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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
Mr. Justice Ajit Bharihoke, Presiding Member and Mrs. Rekha Gupta, Member
BHUPESH GUPTA - Appellant
Versus
ORIENTAL INSURANCE CO. LTD. - Respondent
Revision Petition No. 263 of 2016 (Against The Order Dated 08.06.2015. In Appeal No. 215 of 2012 of The State Commission Punjab). With IA No. 853 of 2016, IA No. 4139 of 2016
Decided on : 13-05-2016
Ms. Samridhi Kapoor, Advocate, for the Petitioner; None, for the Respondent
The central legal point established in the judgment is the interpretation and application of exclusion clauses in insurance policies, specifically Clause 4.8 excluding coverage for congenital diseases.
Headnote:
Insurance Policy - Claim Rejection - Exclusion Clause 4.8 - Summary of Acts and Sections: The court discussed the exclusion clause 4.8 of the insurance policy, which excluded coverage for congenital external and internal diseases. The court also referred to the definition of congenital anomaly under Clause 3.22 of the policy. The judgment highlighted the interpretation and application of these clauses in rejecting the insurance claim.
Fact of the Case:
The petitioner filed a consumer complaint seeking payment for medical expenses under an insurance policy. The claim was rejected by the respondent based on the exclusion clause 4.8, which excluded coverage for congenital diseases. The court analyzed medical records and upheld the rejection of the claim based on the policy's terms and conditions.
Finding of the Court:
The court found that the insurance claim was rightly rejected by the respondent based on the exclusion clause 4.8 of the insurance policy. The court emphasized the evidence of the petitioner's son being diagnosed with congenital heart disease and undergoing surgery, which aligned with the policy's exclusion of congenital diseases.
Issues: The main issue was whether the insurance claim for medical expenses related to congenital heart disease was valid under the insurance policy. The court also considered the petitioner's argument regarding the continuity of the insurance policy and the absence of exclusion clauses in the subsequent policy.
Ratio Decidendi: The court's decision was based on the interpretation and application of the exclusion clause 4.8 of the insurance policy, which excluded coverage for congenital diseases. The court relied on medical evidence and upheld the rejection of the claim by the respondent.
Final Decision: The court dismissed the revision petition and upheld the rejection of the consumer complaint, finding no jurisdictional or legal error in the impugned order.
ORDER
Rekha Gupta—Present revision petition has been filed by the Petitioner/Complainant against the impugned order dated 08.06.2015 passed by State Consumer Disputes Redressal Commission, Punjab, Chandigarh (for short, 'State Commission') in Appeal No.215 of 2012.
2. Facts of the case as per the Petitioner/Complainant are, that the he had availed the services of the Respondent/Opposite Party by getting 'Happy Family Floater Policy' valid w.e.f. 28.2.2010 to 26.02.2011 after paying a premium of Rs. 5,502/- covering himself, his wife, minor son and minor daughter. Accordingly, the Cover Note No.CHD-C53708 dated 26.02.2010 and thereafter, Policy No. 234001/48/2010/2675 was issued. During the policy tenure, his minor son Shubham Gupta was treated for "Dacron Patch Closure of Ventricular Septal defect + infundibular resection" on 15.4.2010 and remained admitted in Escorts Heart Institute and Research Centre Ltd. New Delhi for the period 12.4.2010 to 22.4.2010 and he spent a sum of Rs. 1,65,000/- on his treatment. Claim was lodged with respondent. However, vide letter dated 6.8.2010, the respondent rejected the claim stating that his son Shubham Gupta was diagnosed with congenital heart disease, which was excluded under the terms and conditions of the policy. The petitioner alleged that the claim was wrongly rejected by the respondent in fact no terms and conditions of the policy were supplied to him. Only a policy consisting of two pages was given to the petitioner. The insurance cover for the period 26.2.2010 to 25.2.2011 was in the 3rd year period in continuity and no claim for the same treatment was lodged earlier and the respondent even issued the policy for the 4th year i.e. 26.2.2011 to 25.2.2011. It is further alleged that the respondent was deficient in its services. Hence, a consumer complaint was filed before the District Forum seeking the directions to the respondent to pay a claim of Rs. 1,65,000/- along with interest @ 12% p.a. together with litigation expenses of Rs. 5,500/-.
3. The complaint was contested by the respondent, who filed its written statement raising therein some preliminary objections that the complaint was barred under Section 26 of the Act; there was no deficiency in services on the part of the respondent, therefore, the complaint was not maintainable; after the receipt of report of Dr. Tarsem Lal Gupta and after scrutinising the documents placed on the claim file, the claim of the petitioner was repudiated on the ground that the patient was diagnosed with congenital heart disease in neonatal period, which was excluded under the policy terms and conditions the petitioner was estopped by his own act and conduct to file the complaint and that the complaint was not maintainable as complicated questions of law and facts were involved, which required elaborate evidence which cannot be decided in summary procedure under the Act and the matter was required to be referred to the Civil Court. On merits, it was submitted that the claim of the petitioner was not maintainable, falling under the exclusion clauses of the terms and conditions. Accordingly, it was repudiated on the basis of advice of the Doctor and the documents submitted by the petitioner himself. It was denied that terms and conditions of the policy were not supplied to the petitioner and he was getting a policy for the last 3 years. Further, at no point of time, the petitioner had submitted that the policy's terms and conditions were not supplied to him.
4. District Consumer Disputes Redressal Forum, Ludhiana (for short, 'District Forum') vide its order dated 04.11.2011 while dismissing the complaint observed as under;
"7. Perusing the discharge summary Ex.C6 dated 22.4.2010 Ex.R4, we come across the. "Resume of history" describing that "Shubham Gupta son of the complainant was diagnosed to have congenital heart disease in neonatal period during routine evaluation. He was asymptomatic and was on regular follow-up, who subsequently was brought to EHIRC
