New Delhi:
Delhi based National Consumer Court has asked state owned New India Assurance(NIA) to pay a health claim of Rs 1 lakh to a policyholder which it had rejected earlier saying that treatment disease of the patient ( for which claimant has sought the claim) was due to the alcohol consumption that was not covered in the company's policy.
Prem Narain,presiding member of member the National Consumer court gave his verdict in case of “New India Assurance Co. Ltd. vs Surender Kumar Nanda'' on 17 November, 2017''.
Earlier, NIA had gone to the National Consumer Court against the the order the Delhi State Consumer Disputes Redressal Commission that had asked the NIA to settle the claim in favour of the insured..
A mediclaim policy was purchased by Nanda for himself and his family members. On Feb 28,.2004, Nanda's son was admitted in Pentamed Hospital with complaint of pain in Epigastric Region and was discharged within a month.
Nanda submitted the claim seeking reimbursement of the amount. The claim submitted by Nanda was examined and repudiated by NIA as it was covered under exclusion clause 4.8 of the policy. On March 28,2006, Nanda's complain against NIA was dismissed by the District Forum holding no deficiency of service on the part of NIA . On March 19,2009 Delhi , State Commission allowed the appeal of Nanda and directed NIA to pay Rs.1 lakh to the policy holder
The National Consumer Court explained that the claim submitted by Nanda was examined and repudiated as it was covered under exclusion clause of the policy.
A simple reading of condition of the policy issued by the NIA revealed that any expenditure in connection with or in respect of use of alcohol shall not be admissible under the policy. The terms of the policy are to be construed in the manner in which they are written, said the the National Consumer Court…
Common interpretation could only mean that any expenditure incurred in respect of or in connection with use of alcohol should not be admissible. The expenditure in respect of or in connection of use of alcohol in normal parlance would mean the expenses incurred on actual use of alcohol or in treatment on drug addiction in respect of alcohol. It is not possible to extend the meaning of this clause to cover all cases of diseases, which may have something to do with the use of alcohol, particularly if that disease can be caused due to many other reasons including use of alcohol, said the National Consumer Court..
it is settled law that the terms of the contract has to be strictly read and natural meaning be given to it. No outside aid should be sought unless the meaning is ambiguous.
Clearly, nothing is mentioned in the policy relating to exclusion that treatment expenditure of any disease caused by use of alcohol or arising out of the use of alcohol will not be admissible, said the National Consumer Court..
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 the 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 insurer, said the Court.
The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein, said the the National Consumer Court…
Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended.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 and not with reference to the definition given in other laws. 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 cannot rely on definition given in other enactment, said the Court.