Haryana

StateCommission

A/395/2016

NATIONAL INSURANCE CO.LTD. - Complainant(s)

Versus

ALKA NAGAR - Opp.Party(s)

J.P.NAHAR

28 Nov 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

 

First Appeal    No  :    395 of  2016

Date of Institution  :      06.05.2016  

Date of Decision    :      28.11.2016

 

  

1.      M/s National Insurance Company Limited, C-4, II Floor, C Block Market Paschim Marg, Vasant Vihar, New Delhi.

 

2.      M/s National Insurance Company Limited, having its Divisional Office at 5C ½, Neelam Chowk, Faridabad.

          Now both through its Authorized Signatory Puja Dhawan, Assistant Manager, Regional Office SCO No.332-334, Sector 34A, Chandigarh.

                                      Appellants-Opposite Parties No.1 & 2

 

Versus

 

1.      Smt. Alka Nagar wife of late Captain Bharat Bhushan Nagar, resident of House No.99, Sector 19, Faridabad (Haryana) 121002.

                                      Respondent-Complainant

2.      M/s Park Medi Claim TPA Private Limited, (Third Party Administrator-Health Services) 702, Vikram Tower, Rajendra Place, New Delhi -110008.

 

3.      Insurance Ombudsman Office, Universal Building, 2/2A, Asaf Ali Road, Delhi -110002.

Respondents-Opposite Parties No.3 and 4

 

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Mr. Diwan Singh Chauhan, Member.                        

 

 

 

Argued:                Shri J.P. Nahar, Advocate for appellants.

                             Ms. Ranjna Sharma, Advocate for the respondent No.1-complainant.

                             Service of respondents No.2 & 3 dispensed with vide order dated July 25^th, 2016.

 

 

                                                   O R D E R

 

NAWAB SINGH J.(ORAL)

 

National Insurance Company Limited-opposite parties No.1 and 2 (for short, ‘Insurance Company’) is in appeal against the order dated April 04^th, 2016 passed by District Consumer Disputes Redressal Forum, Faridabad (for short, ‘District Forum’) whereby complaint filed by Smt. Alka Nagar-complainant widow of Captain Bharat Bhushan Nagar was allowed directing the Insurance Company and Park Medi Claim TPA Private Limited-opposite party No.3 to pay Rs.5,00,000/- (Sum Insured) alongwith interest at the rate of 9% per annum from the date of filing of the complaint till realization; Rs.10,000/- as compensation and Rs.5500/- litigation expenses to the complainant on account of expenses incurred by her on the treatment of  her late husband. 

2.      Captain Bharat Bhushan Nagar, deceased alongwith wife Alka Nagar-complainant and son Jayant Nagar purchased Parivar Mediclaim for Family Policy from the Insurance Company for the period April 20^th, 2010 to April 19^th, 2011.  Captain Bharat Bhushan Nagar fell ill on November 07^th, 2010.  He was admitted in Sama Nursing Home, Moolchand Hospital and Apollo Hospital, New Delhi He died on November 18^th, 2010, that is, in all he remained hospitalized for eleven days. The complainant submitted claim with the Insurance Company but it was not settled.  Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed.  

3.      The Insurance Company, in its written version, pleaded that Bharat Bhushan Nagar (since deceased) was a case of Chronic Liver Disease (Ethanol Related) as per death summary (Annexure A-5)  drawn at Inderprastha Apollo Hospital.  As per Exclusion Clause 4.8 of the policy: the claim was not admissible as it did not cover expenses on treatment arising from the use of intoxicating drug/alcohol. 

4.      Bharat Bhushan Nagar (since deceased)-husband of complainant fell ill during the subsistence of the insurance policy.  He took treatment from Sama Nursing Home, Moolchand Hospital and Apollo Hospital, New Delhi. The claim of the complainant was repudiated on the ground that according to the death summary (Annexure A-5) of Captain Bharat Bhushan drawn at Indraprastha Apollo Hospital, New Delhi, the deceased was a case of Chronic Liver Disease (Ethanol related).   As per clause 4.8 of the policy (Annexure A-3), the claim was not admissible because it did not cover the expenses on treatment arising from the use of intoxicating drug/alcohol.  This Commission does not concur with the ground taken by the Insurance Company in repudiating the claim of complainant because there is nothing on record to show that prior to obtaining the policy (Annexure A-3), Captain Bharat Bhushan was suffering and taking treatment for Chronic Liver Disease.  As per the aforesaid clause 4.8 of the policy, the Insurance Company was not liable to make the payment of the expenses incurred on the treatment arising from the use of intoxicating drug/alcohol. The Insurance Company did not lead any evidence to prove that Captain Bharat Bhushan Nagar was drug addict or alcoholic.  There are many causes of liver failure, which reads as under:-

i)        Hepatitis B.

ii)       Hepatitis C.

iii)      Long-term alcohol consumption.

iv)      Cirrhosis.

v)      Hemochromatosis (an inherited disorder that causes the body to absorb and store too much iron)

          vi)      Malnutrition

 

The Insurance Company also did not examine any witness of the Inderprastha Hospital to prove that Bharat Bhushan was ever suffering from Chronic Liver Disease.  The concerned doctor of Inderprastha Hospital has not indicated the period and nature of illness.  Moreover, before obtaining the insurance policy, Captain Bharat Bhushan Nagar, his wife Alka Nagar complainant and son Jayant Nagar were medically examined by the board of doctors constituted by the Insurance Company.  The Insurance Company failed to prove that Captain Bharat Bhushan Nagar had any pre-existing disease. Thus, the impugned order passed by the District Forum is perfectly right and requires no interference.  Accordingly, the appeal is dismissed. 

5.      The statutory amount of Rs.25,000/- deposited by the Insurance Company be refunded to the complainant against proper receipt and identification in accordance with rules.

 

 

Announced 28.11.2016

(Diwan Singh Chauhan) Member

(Nawab Singh) President

UK