DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi- 110016

Case No.111/2019

Ms. Renu Jain,

D 32 East of Kailash New Delhi-110065

….Complainant

Versus

Apollo Munich Health Insurance

3^rd Floor, Building No.18, Ramnath House,

Community Centre, Yusuf Sarai, Delhi-110049

        ….Opposite Party

 Date of Institution    :    22.04.2019    

 Date of Order            :   16.12.2022    

Coram:

Ms. Monika A Srivastava, President

Ms. Kiran Kaushal, Member

Sh. U.K. Tyagi, Member

ORDER

Member: Ms Kiran Kaushal

1.     Facts of the case as impleaded by the Complainant are that complainant got an insurance policy on March, 2016 from Apollo Munich Health Insurance, hereinafter referred to as OP and regularly paid premiums since then. All the necessary medical tests were done by the insurance company before issuing the policy.

2.      Complainant had Post Menopausal Bleeding in early 2017 and had severe pain in the abdomen in November, 2017. Complainant visited two doctors, who advised her to get the uterus removed for the fear of developing cancer. Accordingly, on the advice of the doctors the Complainant got her uterus removed at Sukhmani Hospital, New Delhi.

3.      After getting herself operated, Complainant filed a claim of Rs.1,16,700/- with insurance company with all the original bills and reports. However, insurance company rejected the claim of the complainant on the ground that the Complainant’s claim is covered under Section VI A(ii) of the policy wherein it is stated that –

‘the submitted claim is for the illness which has a specific two year(s) of waiting period as per the policy and the policy start date is 17.03.2016.’

4.      Aggrieved by the repudiation of her claim Complainant approached this Commission with prayer to direct OP to pay full amount of the claim i.e. Rs.1,16,700/- on just and equitable grounds.

5.      Per contra OP states that Complainant submitted the Proposal Form dated 11.03.2016 for issuance of an insurance policy namely Easy Health Individual Standard Policy so as to provide an insurance cover for herself. It  is submitted that policy kit containing all the  relevant documents were duly sent, thereby giving an opportunity to the Complainant to verify and examine the benefits, terms & conditions of the policy taken by the Complainant. For free look, period of 15 days from the receipt of policy was provided to review the terms & contract of the policy. As no objection was received from the complainant within the free look period, therefore the complainant is strictly bound by the terms & conditions of the policy.

6.      It is next stated that complainant submitted her claim on 14.12.2017 for reimbursement of Rs.1,16,650/- for the treatment of Post-Menopausal Bleeding and for the hospitalization period of 11.12.2017 to 12.12.2017. After verification of the claim, it was found that the claim was for illness which has a specific waiting period as per the policy, hence the claim was repudiated in accordance with Section VI A(ii) of the terms & conditions of the policy,   which states that no payment would be made if the disease comes under this specific two years of waiting period. The relevant clause is reproduced as under:-

ii) A waiting period of 24 months from policy Commencement Date shall apply to the treatment, whether medical or surgical, of the disease/ conditions mentioned below. Additionally the 24 months waiting period shall also be applicable to the surgical procedures mentioned under surgeries in the following table, irrespective of the disease/condition for which the surgery is done, except claims payable due to the occurrence of cancer.

7.      It is next submitted that OP Company has acted as per the terms of the policy for rejecting the claim. Therefore it is prayed that the complaint be dismissed being completely baseless, incorrect and unwarranted.

8.      Complainant filed rejoinder to the WS of OP wherein it is stated that the treatment of ‘hysterectomy’ is not mentioned in the original policy. Further it is stated that OP has rejected the claim on the medical diagnoses that it was Post Menopausal Bleeding coupled with acute pain and the treatment given to the insurer was hysterectomy plus BSO. Samples were sent to lab for biopsy test to detect cancer. The Complainant reiterates the fact that hysterectomy and BSO was done on the diagnoses of Post Menopausal Bleeding where the underline cause is cancer.

9.      Evidence and written submissions of the parties are on record. Material placed on record is perused and submissions made on behalf of parties are heard.

10.    Dispute between the parties arose when the claim of the complainant was rejected by OP. As per OP the claim was repudiated according to the terms & conditions of the said policy wherein Section VI A(ii) of the policy  states that no payment would be made if the disease comes under the specific two years of waiting period. Complainant’s claim is that her uterus was removed to rule out any growth of endometrial cancer, if any and the waiting period is not applicable where the underline cause is cancer as per Section VI A(ii),therefore complainant’s case is not covered by the said section.

11.    We are not in agreement with the plea taken by the Complainant as tests can be conducted to rule out certain disease/problems but it does not mean that Hysterectomy was performed on the complainant because of cancer. It is not the case of the complainant that she suffers from cancer. On the contrary complainant’s main problem was that of Fibroids which were removed by conducting Hysterectomy wherein the uterus is removed whereas in Myomectomy (referred as in the first policy provided) is also removal of Fibroids, preserving the uterus. However in complainant’s case the fibroids might have spread little too much, therefore doctors must have found it necessary to perform Hysterectomy. Therefore we are of the considered view that complainant’s case is squarely covered under Section VI A(ii) of the policy.

12.    Having signed the terms & conditions of the insurance policy complainant is bound by them as per judgment of the Hon’ble Apex Court in the case of Oriental Insurance Co. Ltd versus Sony Cheryan reported in (1999) 6 SCC  451 wherein it is held:

‘The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by  insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the  of the insurer.  The insured cannot claim anything more than what is covered by the insurance policy.’

13.    Similarly in the case of General Assurance Society Ltd. vs Chandumull Jain and Anr., reported in (1996) 3 SCR, 500, the Constitution Bench has observed that the policy documents being a contract and it has to be read strictly.

14.    The Hon’ble NCDRC in the matter of National Insurance Co. Ltd, versus Vinod Puri as reported in 1[2014] CPJ 341(National Commissioner) is pleased to hold as under:

‘Insurance contract has to be construed like any other contract on basis of its terms and conditions and outside aid for construction of insurance policy is impermissible.’

15.    In view of the discussion above and the law laid down the complaint is dismissed with no order as to costs.

         File be consigned to the record room. Order be provided to the parties as per rules and uploaded on the website.