BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 507 of 2019
Date of Institution : 30.08.2019
Date of Decision : 27.02.2024.
Smt. Preeti Rani wife of Late Shri Vinod Kumar, aged about 25 years, resident of Quarter No.02, Janta Bhawan Road, Sirsa, District Sirsa now resident of Gali No.7, Preet Nagar, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Apollo Munich Health Insurance Company Ltd., Near Axis Bank Ltd. Sangwan Chowk, Sirsa.
2. Apollo Munich Health Insurance Company Ltd. Mumbai Branch Office, Inzio, 1st Floor, Office 101 Cardinal Gracious Road, Opposite P & G Plaza Chakala Andheri East, Maharashtra- 400099.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR ……………PRESIDENT.
SMT. SUKHDEEP KAUR…………….…….MEMBER
SH. OM PARKASH TUTEJA ……………..MEMBER
Present: Ms. Neeraj, Advocate for the complainant.
Opposite party no.1 already exparte.
Sh. R.K. Mehta, Advocate for opposite party no.2.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 ( now after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred to OPs).
2. In brief, the case of complainant is that husband of complainant Shri Vinod Kumar had purchased a health insurance policy from ops and paid the amount of Rs.5886.85 towards the premium. The ops issued optima restore individual policy No. 160100/11119/AX00019327 valid w.e.f. 06.10.2016 to 05.10.2017 and the policy covered treatment arising from accident or illness and the sum insured amount was Rs. three lacs. That on 07.05.2017 around 10.00 P.M., Vinod Kumar was going towards his house from Grain Market, Sirsa on his motor cycle and in the way a male cow all of a sudden came on the road in front of the motor cycle and Vinod Kumar lost his control over the motor cycle in order to save the male cow and motor cycle struck with the footpath and he sustained multiple injuries on his person in the accident. The complainant received information through the mobile of Vinod Kumar from a passerby and she reached at the spot alongwith her nephew Neeraj Kumar and got admitted Vinod Kumar in General Hospital, Sirsa. That doctor of Civil Hospital, Sirsa asked them to take him to another hospital due to serious injuries and as such they got admitted him in Bombay Hospital, Sirsa where he was treated. It is further averred that however on account of serious condition, Vinod Kumar was discharged on 15.05.2017 and thereafter he was admitted in Jindal Hospital, Hisar and remained admitted there up to 20.07.2017 and more than Rs. seven lacs was spent on his treatment in Jindal Hospital, Hisar and Bombay Hospital, Sirsa also charged a sum of Rs.88,000/- from them. It is further averred that condition of Vinod Kumar was very serious and it was very necessary to save his life, thus the family members could not lodge the report to the police on the day of accident and a rapat no.18 was registered in Police Post Kirti Nagar on 16.07.2017 on the statement of complainant. That Vinod Kumar remained in Coma and during the period of his admission in Lifeline Hospital, Sirsa on 03.08.2017 he succumbed to the injuries. The complainant was the nominee of Vinod Kumar in the said policy. It is further averred that Vinod Kumar remained admitted in Lifeline Hospital from 16.07.2017 till his death and said hospital also charged more than Rs.two lacs from complainant. That main cause behind the death of Vinod Kumar was non availability of money and his life could be saved if the ops’ company would have paid the assured sum amount within time but ops refused to make the payment of the sum assured and issued baseless repudiation letter and committed gross negligence and deficiency in service towards the complainant. It is further averred that vide letter dated 02.06.2017 ops have repudiated the claim of Vinod Kumar on the ground that required information/ documents have not been provided by the insured and they have also mentioned that alcoholic smell was present in the breath and as such they are not able to decide on the admissibility of the case and hence cashless approval would not be possible whereas the doctor mentioned in the MLR that alcoholic smell was present in the breath but he no where mentioned that patient was under the influence of alcohol or the smell of alcohol is real cause of accident. As such the repudiation letter dated 02.06.2017 is wrong, against law and facts and is arbitrary in nature and claim of Vinod Kumar decided by ops in a flimsy and biased manner without taking into consideration the evidence produced by the complainant. It is further averred that complainant also approached the ops number of times and requested to indemnify her claim under the aforesaid policy as well as the expenses incurred on the treatment but the ops did not pay any heed to the genuine requests of complainant. The ops even after passing of the order dated 16.05.2019 in the earlier complaint whereby a direction was issued to the ops to settle and pay the claim, the ops have failed to settle and pay the claim to the complainant despite lodging the claim and submitting the requisite documents and have caused unnecessary harassment and deficiency in service towards the complainant. Hence, this complaint seeking direction to the ops to pay a sum of Rs.three lacs being the sum insured amount alongwith interest, further Rs. three lacs as compensation for harassment, to pay amount of Rs.9,88,000/- spent in above said hospitals and also to pay litigation expenses.
3. On notice, ops appeared. Op no.1 filed written statement through Ramesh Kumar in which it is submitted that a policy valid w.e.f. 06.10.2016 to 05.10.2017 was issued by Ramesh Kumar in favour of the complainant on the instructions and directions of the ops and the complainant is legally entitled to get indemnify her claim under the policy in question.
4. Op no.2 also filed written statement taking certain preliminary objections. While admitting the contents about issuing of the policy in question to the insured for the period 06.10.2016 to 05.10.2017 for sum assured opted as per PF, it is submitted that on 06th June, 2019 reimbursement claim was received from the complainant for his husband who got admitted at Bombay Hospital, Sirsa with diagnosis of RTA head got injured due to accident with date of admission 08.05.2017 and date of discharge 15.05.2017 with claim amount of Rs.6,91,673/-. That post reviewing the documents, it was noted in Bed Head Ticket which was confirming about alcohol intake at the time of incidence which is excluded under policy terms and conditions. Accordingly, the claim of the complainant was rejected vide rejection letter dated 17.06.2019 stating therein that “The submitted claim is for treatment of road traffic accident which is a consequence/ complication of Alcohol/ drug intake. Treatment related to Alcohol abuse/ substance abuse is excluded in the policy. Hence we regret to inform you that your claim has been repudiated under section V, C, iv of the policy terms and condition”. On merits also, it is submitted that documents were not complete to process the cashless request so queries were raised to hospital. That upon receipt of replies from the hospital, it was noted in “Bed Head Ticket” that “Alcohol smell present in Breath” and also observed that provided documents are not sufficient to process the Cashless request so cashless request was rejected stating “Cashless facility cannot be granted as the required information/ documents has not been provided by the provider/ insured to decide admissibility. However, insured can be file the claim for reimbursement post completion of the treatment with all medical and financial records. The admissibility of the claim would be decided post review of the documents and policy conditions- 1. MLC copy and certificate from treating Doctor who has first attended to the patient soon after the history of accident confirming if member under influence of alcohol at the time of accident from Sirsa, Bombay Hospital, 2. We have observed gross discrepancy/ies in the documents provided (as per bed head ticket dated 8/5/2017 at 10.03 a.m., alcoholic smell was present in breath and the same was denied in query reply) because of which we are not able to decide on the admissibility of the case and hence cashless approval would not be possible at this juncture.” It is further submitted that when the answering op has already rejected the claim of complainant then the question of requesting the op does not arise. The answering op is not bound to pay any amount to the complainant due to non fulfillment of terms and conditions of the policy cover. It is further submitted that complainant had submitted claim with op’s company on 06.06.2019 and same was already rejected by the op’s company vide letter dated 17.06.2019 as per policy terms and conditions as per direction given by the Hon’ble Commission. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered her affidavit Ex. CW1/A and documents Ex.C1 to Ex.C121.
6. Since none appeared on behalf of op no.1, therefore, op no.1 was proceeded against exparte vide order dated 26.05.2022.
7. Op no.2 has tendered affidavit of Sh. Vivek Yadav, Senior Manager as Ex. RW2/A and documents Ex.R1 to Ex.R5.
8. We have heard learned counsel for the parties and have gone through the case file carefully.
9. Admittedly the husband of complainant namely Vinod Kumar purchased Optima insurance policy from the ops for the period 06.10.2016 to 05.10.2017 for the basic sum insured amount of Rs.3,00,000/- which fact is also evident from policy schedule (Ex.C1 filed in earlier complaint). It is also proved on record that during the period of policy on 07.05.2017 insured Vinod Kumar met with an road side accident and suffered serious injuries on his person including head injury and firstly he was taken to Civil Hospital, Sirsa where from he was taken to Bombay Hospital, Sirsa where he remained admitted up to 15.05.2017. Thereafter, he was admitted to Jindal hospital, Hisar where he remained admitted up to 20.07.2017 and ultimately he succumbed to the injuries on 03.08.2017 in Lifeline Hospital, Hisar. The cashless request for treatment of insured and claim of complainant after death of insured has been rejected by the ops vide letters dated 02.06.2017 and 17.06.2019 on the ground that alcoholic smell was present in breath of the insured and road traffic accident is a consequence/ complication of Alcohol/ drug intake and treatment related to alcohol abuse/ substance abuse is excluded in the policy. The op no.2 in this regard has relied upon bed head ticket dated 08.05.2017 of Civil Hospital, Sirsa as Ex.R4 in which it is mentioned that alcoholic smell present in breath. However, mere smell of alcohol cannot be construed to mean that person was intoxicated or was under influence of any liquor. The blood test or urine test of the insured was not conducted to actually ascertain that he was under the influence of liquor. It is also a commonly known fact that certain cough syrups also contain some amount of alcohol and therefore, without any tests of blood and urine, it cannot be said that insured was under the influence of liquor. In this regard, the Hon’ble Karnataka State Consumer Disputes Redressal Commission in case titled as Mohan Singh Versus Citybank N.A. & anr. 2009 (1) CPJ 112 relied upon by learned counsel for complainant has held that “Mere smelling of alcohol in food not mean that person who died was under influence of liquor. No evidence has been produced to the effect that he was under the influence of intoxicating liquor. Insurance company held liable under policy.” Reliance in this regard can also be placed on the observations of the Hon’ble National Commission in case titled as M/s New India Assurance Co. Ltd. Vs. Ashonder Pal Singh II (2015) CPJ 758 (NC) decided on 25.03.2015. So as mentioned above, in this case also the ops have wrongly repudiated the genuine claim of the complainant. Though, the complainant has claimed insured amount as well as reimbursement of expenses incurred on the treatment of insured Vinod Kumar her husband to the tune of Rupees nine lacs eighty eight thousand and has placed on file various bills and receipts on file, but however, from the policy documents i.e. policy schedule, it is evident that basic sum insured amount under the policy was Rs. three lacs and as such claim amount cannot exceed the amount of Rs. three lacs. However, by not paying the said insured amount the ops have also caused unnecessary harassment and mental agony to the complainant who has lost his husband at such a young age of about 35 years. The complainant has to file second complaint as earlier also vide order dated 16.05.2019 on the statements of the parties a direction was issued to the ops to consider, settle and pay the claim of complainant within 60 days from the receipt of claim and required documents from the complainant and as such there is grave deficiency in service on the part of ops.
10. In view of our above discussion, we allow the present complaint and direct the opposite parties ( specially op no.2) to pay the insured amount of Rs. three lacs to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 30.08.2019 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.25,000/- as compensation for harassment and Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President,
Dated: 27.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
