ORDER

08.11.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that complainant had purchased Health Guard-Individual Policy from the authorized agent of OP2 on 28.04.2014 bearing policy no.OG-15-1104-8401-00000171. It is stated that complainant had regularly renewed the policy for the subsequent year 2015-16 and 2016-17 and paid premium. It is further stated that on 14.11.2015 the complainant accidently consumed about two tea spoon of phenyl and was admitted in Bhagwan Mahavir Hospital near Madhuban Chowk, Rohini at around 3.30 am and discharged on 17.11.2015. It is stated that complainant paid a bill of Rs.5,05,000/- from her pocket.
2. It is stated that after discharge complainant applied for reimbursement of the bill and submitted all relevant documents in original with OP1. It is further stated that on 30.12.2015 complainant received the requirement letter regarding the deficiency in the claim document as medico legal certificate was not attached with the claim documents. It is stated that complainant had written a letter dated 15.02.2016 about the non receipt of MLC report as neither she was given the MLC report by the hospital nor by the police. It is stated that complainant was in regular contact with OP1 through mail regarding the MLC report and Dr. Pankaj Internal Investigator who had visited the home of complainant at or around last week of December 2015 or first week of January 2016 but nothing regarding the reimbursement of the claim was done by OP1 and 2.
3. It is stated that complainant received the copy of MLC around second week of March 2016 and same was submitted on 16.03.2016 with OP1. It is further stated that to the utter shock and surprise of the complainant, a repudiation letter dated 19.03.2016 received and a mail dated 17.04.2016 received by complainant. It is stated that as per terms and conditions mentioned in the policy/brochure under the heading of “What Are The Exclusions And Waiting Period Under The Policy”, the complainant is entitled for reimbursement of the bill for her treatment in the hospital. It is stated that complainant got issued legal notice dated 09.06.2016 to OP1 and 2 and received a reply dated 15.07.2016 from OP2.
4. It is stated that despite receiving all the documents OP1 and 2 deliberately and malafidely repudiated the claim of the complainant on 19.03.2016. It is stated that the conduct of OP1 and 2 clearly establish guilty of unfair practice and deficiency in providing services. It is stated that complainant had suffered mental agony, loss both in terms of time and money and also incurred legal expenses.
5. The complainant is seeking direction and order against OP1 and 2 to pay Rs.1,50,500/- (bill paid in hospital and compensation for mental agony) and Rs.22,000/- on account of legal expenses.
6. OP1 and 2 filed WS and taken preliminary  objections that the complainant is in breach of policy conditions which are conditions precedent to liability of the insurer. It is stated that the claim has rightly been repudiated and there is no deficiency in service on the part of OP1 and 2. It is stated that complaint is not admissible under CP Act, 1986. It is stated that by consuming lizol, chemical used for cleaning floor and is similar to phenyl in enough quantity, the complainant tried to cause intentional self injury may be with an intention to commit suicide, therefore, it comes within exclusion clause no.11 of the Health Guard Policy.
7. It is stated that the fact is very clear from the undated declaration given by the complainant to OP1 and 2 which is as, “on 13.11.2015 at about 11 in the night by mistake I consumed Lizol floor cleaner which my mother had put in the bottle of mouth wash Listrine but when I started having irritation in my throat and then I told my mother that I am having irritation in my throat because I have consumed Listerine than my mother said that she had put Lizol in the  bottle of Listrine”.
8. It is stated that the story is concocted by the complainant and an after though since lizol has such pungent smell that a person using it would immediately come to know about the nature of chemical and would be absolutely impossible to put it in ones mouth and the fact that the complainant consumed a few spoons equivalent of the chemical cannot be believed. It is further stated that even the liquid Listrine which is normally used as a mouth freshner and an anti infecting agent of the mouth before going to sleep at night is also quite pungent  when poured in the mouth for gargling a few time and then throw it out and is quite impossible to consume.
9. It is stated that moreover complainant alleged that she consumed the liquid presuming it to be listrine is also concocted and cannot be believed for even the liquid is meant for the purpose of gargling and throwing it out and absolutely not meant for drinking or consuming and it would take a great effort on the part of the person consuming it to take even one gulp down ones throat to the stomach unless one has an intention to cause self injury.
10. It is stated that the story related by the complainant is merely to take undue claim from the OP1 and 2 after having come to know that such  attempt to cause self injury or to attempt suicide is not covered by the policy and as such no claim would be payable. It is stated that claim has rightly been repudiated, therefore, complaint is liable to be dismissed. It is stated that complainant did not supply certain important documents necessary in the eyes of law for the purpose of settlement of claim such as MLC as per condition no.4 (c) of the policy. It is stated that the fact that certain documents were not given in time is evidence from the letter of the complainant dated 12.02.2016 where she mentioned that she was not able to obtain the MLC report either from the police or from the hospital. It is stated that the settlement of the complainant also appears to be concocted since the MLC no. 1454 was ready on 14.11.2015, therefore, the claim was rightly repudiated by OP1 and 2.
11. On merit all the allegations are denied and contents of preliminary objections reiterated. It is stated that complainant is not entitled to any relief.
12. Complainant filed rejoinder to the WS of OP and denied all the allegations made therein and reiterated contents of complaint. It is stated that the averments that complainant tried to cause intentional self injury/suicide is an after thought and well planned to maline the reputation of complainant in the eyes of hon’ble forum and get favorable orders. It is stated that complainant is entitled to all the reliefs claimed in the complaint.
13. Complainant filed evidence by way of her affidavit. In the affidavit contents of complaint are reiterated. Complainant relied  on copy of policies Ex.CW1/1 (colly), copy of follow up prescription Ex.CW1/2, copy of reimbursement claim Ex.CW1/3, copy of requirement letter Ex.CW1/4, copy of letter dated 15.02.2016 Ex.CW1/5, copy of emails Ex.CW1/6 (colly), copy of letter dated 19.03.2016 Ex.CW1/7, copy of mail dated 17.04.2016 Ex.CW1/8, copy of policy/brochure Ex.CW1/9, copy of legal notice dated 09.06.2016 Ex.CW1/10, postal and courier receipt Ex.CW1/11 (colly), copy of letter dated 28.07.2016 Ex.CW1/12 and copy of postal receipt alongwith PODs Ex.CW1/13 (colly).
14. OP filed evidence by way of affidavit of Dushyant Kumar Meena Senior Executive Legal. In the affidavit contents of WS reiterated.
15. Written arguments filed by complainant as well as OP1 and 2.
16. We have heard Dr. Seema Singhal counsel for complainant and Sh. Raghav Gupta proxy for Sh. R.K Gupta counsel for OP1 and 2.
17. It is admitted case of the parties that complainant had purchased a Health Guard-Individual Policy from OP Insurance Co. on 28.04.2014 and duly paid the premium upto 2016-2017. The complainant alleged that on 14.11.2015 she had accidently consumed two tea spoon of phenyl and admitted in Bhagwan Mahavir Hospital and discharged on 17.11.2015. The complainant alleged that after lodging the claim with the OP Insurance Co. Dr. Pankaj internal investigator visited the home in December 2015 or first week of January 2016 and she had also mailed MLC report to OP Insurance Co. The complainant alleged that the claim was repudiated on 19.03.2016 deliberately and malafidely.
18. The OP insurance co. alleged that complainant tried to cause intentional self injury may be with an intention to commit suicide, therefore, exclusion clause no. 11 of the Health Guard Policy comes into play. The OP insurance co. further alleged that as per complainant she consumed Lizol instead of Listerine by mistake. We have gone throught the photocopy of MLC of Bhagwan Mahavir Hospital. As per MLC the complainant was got admitted and local police was called but she was not fit to give statement at the time of admission. It is pertinent to mention here that the complainant did not submit the MLC alongwith the claim documents. As per record a photocopy of unsigned statement available. In this statement complainant alleged that on 13.11.2015 at about 11 PM in the night her mother by mistake put Lizol in the Listerine Mouthwash bottle and complainant had consumed mistakenly. This statement is not inspiring confidence as the colour of Listerine Mouthwash and Lizol are totally different and in the late hour of night there is very remote chance of taking Listerine. It is pertinent to mention here that Listerine is a mouthwash and a prudent person knows that it is for gargle and not for drinking or consuming. It seems that complainant had consumed the sufficient quantity of Lizol for inflicting self injury and the medical report also support this fact as she was not fit for statement at the timeof admission in the hospital. The facts and circumstances as explained by the complainant does not inspire confidence and it cannot be ruled out that complainant consumed the Lizol for inflicting self injury. In these peculiar circumstances of the case we are of considered opinion that repudiation of claim by the insurance company is just, fair and legal.
19. On the basis of above observation and discussion, present complaint is dismissed. No order as to cost. File be consigned to record room.
20. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  08.11.2024.

           SANJAY KUMAR                                                   RAJESH

                         PRESIDENT                                                           MEMBER