Returning to the facts of the present case, the strict and actual interpretation of Clause 4 reflects that the Insurance Company is permitted to exclude the expenses borne in case the insured person is suffering from any kind of Pre-existing disease(s) until the insured person is continuously covered under the policy for a minimum period of 48 months. What constitutes Pre-existing disease has been provided in the Insurance Policy itself, which reads as follows:-
“Pre-existing condition/disease definition- any condition, ailment, or injury or related condition for which insured person had signs and symptoms and / or were received medical advice/treatment 48 months prior to his/her Super Top Up Medicare policy with the company”
15. The aforesaid definition clause makes it abundantly clear that in order for a disease to be categorized as pre-existing disease, the Insured must have received medical advice/treatment 48 months prior to purchasing the policy for that particular disease. Whereas, the facts are crystal clear that the prior disease on which the Insurance Company has relied to repudiate the claim of the Insured, was last treated in the year 2004 i.e. 5 years before the Policy No. 2 was purchased. Hence, it cannot be said that the case of the Insured fulfils the essentials of the Pre-Existing disease provided in the Insurance policy.
IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL COMMISSION
FIRST APPEAL NO. 161/2016
IN THE MATTER OF
UNITED INDIA INSURANCE COMPANY LTD. Vs
MANMOHAN SINGH
CORAM:
HON’BLE DR. JUSTICE SANGITA DHINGRA SEHGAL (PRESIDENT)
HON’BLE SH. ANIL SRIVASTAVA, (MEMBER)
PER: HON’BLE DR. JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT PRONOUNCED ON: 02.08.2021
1. Vide the present Judgment, we shall be adjudicating two Appeals namely FA No. 161/2016 titled as “United India Insurance Company Ltd. V. Manmohan Singh” whereby the Insurance Company has impugned the order dated 28.12.2015 passed by the District Forum-II,
Udyog Sadan, Qutub Institutional Area, New Delhi in Complaint case No. 306 of 2011, titled as ‘Sh. Manmohan Singh v/s United India Insurance Co. Ltd. and also FA No. 127/2016 titled as “Manmohan Singh V. United India Insurance” whereby Manmohan Singh (hereinafter referred to as “Insured”) has sought enhancement of the amount awarded by the District Forum vide the aforesaid order.
2. Brief facts necessary for adjudication of these appeal are that in 1991, Insured had purchased an Individual Health insurance Policy from the Insurance Company and had been renewing the same ever since. Initially, the policy had an upper limit to the insurance claim in case of heart diseases at Rs. 1,50,000/-. The Insured had suffered from heart diseases in the years 2000 and 2004, wherein the Insurance Company had invoked the upper limit clause and had only reimbursed Rs. 1,50,000/- as insurance claim to the Insured.
3. Thereafter, in 2007, the Insurance Company changed the Insurance Policy and added some exclusionary clauses with respect to the pre-existing diseases.
4. The policy bearing no. 041200/48/08/97/0003252 (Hereinafter referred to as “Policy No. 1”) was valid from 23.09.2009 to 22.03.2010 covering sum insured upto Rs. 5,25,000/-. Further, the Insured as a measure of abundant precaution, had purchased another Super Top Up policy bearing no. 041200/48/08/36/00003270 (Hereinafter referred to as “Policy No. 2”) valid from 04.03.2009 to 03.03.2010 covering sum insured upto Rs. 10,00,000/- .
5. The Insured got admitted to the Indraprastha Apollo Hospital from 05.09.2009 to 06.09.09 for treatment of Automatic Implantable Cardioverter Defibrillator (AICD) and a bill was raised for Rs. 6,87,477/-. The Insured lodged a claim of Rs. 3,00,000/- under Policy No.1 and Rs. 3,87,000/- under Policy No. 2.
6. However, the Insurance Company discharged only an amount of Rs. 1,50,000/- under Policy No. 1 and repudiated the claim of the Insured under Policy No. 2 on account of the exclusionary clause in the terms and conditions of the Policy. Being aggrieved by Repudiation of claim under the Policy No. 2, the Insured approached the District Forum, alleging deficiency of services on the ground of repudiation of the Insurance Claim.
7. The District Forum vide the order dated 28.12.2015 allowed the complaint filed by the Insured and held as under:-
“The facts are not in dispute. The only question which arises for consideration is, whether the claim of the Complainant had been rightly and legally rejected by the OP by taking shelter of exclusion clause 4.1 of the terms and conditions of the mediclaim policy in question? The exclusion clause 4.1 has already been reproduced hereinabove.
In Oriental Insurance Co. Ltd. Vs. Shankarlal R. Patnani III (2005) CPJ 2004 Chhattisgarh State Consumer Dispute Redressal Cornmission it has been held that every mediclaim treatment is preceded by clinical or other examination of the patient and discretion as to nature and manner of such tests lies with doctor and, therefore, mediclaim of the insured cannot be rejected or repudiated on this ground. In the present case, the Complainant was admitted in the hospital on 05.09.09, he had two claim policies of the OP Company. He had submitted claim under both the policies. The OP cleared the payment of Rs.1,50,000/- of one policy and the claim was rejected/repudiated in the Super Top Up Medicare Policy on the basis of exclusion clause 4.1. Therefore, we do not have any iota of evidence or material on record which may show that the case of the Complainant was covered under exclusion clause 4.1 of the Super Top Up Medicare Policy. Therefore, it is a clear cut case of deficiency in service on the part of OP and it must have resulted in causing mental pain and agony to him.
In view of above discussion we allow the complaint and direct the OP to pay an amount of Rs.150000/- (the highest amount payable under Super Top Up Medicare Policy for the disease) towards mediclaim amount alongwith 6% interest per annum from the date of rejection of the claim till the date of realization and an amount of Rs. 20,000/- towards compensation for mental pain and agony including litigation charges within one month from the date of receipt of copy of this order.”
8. Aggrieved by the order of the District Forum, both the Insurance Company and the Insured filed separate appeals before this commission. The appeal of the Insurance company i.e. FA-161/2016 has been filed on the following grounds:-
(a) That the District Forum has failed to appreciate that the claim does not fall within the scope of coverage given in policy and is barred under Clause 4 of the Super Top Up Medicare Policy.
(b) That the District Forum failed to appreciate that the Insured has undergone the AICD treatment during the inception of the Policy for a pre-existing disease hence is barred by exclusion clause 4.1 of the said policy.
9. The appeal of the Insured i.e., FA 127/2016 has been filed on the following grounds:-
(a)That the Impugned order should be set aside on the ground that the District Forum has rightly held the Insurance Company deficient in providing services, however, has erred in awarding the claim to the extent of Rs. 1,50,000/- under the Super Top Up Policy/ Policy No. 2.
(b)The District Forum failed to consider the fact that since the case of the Insurance Company is not covered under the Exclusion clause of the Super Top Up Policy, he is entitled to a claim of Rs. 3,87,000/-.
10. We have perused the material available on record as well as the impugned judgment.
11. The undisputed facts are that the Insured availed two policies from the Insurance Company and thereafter was admitted to the Apollo hospital for treatment of AICD and borne expenses to the extent of Rs. 6,87,477/-. The Insurance Company allowed the claim under Insurance Policy No. 1 to the extent of Rs. 1,50,000/- and repudiated the claim under Insurance Policy No. 2 on the ground of pre-existing disease.
12. The repudiation of the claim was done by the Insurance Company relying on the Exclusionary Clause 4 which reads as under:-
“4. 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 respect of 4.1 Any Pre-existing condition(s) as defined in the policy until 48 months of continuous coverage of such insured person have elapsed since inception of his/her Super Top Up Medicare policy with the Company. Pre-existing condition/disease definition- any condition, ailment, or injury or related condition for which insured person had signs and symptoms and / or were received medical advice/treatment 48 months prior to his/her Super Top Up Medicare policy with the company”
13. Before commenting on the merits of the case, we deem it appropriate to refer to the law laid down by the Hon’ble Apex Court governing the interpretation and construction of the Insurance Policy. The Hon’ble Supreme Court has time and again held that the terms of the insurance policy are to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely. We tend to rely upon the dicta of recent Hon’ble Supreme Court decision in the case titled Sushilaben Indravadan Gandhi and Another V/s New India Assurance Company Limited and Others reported at 2020 SCC OnLine SC 367 wherein the Hon’ble Apex Court held that:-
“31. Likewise, in Export Credit Guarantee Corpn. of India Ltd. v. Garg Sons International, (2014) 1 SCC 686, this Court held:
“11. The insured cannot claim anything more than what is covered by the insurance policy. “The terms of the contract have to be construed strictly, without altering the nature of the contract as the same may affect the interests of the parties adversely.” The clauses of an insurance policy have to be read as they are. Consequently, the terms of the insurance policy, that fix the responsibility of the insurance company must also be read strictly. The contract must be read as a whole and every attempt should be made to harmonise the terms thereof, keeping in mind that the rule of contra proferentem does not apply in case of commercial contract, for the reason that a clause in a commercial contract is bilateral and has mutually been agreed upon. (Vide Oriental Insurance Co. Ltd. v. Sony Cheriyan [(1999) 6 SCC 451] , Polymat India (P) Ltd. v. National Insurance Co. Ltd. [(2005) 9 SCC 174 : AIR 2005 SC 286] , Sumitomo Heavy Industries Ltd. v. ONGC Ltd. [(2010) 11 SCC 296 : (2010) 4 SCC (Civ) 459 : AIR 2010 SC 3400] and Rashtriya Ispat Nigam Ltd. v. Dewan Chand Ram Saran [(2012) 5 SCC 306 : AIR 2012 SC 2829].)”
Likewise, in BHS Industries v. Export Credit Guarantee Corpn. Ltd., (2015) 9 SCC 414, this Court held:
“31. As has been held in Chandumull Jain [AIR 1966 SC 1644 : (1966) 3 SCR 500] by the Constitution Bench that in a contract of insurance, there is a requirement of good faith on the part of the insured and in case of ambiguity, it has to be construed against
the company. As per other authorities, the insurance policy has to be strictly construed and it has to be read as a whole and nothing should be added or subtracted. That apart, as has been held in Polymat India (P) Ltd. [(2005) 9 SCC 174] , it is the duty of the Court to interpret the document as is understood between the parties and regard being had to the reference to the stipulations contained in it. ”
14. Returning to the facts of the present case, the strict and actual interpretation of Clause 4 reflects that the Insurance Company is permitted to exclude the expenses borne in case the insured person is suffering from any kind of Pre-existing disease(s) until the insured person is continuously covered under the policy for a minimum period of 48 months. What constitutes Pre-existing disease has been provided in the Insurance Policy itself, which reads as follows:-
“Pre-existing condition/disease definition- any condition, ailment, or injury or related condition for which insured person had signs and symptoms and / or were received medical advice/treatment 48 months prior to his/her Super Top Up Medicare policy with the company”
15. The aforesaid definition clause makes it abundantly clear that in order for a disease to be categorized as pre-existing disease, the Insured must have received medical advice/treatment 48 months prior to purchasing the policy for that particular disease. Whereas, the facts are crystal clear that the prior disease on which the Insurance Company has relied to repudiate the claim of the Insured, was last treated in the year 2004 i.e. 5 years before the Policy No. 2 was purchased. Hence, it cannot be said that the case of the Insured fulfils the essentials of the Pre-Existing disease provided in the Insurance policy.
16. Since the moot argument of the Insurance Company vide which they have impugned the order of the District Forum has been answered in the negative, the appeal filed by the insurance company i.e. FA No. 161/2016 titled “United India Insurance Company Limited V. Manmohan Singh” is dismissed.
17. So far as the appeal filed by the Insured i.e. FA No. 127/2016 titled “Manmohan Singh V. United India Insurance Company Limited” is concerned, the same has been filed for enhancement of the compensation amount. The Insured in his prayer clause has sought for an amount of Rs.6,87,000/- as the mediclaim amount which includes Rs. 1,50,000/- from the Policy No. 1 and Rs. 3,87,000/- from Policy No.2.
18. The perusal of the District Forum record reflects that it has already allowed 1,50,000/- from Policy No. 2. So far as the remaining amount of Rs. 2,37,000/- from Policy No. 2 is concerned, the policy does not carry a upper limit/cap on the payment of the claim amount in any case and the District Forum erred in holding that there was a cap of Rs. 1,50,000/- on the claim amount under Policy no 2 i.e. Super Top Up Policy. Hence, the Insured is entitled to the amount of Rs. 3,87,000/- under the policy No. 2 .
19. However, the Policy no.1 is clear that for Mediclaim related to heart diseases, there is a capping where a maximum of Rs. 1,50,000/- can be paid. Since the said amount has already been disbursed by the Insurance Company even before the Litigation commenced, there remains no amount payable by the Insurance Company under Policy No. 1 to the Insured.
20. Consequently, the appeal filed by the insured i.e. FA. No. 127/2016 titled “Manmohan Singh V. United India Insurance Company Limited” is partly allowed. The Insurance Company is directed to pay an amount of Rs. 3,87,000/- instead of Rs. 1,50,000/- as awarded by the District Forum along with an interest @ 6% p.a. calculated from 06.09.2009 (the date on which the Insured was discharged from the Hospital) till 02.08.2021 (being the date of the present judgment), which is subject to the condition that the Insurance Company pays the entire amount on or before 31.10.2021 and in case the Insurance Company fails to refund the amount on or before 31.10.2021, the entire amount is to be refunded with an interest @ 9% p.a. calculated from 06.09.2009 (the date on which the Insured was discharged from the Hospital) till the actual realization of the amount.
21. Additionally, the Insurance Company shall also be liable to pay an amount of Rs. 50,000/- instead of Rs. 20,000/- as allowed by the District Forum as litigation cost, compensation for mental agony, etc.
22. Applications pending, if any, stands disposed of in terms of the aforesaid judgment.
23. 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.
24. File be consigned to record room along with a copy of this judgment.
(DR. JUSTICE SANGITA DHINGRA SEHGAL)
PRESIDENT
(ANIL SRIVASTAVA)
MEMBER
Pronounced On:
02.08.2021
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