BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
VAZHUTHACAUD, THIRUVANANTHAPURAM.
PRESENT
SRI. P. SUDHIR : PRESIDENT
SMT. R. SATHI : MEMBER
SMT. LIJU B. NAIR : MEMBER
C.C. No. 212/2010 Filed on 13.07.2010
ORDER DATED: 12.06.2018
Complainant:
Shajad, Akba Furniture, T.C. No. 66/2894, Pachaloor, Thiruvananthapuram.
(By Adv. Arshad Khan. A.R)
Opposite party:
Bajaj Allianz Life Insurance Company Ltd., 1st Floor, Arun Krishna Building, Near Krishnan Kovil, Neyyattinkara, Thiruvananthapuram.
(By Adv. Dhanya. R)
This case having been heard on 15.03.2018, the Forum on 12.06.2018 delivered the following:
ORDER
SRI. P. SUDHIR: PRESIDENT
Gist of the complainant’s case is that complainant had availed insurance from the opposite party insurance company on 10.01.2009 by paying an amount of Rs. 3,287/-. The membership number of the complainant is BAFCF057569A. The complainant was admitted to the Ananthapuri Hospitals and Research Institute, Chackai, Thiruvananthapuram on 20.12.2009. He had fallen from the terrace of a single storey house. He had fracture of lumbar vertebra and fracture of lumbar spine. He underwent surgery and had to remain hospitalized till 08.01.2010. On 06.01.2010 the opposite party approved Rs. 40,000/- as admissible part towards hospital expenses. On 08.01.2010 i.e; the date of discharge, the opposite party issued a letter to the hospital stating that the initially approved Rs. 40,000/- has been withdrawn and no subsequent claims were being denied as well on the ground that “it is evident that the member is suffering from seizure disorder and has history of chronic alcoholism. It cannot be out ruled that the fall was under the influence of alcohol or from an episode of seizure disorder. Hence the claim is rejected”. The complainant was denied the claim on baseless grounds. There is no evidence to support the erroneous presumption of the opposite party insurance company that the fall from the terrace was due to seizure or because of being under the influence of alcohol. In fact the medical records show otherwise. The records clearly indicate that the complainant was conscious and oriented at the time of admission. So also because of the denial of the claim the complainant had to unnecessarily stay hospitalized for three days more. That caused mental agony to the complainant and his family. The complainant had to run from pillar to post to arrange the money to settle his hospital bills since his legitimate claim was denied by the opposite party. In fact he had to borrow from his near and dear and friends to settle the hospital bills. Hence complainant approached this Forum for full settlement of the discharge bill of Rs. 1,17,339/- and for damages.
Notice sent to opposite party. Opposite party filed version stating that the complainant had availed insurance policy from this opposite party in the name and style ‘Bajaj Allianz Family Care First’. As per the request of the complainant, opposite party has approved Rs. 40,000/- towards hospital expenses on 06.01.2010. But from the medical records forwarded by Ananthapuri Hospital it is clearly evident that the complainant was admitted to the hospital after falling from the terrace of a single storey house under the influence of alcoholism. The records clearly indicate that the complainant was suffering from seizure disorder and has history of chronic alcoholism. Hence the claim for insurance was rejected by the opposite party. There is no deficiency of service on the part of the opposite party as alleged. As per the rules of the company treatment directly or indirectly arising from alcoholism or drug abuse and any illness or physical injury which may be suffered after consumption of intoxication liquors or drugs is excluded from the above said policy.
Issues:
- Whether there is deficiency of service on the part of opposite party?
- Whether the complainant is entitled for the reliefs sought for?
Issues (i) & (ii):- Complainant filed chief examination affidavit and Exts. P1 to P5 marked and examined as PW1. PW1 cross examined by opposite party. Opposite party filed chief examination affidavit and Exts. D1 & D2 marked and examined as DW1. DW1 cross examined by complainant. The case is based upon an insurance contract and both parties are bound by the terms and conditions of the policy. As per the company policy terms and conditions stated in clause 6, the company shall not be liable to make any payment if hospitalization or medical expenses or claims are attributable to or based on, or arise out of, or are directly and indirectly connected to any of the following: Clause 6(r) treatment directly or indirectly arising from alcoholism or drug abuse and any illness or physical injury which may be suffered after consumption of intoxication liquors or drugs. The complainant had accepted every terms and conditions of the policy and he concealed the pre existing ailment suggested for surgery and previous history of chronic alcoholism and seizure disorder that are against the company policy terms and conditions for claiming the mediclaim. Here in this case there is history of past ailments for the complainant, but the treatment records are not supporting that the fall is due to past ailments. The rejection of the claim as per Ext. P4 is that “From the discharge summary it is evident that the member is suffering from seizure disorder and has history of chronic alcoholism. It cannot be out ruled that the fall was under the influence of alcohol or from an episode of seizure disorder. Hence this claim is rejected”. So the opposite party on assumption and presumption rejected the claim. No medical records show that the fall was due to seizure or alcoholism. Complainant has climbed the terrace for rectification of his dish antenna. So the complainant is an energetic man and working as cashier in Hotel Horizon. Since there is no nexus proved by the opposite party that the past ailments are the reason for fall, denial of the claim is deficiency of service on the part of opposite party and opposite party is liable for the same. Hence we are of the opinion that there is deficiency of service on the part of opposite party and opposite party is directed to pay the discharge bill amount of Rs. 1,17,339/- to the complainant and to pay Rs. 10,000/- as compensation for the mental agony suffered by the complainant and Rs. 5,000/- towards the cost of the proceedings.
In the result, complaint is allowed and opposite party is directed to pay the discharge bill amount of Rs. 1,17,339/- (Rupees One Lakh Seventeen Thousand Three Hundred and Thirty Nine only) to the complainant and to pay Rs. 10,000/- (Rupees Ten Thousand only) as compensation for the mental agony suffered by the complainant and Rs. 5,000/- (Rupees Five Thousand only) towards the cost of the proceedings within one month from the date of receipt of this order failing which Rs. 1,27,339/- (Rs. 1,17,339/- + Rs. 10,000/-) carries interest @ 6% per annum from the date of default.
A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.
Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the Open Forum, this the 12th day of June 2018.
Sd/-
P.SUDHIR : PRESIDENT
Sd/-
R. SATHI : MEMBER
Sd/-
LIJU B. NAIR : MEMBER
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C.C. No. 212/2010
APPENDIX
I COMPLAINANT’S WITNESS:
PW1 - Shajad
II COMPLAINANT’S DOCUMENTS:
P1 - Premium receipt
P2 - Copy of treatment certificate
P3 - Copy of approval letter dated 06.01.2010
P4 - Copy of letter of denial of claim
P5 - In-patient settlement receipt
III OPPOSITE PARTY’S WITNESS:
DW1 - Arun Menon
IV OPPOSITE PARTY’S DOCUMENTS:
D1 - Copy of Request Form for cashless payment to provider
D2 - Copy of treatment certificate
Sd/-
PRESIDENT
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