य Rheumatologist चिकित्सक एज.जे. गुप्ता के उपचाराधीन थी। श्रीमती प्राची जैन की कथित गम्भीर बीमारी की स्थिति को दृष्टिगत रखते हुये डा. एस.जे. गुप्ता द्वारा उसे Rituximab इन्जेक्शन लगवाये जाने हेतु उसे परामर्श दिया गया। वरिष्ठ विशेषज्ञ डाक्टर एस.जे. गुप्ता द्वारा परामर्शित इस हेतुउसके पैथालोजी टेस्ट एवं चिकित्सीय टेस्ट कराने के उपरान्त, उक्त Rituximab इन्जेक्शन लगवाये जाने हेतु दिनांक 10.5.2016 समय 10.48.11 बजे श्रीमती प्राची जैन इन्द्र प्रस्थ अपोलो अस्पताल नई :9: दिल्ली में भर्ती हुई, जहां Rituximab इन्जेक्शन लगाने से पूर्व उसके समस्त आवश्यक पैथालोजी टेस्ट एवं चिकित्सीय टेस्ट किये गये एवंइन टेस्टों की सन्तुष्टि के उपरान्त ही इन्द्र प्रस्थ अस्पताल नई दिल्ली में श्रीमती प्राची जैन को Rituximab इन्जेक्शन लगाया गया, जिसके लिए दिनांक 10/11.5.2016 की रात को उसे चिकित्सक परामर्श के अनुसार, इन्द्र प्रस्थ अपोलो अस्पताल नई दिल्ली में भर्ती रहना पड़ा एवं सम्बन्धित वरिष्ठ चिकित्सक डा. एस.जे. गुप्ता के परामर्श एवं निर्देशानुसार जहां से वह दिनांक 11.5.2016 को समय 11.28.39 बजे डिस्चार्ज की गई तथा इसहेतु चिकित्सीय परामर्श के अनुसार दिनांक 24.5.2019 को उसे 15 दिन के अन्दर पुन: इन्द्र प्रस्थ अपोलो अस्पताल नई दिल्ली जाकर वरिष्ठ चिकित्सक एस.जे. गुप्ता से परामर्श करना पड़ा।
यह तथ्य निर्विवादित है कि दिनांक 10.5.2016, 11.5.2016 एवं दिनांक 24.5.2016 को श्रीमती प्राची जैन को इलाज के सम्बन्ध में, प्रतिपक्षी बीमा कंपनी द्वारा जारी की गई, प्रश्नगत मेडिक्लेम बीमा पालिसी प्रभावी थी, तथा इस मेडिक्लेम बीमा पालिस के अन्तर्गत परिवादी नितिन कुमार, उसकी पत्नी श्रीमती प्राची जैन एवं उसकी पुत्री कु. मान्या जैन का अंकन-8,00,000/-रूपये की राशि हेतु मेडिक्लेम जोखिम कवर था। परिवादिनी द्वारा दिनांक10.5.2016, 11.5.2016 एवं 24.5.2016 को अपनी पत्नी के इलाज से सम्बन्धित अंकन-98,735/-रूपये एवं अंकन-11,563/-रूपये के बिल पत्रावली पर उपलब्ध कराये गये हैं, जिनके सम्बन्ध में उसके द्वारा दो बीमा क्लेम क्रमश: संख्या-17RBO1NIA0280 अंकन-98,375/-रूपये एवं बीमा क्लेम संख्या-17RBO1NIA0335 अंकन-11,563/-रूपये प्रस्तुत किये गये थे। मगर, प्रतिपक्षी बीमा कंपनी द्वारा बिना किसी उचित आधार के केवल एक सम्भावित आधार लेते हुये, श्रीमती प्राची जैन के इलाज से सम्बन्धित उक्त दोनों बीमा क्लेम मनमाने रूप से निरस्त कर दिये गये, जिसे हमारे मत में एक सद्भावी उपभोक्ता के प्रतिप्रतिपक्षी बीमा :10: कम्पनी की निर्धारित सेवा में कमी, उपेक्षा एवं लापरवाही के अन्तर्गत ही माना जायेगा, तथा ऐसी स्थिति में, हस्तगत प्रकरणके अन्तर्गत,प्रतिपक्षी बीमा कम्पनी के विरूद्ध मांगे गये अनुतोष हेतु परिवादी का यह उपभोक्ता परिवाद हमारे मत में आंशिक रूप से स्वीकार किये जाने योग्य है।"
Having heard the learned Counsel for the parties and after going through the material and evidence available on record and particularly the findings recorded by the learned District Consumer Commission, I am of the considered opinion that the order passed by the learned District Consumer Commission is fully justified and is correct, as such need no interference and as such is liable to be upheld.
In view of above I am of the view that the appeal has no force and is liable to be dismissed with cost of Rs.1,00,000/-.
ORDER The appeal is dismissed with cost of Rs.1,00,000/- (Rupees One Lac Only) which shall be paid by the appellant to the complainant within a period of 30 days. The judgment and order of the District Consumer Commission, Meerut is confirmed.
Any amount deposited by appellant in appeal under Section 15 of the Consumer Protection Act, 1986 shall be remitted to District Consumer Commission, Meerutalongwith interest accrued for disposal in accordance with this judgment.
Let copy of this order be made available to the parties as per rules.
The Stenographer is requested to upload this order on the website of this Commission at- the earliest.
( JUSTICE ASHOK KUMAR ) PRESIDENT Pnt.
[HON'ABLE MR. JUSTICE PRESIDENT] PRESIDENT [HON'BLE MR. JUSTICE ASHOK KUMAR] PRESIDENT