CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)

ISBT KASHMERE GATE DELHI

CC/314/2014

No. DF/ Central/                                                                      Date

Sh. Rinku Taneja(since diseased)

S/o Sh. R.C. Taneja

R/o 1685, Gali No. 35, Naiwala,

Karol Bagh, New Delhi-110005.

Through his LRs

Smt. Savitri Taneja(Mother)

R/o 1685, Gali No. 35, Naiwala,

Karol Bagh, New Delhi-110005.

Smt. Anjali Taneja(Wife)

R/o 1685, Gali No. 35, Naiwala,

Karol Bagh, New Delhi-110005.

Ms. Nikita Taneja(Daughter-minor)

R/o 1685, Gali No. 35, Naiwala,

Karol Bagh, New Delhi-110005.                                              …..COMPLAINANT   

 VERSUS

Apollo Munich Health Insurance Co. Ltd.

Through its Manager

Office at: 1^st Floor, 6&7, B.K. Roy Court,

Asaf Ali Road, New Delhi-110002.

Also at:

Apollo Munich Health Insurance Co. Ltd.

10^th Floor, Building No. 10, DLF Cyber City,

DLF City Phase-II, Gurgaon, Haryana-122002.

The Manager

Apollo Munich Health Insurance Co. Ltd.

Regd. Office at: Apollo Hospital Complex,

Jubilee Hills, Hyderabad-500033.                                     …..OPPOSITE PARTIES

Quorum  : Ms. Rekha Rani, President

                 Mr. R.C. Meena, Member

ORDER

Ms. Rekha Rani, President

1. Instant complaint was filed under Section 12 of the Consumer Protection Act, 1986 as amended inter-alia pleading therein that complainant along with his family members took a Health Insurance Cover from Apollo Munich Health Insurance Co. Ltd. (in short OP) for an amount of Rs. 2,00,000/-.  OP issued a cover note with family Id No. 10000497731 in favour of the complainant and the said policy was renewed from time to time as per details given in Para 3 of the complaint.  Complainant fell ill in the month of May, 2013.  He was admitted in Sir Ganga Ram Hospital on 14.05.2013.  He was operated for liver transplant and was discharged on 24.05.2013.  He was again admitted on 12.07.2013, 29.08.2013 and 25.11.2013.  He spent an amount of Rs. 2,50,000/- approximately during the period of hospitalization and OP was intimated and claim for reimbursement of the expenses was filed.  OP repudiated the claim on the ground that ailment suffered by the complainant was due to alcohol consumption.  Repudiation is contrary to the certificate issued by Dr. Piyush Ranjan who had clearly stated that “patient has be obstruent from alcohol after transplant.  Bliary structure is a complication of lever transplant and is not related to alcohol.”  Hence the instant complaint was filed seeking direction to OP to pay to the complainant a sum of Rs. 3,00,000/- , Rs. 2,00,000/- as compensation for causing mental agony and Rs. 21,000/- as litigation expenses.
2. OP contested the claim vide its written statement.  It is stated that OP received 5 cashless claim of the complainant between 22.11.2011 to 12.07.2013.  All the claims were related to Alcoholic liver disease and its follow-up cases and as such all of them were rejected as complications arising out of abuse of alcohol as per standard exclusion under the policy.
3. Parties adduced evidence by way of affidavits.  We have perused the case file.
4. Complainant was suffering from chronic liver disease caused by consumption of alcohol which is established on discharge summary dated 23.04.2012. 
5. The facts of the instant complaint are similar to the facts of the case titled M/s Oriental Insurance Co. Ltd. vs. Sh. Aloke Goyal before State Commission, Delhi in First Appeal No. 618/2015.  The issue before State Commission was Whether Ld. District Forum was justified in allowing the complainant despite the condition of the policy that Individual Mediclaim Policy does not cover the expenses in respect of disease related to use/misuse and abuse of alcohol.

The District Forum relied on a certificate issued by Dr. A. S. Soin in which he stated that “the diseased was suffering from Hepatitis C Virus and his condition was not related to any abuse of alcohol.”

The insurer relied on the discharge summary according to which the diseased was diagnosed as ‘CLD-HCV/Ethanol (alcohol) related CLD with details recurrent upper GI bleed admitted for TIPS.State Commission vide its order dated 12.11.2018 accepted the contention of the insurer and held that:

1. 4.8 is applicable and accordingly we find no infirmity with the decision of the insurer relying on the said clause 4.8. The said clause is a part of the contract between the insurer and the insured with which both of them are bound. It is a trite law that insurance is also a contract like any other contract. The Hon’ble apex court in the matter of Industrial Promotion and Investment Corporation of Orissa Ltd. Versus New India Assurance Company as reported in AIR 2016 SC 3908 is pleased to hold as under:

“it is well-settled law that there is no difference between a contract of insurance and any other contract and that it should be construed strictly without adding or deleting anything  from the terms thereof”

12. Similar view has been taken by the Hon’ble Apex Court in the following matters, namely,

1. United India Insurance Co Ltd Versus Oriental Insurance Pvt Ltd as reportedin (2016) 3 SCC 49.
2. Sikka Papers Ltd Versus National Insurance Co. Ltd as reputed in (2009) 7 SCC 777.”

          In the instant case as per the discharge summary issued by Sir Ganga Ram Hospital dated 23.04.2012 the complainant was diagnosed as CLD (Ethanolic) decompensated with ascites, HE, SBP, GI Bleed.

Accordingly in view of the aforesaid judgment repudiation of claim by OP was justified being a case of alcoholic liver disease, its follow up under medical exclusion clause of the insurance policy.  Copy of this order be sent to the parties as statutorily required. File be consigned to record room.

Announced this            Day of                       2019.