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2017 Supreme(P&H) 2540
IN THE HIGH COURT OF PUNJAB AND HARYANA
M.M.S. BEDI, J.
Apollo Munich Health Insurance Company Limited – Appellant
Versus
Permanent Lok Adalat – Respondent
CWP No. 9522 of 2014
Decided On : 24-05-2017
For the Appellant :Sandeep Suri, Advocate.
For the Respondents:Prateek Rathee, Advocate.
The central legal point established in the judgment is that a narrow interpretation of exclusion clauses in insurance policies, which would unreasonably disadvantage the insured, may render the contract unreasonable and unconscionable.
Headnote:
Insurance Policy - Medical Claim - 6 (e) (vi) of the terms and conditions of the Health Insurance Policy - [6 (e) (vi)] - The court discussed the exclusion clause in the insurance policy, which excluded coverage for congenital internal diseases, defects, or anomalies, and genetic disorders. The court interpreted the clause in the context of the specific medical condition of the insured and concluded that denying the medical claim based solely on the possibility of the disease being congenital was not acceptable. The court emphasized that a narrow interpretation of the exclusion clause would render the contract unreasonable and unconscionable, and held that the insured's claim was bona fide and rightly allowed by the Permanent Lok Adalat.
Fact of the Case:
The insured filed a claim against the insurance company for medical expenses incurred for treatment of a heart condition. The insurance company denied the claim based on an exclusion clause in the policy, citing the possibility of the disease being congenital.
Finding of the Court:
The court found that denying the medical claim solely on the ground that the disease could be congenital was not acceptable. The court held that the insured's claim was bona fide and rightly allowed by the Permanent Lok Adalat.
Issues: The issues involved the interpretation of the exclusion clause in the insurance policy and the jurisdiction of the Permanent Lok Adalat.
Ratio Decidendi: The court's decision was based on the interpretation of the exclusion clause, the reasonableness of the contract, and the bonafide nature of the insured's claim.
Final Decision: The court dismissed the petition and upheld the decision of the Permanent Lok Adalat, allowing the insured's claim for medical expenses.
M.M.S. BEDI, J.
1. The present writ petition has been preferred against the order dated February 12, 2014 passed by Permanent Lok Adalat (PUS), Gurgaon directing the petitioner to pay a sum of Rs. 3 lacs along with interest @ 9% per annum in case of failure to pay the amount within a period of 45 days from the date of the order i.e. February 12, 2014.
2. Briefly the facts of the case are that respondent No.2 had taken Easy Health Standard Two Years policy w.e.f. August 19, 2011 to August 18, 2013 from the petitioner Insurance Company. The Insurance policy included medical coverage of the hospitalization etc. to the extent of Rs. 3 lacs. Petitioner has charged Rs. 19068/- including service tax as yearly premium from respondent No.2 which had been duly paid. Respondent No.2 claimed in the petition that she suffered from shortness of breath or chest discomfort as such approached Medanta The Medicity, where respondent No.2 was advised some tests as such she was admitted on May 1, 2013 and discharged on May 13, 2013. At the time of admission, respondent No.2 had supplied all the relevant documents including the policy etc. for getting medical benefits from the petitioner Company to the hospital. The hospital had asked respondent No.2 to pay a sum of Rs. 6,06,135/- regarding the treatment and hospitalization expenses etc. Respondent No.2 paid the entire amount to the hospital on account of petitioner informing that respondent No.2 was not entitled to the said amount from her policy. Subsequently respondent No.2 applied to the petitioner Company for the entire expenditure incurred on treatment and hospitalization. On petitioner's failing to settle the claim, respondent No.2 filed an application before Permanent Lok Adalat (PUS) Gurgaon against the petitioner.
3. The petitioner contested the claim on the grounds of Permanent Lok Adalat having no jurisdiction involving disputed questions of law and facts; respondent No.2 having not come to the Adalat with clean hands; and application being an abuse of the process of the Court. The disease of respondent No.2 was alleged to be included in the exclusion clause being congenital internal disease, as per the policy. In the reply on merits, it was pleaded that in April 2013 request for cashless treatment was received for Cholecystitis, Cholelithiasis and it was approved as the treatment was admissible under the terms and conditions of the policy and was settled with the hospital for Rs. 13753/- but the cashless request made by respondent No.2 from Medanta the Medicity, Gurgaon for treatment of Severe Aortic Stenosis (which is heart disease) with complaint of Dysponea of Exertion (DEO) for one and half years, giddiness and gall bladder stones along with discharge summary of Columbia Asia Hospital were diagnosed to be the cause of acute Cholecystitis with Severe Aortic Stenosis. The proposed line of treatment was Coronary Angiography followed by Aortic Valve Replacement (AVR). The petitioner took up the plea that since in the preauthorization form as well as medical documents respondent No.2 was stated to be suffering from Hypertension and Diabetes and as such vide Additional Information Request Form dated May 2, 2013, the treating hospital was required to the following:-
(i) Treating doctor certificate for exact history and duration of present ailment (heart disease, HTN, DM) with first consultation note when the disease was first diagnosed.
(ii) All past treatment record;
(iii) All relevant investigation reports with detailed treatment and vital charts."
4. In response to the said query, the treating hospital sent a response by mentioning on the query letter that hypertension and Severe Aortic Stenosis were recently diagnosed but did not provide first consultation papers for hypertension and diabetes, therefore again a query vide letter dated May 2, 2013 was sent to the treating hospital to provide first consultation note when the disease was first diagnosed (HTN, DM). In response thereto,
