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NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI
Sudip Ahluwalia, Presiding Member
Brij Mohan – Petitioner
versus
New India Assurance
Co. Ltd. and Anr. – Respondents
Revision Petition No.2213 of 2015
Decided on 8.11.2023
Counsel for the Parties:
For the Petitioner:Mr. Pawan Kumar Ray, Advocate
For the Respondent:Mr. Salil Paul, Advocate
IMPORTANT POINT
Contract of Insurance – It is well settled that a contract of Insurance is to be honoured strictly in terms of the conditions specified in the Policy without making any alteration in the words used therein.
Headnote:
Consumer Protection Act, 1986 – Section 21(b) [Consumer Protection Act, 2019 – Section 58(1)(b)] – Services – Mediclaim Policy – Interpretation of Contract – In the present case, however, the Petitioner/Complainant had claimed to have been admitted as an Indoor Patient in “Singla Nursing Home and Eye Hospital, Kotkapura” as mentioned in Para 2 of his original complaint. He was diagnosed to be suffering from “Vitreous Hemorrhage in the left eye”, was prescribed some medicines and discharged on the next day. It was nowhere his case that he had undergone any actual surgery or surgical procedure during such “Hospitalization” – Thus, it is well settled that a contract of Insurance is to be honoured strictly in terms of the conditions specified in the Policy without making any alteration in the words used therein. When written advise by a Medical Practitioner was necessary to constitute Hospitalisation in terms of the specific Clause 3.4 of the Policy, failure to secure such written advise prior to the admission would consequently have the effect of exempting the Insurance Company from any liability to satisfy the Insurance claim – Petition dismissed. [Paras 5 to 12].
Result: Petition dismissed.
ORDER
Sudip Ahluwalia, Member—The present Revision Petition under Section 21(b) of Consumer Protection Act, 1986 has been filed by Petitioner against the impugned Order dated 09.04.2015 passed by the State Consumer Disputes Redressal Commission, Punjab, in First Appeal No. 19 of 2013 vide which the Appeal filed by the Respondent No. 1/Insurance Company Appeal was allowed.
2. Brief facts of the case are that the Complainant purchased a Mediclaim Policy bearing No. 360701/34/10/11/00000314 from the Insurance Company for the period from 10.11.2010 to 09.11.2011 and Respondent No. 2/TPA was appointed as Third Party Administrator for verification of the treatments. On 02.02.2011, the Complainant suddenly lost vision in his left eye and he immediately rushed to Dr. Som Nath Singla at Singla Nursing and Eye Hospital, Kotkapura, where he was admitted as an indoor patient on the same day. He was examined by the said Doctor and was diagnosed as suffering from ‘vitreous haemorrhage’ in the left eye. He was further told that some blood clot had affected the vision of the left eye. He was prescribed some medicines and was discharged on 03.02.2011, having spent Rs. 3,880/- during the treatment at Hospital. Thereafter he went to Amritsar on 04.02.2011 for further treatment at Sri Guru Ram Dass Institute of Medical and Research, Amritsar. The Doctors there examined his eyes and informed that the blood clot had badly damaged his left eye, and prescribed certain medicines. He was referred to Dr. Khurana for further treatment; After seeing the Test Reports he was prescribed some more medicines and was advised to re-visit after 15/20 days. He spent Rs. 3,424/- on medicines. On 23.02.2011, when he revisited Amritsar, the Doctors added some more medicines and he had to spend another amount of Rs. 2,925/-. On 28.02.2011, he fell down unconscious and was taken to Dr. Pirthipal Memorial Hospital, Kotkapura, for treatment. He incurred additional expenses of Rs. 1,698/- for medicines. On 01.03.2011, he visited the CMC Hospital, Ludhiana where necessary tests were conducted and medicines were prescribed, and he spent Rs. 21,382/- during the treatment there. On 27.03.2011, he visited Singla Nursing and Eye Hospital for further consultations where he was informed that he needed laser treatment and he spent another amount of Rs. 2,000/-. On 29.03.2011, he visited Dr. Sohan Singh Eye Hospital, Amritsar for further consultation where he was informed that there was no need for laser treatment. However, he was prescribed some medicines which cost him Rs. 2,196/-. On 26.04.2011, he visited GGS Medical College and Hospital, Faridkot where he was advised Homocysteine Test and he spent Rs. 2,377/- on the Test and other medicines. Thus in total, he spent Rs. 40,000/- for the treatment of his left eye and thereafter submitted all the original bills along with necessary documents to the Insurance Company who sent the same for verification to the TPA. Thereafter, he received a letter dated 07.06.2011 from Respondent No. 2/TPA informing him that his claim has been refused. Aggrieved by the act of the Insurance Company and the TPA, he filed Complaint before District Forum, Faridkot.
3. The District Forum vide its Order dated 23.10.2012 allowed the Complaint. The relevant extracts of the Order of the District Forum are set out as below—
“10. ….So, the main objection of the OP-1 was that the complainant never remained indoor patient during his treatment is not correct and the same is rejected. On 28.02.2011, the complainant became unconscious and fell down and he was admitted at Dr Pirthi Pal Memorial Hospital, Kotkapura for one day. There Dr. Manvir Gupta referred the complainant for further treatment of CMC, Ludhiana. All necessary tests and investigations were done by the Doctor which they think is compulsory for the treatment. So, the complainant remained under the active management of the qualified doctors and eye surgeons.
11. The complainant has been regularly in
