Varinderpal Singh Saini, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35 and 36 against the opposite party on the allegations that the complainant alongwith his family members viz; Sandeep Kaur (wife), Sahibpal Singh (son) and Mankirat Kaur (daughter) has purchased one policy under the name of Family Health Optima Insurance Plan bearing Policy Number P/211226/01/2021/002189 from opposite party No. 1 on  24.11.2022 for the period of one year i.e. w.e.f. 24.11.2020 to 23.11.2021 and this policy was again renewed w.e.f. 24.11.2021 to 23.11.2022 under the same terms and conditions in the name of complainant and his family members. At the time of purchasing the above said policy from OP No. 1, the complainant along with his family members were having good health and does not suffer from any aliment. On 20.01.2022 the complainant suddenly received accidental injury on his body on account of electric shock thereby falling on the mirror lying nearby the complainant and immediately after receiving injury, he was rushed to Guru Nanak Dev Super Specialty Hospital, Goindwal Sahib Road, Tarn Taran by his family members, where he remained admitted for his treatment w.e.f. 20.01.2022 to 06.02.2022, and an amount of Rs. 4,95,938/- has been borne by the complainant for his medical treatment in the said hospital. The said accidental injury is covered under the name of Family Health Optima Insurance Plan i.e. the insurance policy so purchased by the complainant along with his family members. Later on, on 06.02.2022, the complainant was discharged from the said hospital and after the discharge from the said hospital, the concerned doctor, who medically examined/ treated the complainant asked him to visit at Swift Hospital, Amritsar, for check-up purpose. The complainant many times visited in Swift Hospital, Amritsar in order to his check up where the complainant too incurred so many expenses for his treatment e.g. doctor's treatment, travel expenses, transportation, food, etc. Since the date of incident i.e. on 20.01.2022 and uptill today, the complainant expended Rs.4,98,757/- approximately on his medical treatment. The complainant is entitled to recover a total amount of Rs.4,98,757/- from the opposite parties as reimbursement amount on his medical treatment. As per the policy purchased by the complainant along with his family members, the opposite parties are duty bound to pay all the claims as per the terms and conditions of the policy to the complainant along with interest thereon because the said policy are covered we.f. 24.11.2021 to 23.11.2022.   The complainant has paid a total amount of Rs. 4,98,757/- for his medical treatment, as such, he is very much entitled to receive the benefits and subsist as per the terms and conditions of the insurance policy being the consumer of the opposite parties. The complainant also sent a legal notice dated 11.03.2022 through his counsel for reimbursement of medical expenses but no response has been given by the opposite party, as such, my client is entitled to recover the bills amount as per the bills enclosed. The said Claim Form has been duly submitted by the complainant within time but till date the opposite parties have not released the insurance amount in favour of the complainants. The opposite parties were requested many a times to admit their claim of releasing the insurance amount regarding reimbursement of medical expenses and even a notice dated 11.03.2022 has also been served upon the opposite parties but the opposite parties have not replied to the said notice. And prayed that the opposite parties may kindly be directed to reimburse the whole claim amount to the tune of Rs. 4,98,757/- alongwith interest @ 18% P.A. as well as Rs. 50,000/- as compensation on account of mental and physical harassment caused to the complainant and litigation charges to the tune of Rs. 20,000/-. Alongwith the complaint, the complainants have placed on record self attested copy of legal notice dated 11.3.2022 for reimbursement of medical claim Ex. C-1,  Self attested original postal receipt dated 11.03.2022 Ex.C-2,  Self Attested Policy bearing No. P/211226/01/2021/002189 of Star Health and Allied Insurance Company Limited Ex.C-3, Self Attested Policy bearing No. P/211226/01/2022/002936 of Star Health and Allied Insurance Company Limited Ex.C-4, Self Attested Bill bearing no.F2122003617 dated 06.02.2022 of Guru Nanak Dev Super Specialty Hospital, Tarn Taran, amounting to Rs.4,95,938/- Ex.C-5, Self Attested Bill No.OP187994 dated 21.02.2022 of Guru Nanak Dev Super Specialty Hospital, Tarn Taran amounting to Rs.1319/- Ex.C-6, Self Attested Bill/Receipt no.9734 dated 11.02.2022 amounting to Rs.1200/- of Swift Hospital, Amritsar Ex.C-7, Self Attested Bill/Receipt no.9800 dated 22.02.2022 amounting to Rs.300/- of Swift Hospital, Amritsar Ex.C-8,  Self attested copy of Bill bearing receipt No. 2122118701 dated 6.2.2022 of Guru Nanak Dev Super Specialty Hospital Tarn Taran amounting to Rs.200/- Ex. C-9, Self attested copy of Adhar Card of the complainant Ex. C-10, Self attested copy of affidavit Ex. C1/A.

2        After formal admission of the complaint, notice was issued to Opposite Parties and opposite parties appeared through counsel and filed written version contesting the complaint by taking interalia pleadings. The insured availed Family Health Optima Insurance Plan vide policy No. P/211226/01/2022/002936 for the period of 24-11-2021 to 23- 11-2022 covering Mr. Amrinderpal Singh- self, Mrs. Sandeep Kaur  spouse and two dependent children Mr. Sahibpal Singh & Ms. Mankirat Kaur for the sum insured of Rs.5,00,000/-. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC.ATTACHED". The Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The Complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. As per settled principle of law of Apex court clearly proves beyond doubt that the Ignorance of terms and conditions of the policy is no excuse and provides no shelter to the complainant. As per settled principle of law of Apex court clearly held beyond doubt that the Rights and liabilities strictly governed by the policy of insurance - No exception or relaxation can be made on ground of equity. The complaint is vague, improper, and illegal and against the facts, hence the same is not maintainable in the eye of law and the same deserves to be dismissed. The complainant has moved the present complaint with malafide intention and ulterior motives to grab illegal amount from the opposite party, hence, the complaint is not maintainable in the eye of law and the same deserves to be dismissed. The opposite party had rendered all possible services to the complainant, and there was/is no deficiency in services on the party of the insurance company, as such the complaint deserves to be dismissed. The complainant has not come to the Commission with clean hands and has concealed material facts from this Hon'ble Commission, therefore, the complainant is not entitled for any relief as claimed. It is submitted here that insured patient Mr. Amrinderpal Singh was admitted at Guru Nanak Dev Super Specialty Hospital-Goindwal Sahib Road on 20-01-2022 for the treatment of Suicidal attempt laryngeo tracheal trauma B/L (both) wrist wound. As per documents submitted by the insured in support of his claim that is the Discharge summary from Guru Nanak Dev Super Specialty Hospital dated 06/02/2022 the insured patient was diagnosed for suicidal attempt laryngeo tracheal trauma B/L wrist wound. It is evident from the above findings that the insured treated for suicidal attempt laryngeo tracheal trauma, which is related to intentional self injury. Therefore, the claim of complainant was rejected and intimation to this affect was given to him vide letter dated 26.4.2022. That as per terms and conditions of the policy the complainant is entitled for any claim. The relevant clause is reproduced herein below: -

As per 3.exclusion, "The Company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of; Intentional self-injury - Code Excl 22".

It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy. It is a matter of contract and in terms of the contract, the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they have to rely on the terms of the Contract. The complainant is estopped by his own act and conduct from filing the present complaint, as the complaint has been filed without any cause of action. The complainant has got no locus standi to file the present complaint. The complaint has been filed without any cause of action against the opposite parties. The opposite parties have denied the other contents of the complaint  and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed ion record Self attested affidavit of Sumit Kumar Sharma, Senior Manager Ex.OP1,2/1, self attested copy of authority letter Ex.OP1,2/2, self attested copy of proposal form Ex.OP1,2/3, self attested copy of policy schedule Ex.OP1,2/4, self attested copy of terms and conditions Ex.OP1,2/5, self attested copy of claim form Ex.OP1,2/6, self attested copy of discharge summary dated 06.02.2022 Ex.OP1,2/7, self attested copy of final bill Ex.OP1,2/8, self attested copy of repudiation letter dated 26.04.2022 Ex.OP1,2/9, self attested copy of billing sheet is Ex.OP1,2/10,  Without prejudice to whatever has been stated earlier in this written statement, even assuming without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant-petitioner, it is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs.3,05,640/- (A detailed of billing sheet attached as Ex.OP1,2/10).

3        We have heard the Ld. counsel for the parties and have carefully gone through the record.

4        We have heard the Ld. Counsel for the complainants and opposite parties and have gone through the evidence and documents placed on the file by the parties.

5        In the present case insurance is not disputed. It is also not disputed that the complainant has obtained insurance policy from the opposite party. The opposite party has repudiated the claim of the complainant vide repudiation letter dated 26.4.2022 Ex. OP1,2/9 and operative Para is reproduced as follows:-

.….We have processed the claim record relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of LACERATED WOUND ON THE NECK. It is observed from the hospital records including  discharge summary that the insured patient is admitted for suicidal attempt laryngeo tracheal trauma, which is related to intentional self injury

As per Exclusion- Code Excl 22 of the above policy, the company is not liable to make any payment in respect of any expenses for treatment of a condition arising out of an act of intentional self injury

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim

The above said decision has been taken as per the terms and conditions of the policy and based on the claim details/ documents submitted…..”

The opposite parties have placed on record discharge summary of patient Ex. OP1, 2/7 which shows the reason for admission  “C/O LACERATED WOUND ON NECK B/L LACERATION ON WRIST FOR 1 HOUR DIAGNOSES:- SUICIDAL ATTEMPT LARYNGEO TRACHEAL TRAUMA// B/L WRIST WOULD” As such, the discharge summary shows that the complainant attempted suicide attempt, consequently, as per terms and conditions of the policy, medical reimbursement under suicidal attempt is not maintainable. Both the parties are bound by the terms and conditions of the policy. As such, the complainant is not entitled to reimbursement amount as prayed for in the present complaint. As regards conveyance of terms and conditions of the policy to the complainant, it has been held by the Hon'ble State Commission in case Tarun Bansal & Anr Vs. Reliance General Insurance Company Ltd. & Ors II(2007) CPJ 295 that the terms and conditions are part of the policy. The complainant cannot be allowed to blow hot and cold in the same breath by saying that he is lodging claim under the same policy and yet says that the exclusion clause i.e. terms and conditions of the same policy would not be applicable as having not been conveyed . The Hon'ble State Commission has relied upon the ruling of the five judge bench of the Apex Court in General Assurance Society Ltd. Vs. Chandmull Jain and Anr. AIR 1966 Supreme Court 1644. It has been further held by the Hon'ble Apex Court in case M/s Suraj Mal Ram Niwas Oil Mills (P) Ltd Vs. United India Insurance Co.Ltd & Anr that in a contract of insurance the rights and obligations are governed by the terms of the contract. Term of contract of insurance have to be strictly construed. No exception can be made on the ground of equity- in construing the terms of a contract of insurance, the words used therein must be given paramount importance and it is not open for the court to add, delete or substitute any word. In this case also contract of insurance between the parties is based on terms and conditions of the policy and must be followed in letter and spirit. Opposite party has rightly not given the claim in this case to the complainant as per terms and conditions of the policy which was the base of the contract of insurance between the parties.

6        In view of the above discussion, the complaint is without merit and the same is hereby dismissed with no order as to costs.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission.

26.06.2024