DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-WEST

GOVT. OF NCT OF DELHI

CSC-BLOCK-C, POCKET-C, SHALIMAR BAGH, DELHI-110088.

Case No.CC.1148/2012                                                   Dated:

IN THE MATTER OF :

Master Mannan Gupta (Minor),

Through his father

Sh. Shailender Gupta,

R/o C-315, Vivek Vihar,

Delhi-110091.                                                           ….                               Complainant(s)

VERSUS

1. United India Insurance Co. Ltd.,

Through its Divisional Manager

Divisional Office-27,

Lusa Tower, A-2/3, Nani Wala Bagh,

Azadpur Ring Road,

Delhi-110033.

2. Medi Assist India Private Ltd.,

B-20, Sector-2, Near Sector-15,

Metro Station, Opposite HCL Com Net,

•                         ….                              Opp. Party(s)

ARUN KUMAR ARYA, PRESIDENT

ORDER

1. The complainant has filed the present complaint against the OPs u/sec. 12 of Consumer Protection Act, 1986 claiming the deficiency on the part of OPs.  The facts as alleged in the complaint are that the complainant got himself insured from the OP vide Policy No.222700/48/1197/00003758 being “Individual Health Insurance Policy-2010” for a period of one year commencing from 20.03.2012 to 19.03.2013.  The complainant was admitted in Max Super Specialty Hospital, New Delhi on 04.07.2012 with diagnosis of “Corrosive Poisoning (Indigestion of acid).  The complainant was discharged on 17.07.2012, Rs.1,86,754/- was spent on the treatment of the complainant. On 20.07.2012 complainant filled the claim form and submitted the same to OP-2 who is the TPA of OP-1, alongwith necessary documents. The complainant was once again admitted on 27.07.2012 at Max Super Specialty Hospital. The complainant further incurred expenses on the treatment to the tune of Rs.40,471/-
2. Vide letter dated 29.08.2012, OP-2 confirmed the receipt of the claim in question but the said claim was repudiated by OP on the ground that patient was admitted in Max Balaji Hospital on 04.07.2012 and diagnose as a case of corrosive  poisoning and that while going through the claim documents, it was revealed that the child was suffering from severe Psychosomatic disorder, stresser positive mentioned on the progress report. It is further stated that the claim of the complainant had been repudiated on absolutely baseless ground.  Hence, the complainant has filed the present complaint against the OPs.
3. The complaint has been contested by the OPs.  OPs filed their written statement wherein it has been stated that the repudiation is justified as the claim of the complainant is squarely covered under Exclusion Clause No.4.6 of the policy in question which reads as under:-

“The company shall not be liable to make any payment under this policy in respect of any expense whatsoever incurred by any insured person in connection with or in resect of the following diseases:-

“Convalescence, general debility run down condition or res cure, obesity treatment and its complications including obesity, Congenital external disease / defects or anomalies, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, veneral diseases, intentional self injury and use of intoxication drugs / alcohol.”

4. The OPs prayed for dismissal of complaint on the above ground.
5. Perusal of the record shows that notices were served to both the OPs for participating in proceedings the but they failed to appear before this Commission, hence vide order dated 21.11.2017 both the OPs were proceeded exparte by our Predecessor Bench.
6. Both the parties have filed their evidence by way of affidavit.  We have heard the arguments advance at the Bar on behalf of complainant despite repeated calls, OP failed to appear to address the arguments.
7. Perusal of the record shows that the complainant was admitted at Max Super Specialty Hospital on 04.07.2012 with diagnose of Corrosive Poisoning (Ingestion of acid).  The complainant incurred the bill to the tune of Rs.2,00,000/- (including prepaid and postpaid bills).  He lodged the claim with the OPs for reimbursement of the same. The OPs taking the shelter of Exclusion Clause No.4.6 of the policy terms and conditions repudiated his claim.  As per the pleadings the contention of the OPs is that as per the medical progress note dated 06.07.2012, it is revealed that insured was suffering from Psychosomatic disorder, stresser positive and hence it is covered under the exclusion clause. It is further contended by OPs that arrogant behavour of the child was derived through a TV serial -Crime Patrol due to which he intentionally ingested acid and tried to injured himself.
8. On the contrary, it is contended by the counsel for complainant that complainant is minor aged of 10 and half year and unknowingly he ingested the acid. It is further contended that there is no such medical record which proves that child was suffering from Psychosomatic disorder and prayed that repudiation is unjustified.
9. We have gone through the medical record attached by the complainant alongwith its complaint.  No such progress report is found to be attached. We have also gone through the written statement as well evidence filed by the OPs.  The OPs have failed to place on record any such progress report dated 06.07.2012 on the basis of which the OPs contended that child/insured was suffering from Psychosomatic disorder. On the contrary, the complainant has placed on record the certificate issued by Bal Bharti Public School dated 02.03.2016 which shows that the complainant was admitted in this school since 2006 and he had a good moral character and participated in various activities like Football and Yoga.  This clearly shows that the complainant is an active child and does not suffer from any Psychosomatic disorder as alleged by OPs.  Moreover, the OPs have failed to place on record any document which substantiate their contentions regarding suffering of the insured from Psychosomatic disorder. 
10. In view of the above, the repudiation of the claim by the OPs is unjustified arbitrary and baseless which amounts to deficiency in service. 
11. We therefore hold OPs guilty of deficiency in service and direct it to pay the complainant as under:-

1. A sum of Rs.2,00,000/- alongwith interest @6% per annum from the date of filing of complaint till date of payment. 
2. Pay to complainant a sum of Rs.15,000/- as compensation on account of mental agony suffered by him and Rs.10,000/-  as litigation cost.
3. OP is directed to comply the order within 30 days from the receipt of this order.
   3. www.confonet.nic.in. File be consigned to Record Room.

Announced in open Forum on   _____________.

                                                       (ARUN KUMAR ARYA)

                PRESIDENT

(NIPUR CHANDNA)                                            (R C MEENA)

                    MEMBER                                                       MEMBER