Order 19 dt. 27/12/2016
The case of the complainant in brief is that the complainant obtained a mediclaim policy with o.ps. and the sum assured was Rs.2 lakhs. On 23.5.13 the complainant felt physical problem and he was taken to local hospital. Since he was not given proper treatment at the hospital the relatives of the complainant released him from the hospital and took him to Apollo Gleneagles Hospital, Kolkata and he was treated for acute pancreatitis. After release from the Apollo Gleneagles Hospital the complainant claimed the amount incurred by him for his medical treatment which was repudiated by o.ps. resulting in claiming of the said amount as well as claimed Rs.2 lakhs for compensation.
The o.ps. contested this case by filing w/v and denied all the material allegations of the complaint. It was stated that the insurance policy is based upon contract whereby the proposal along with the first insurance premium is received from the proposer who intends to take the insurance policy. The policy holder and company are bound by the terms and conditions of the insurance policy. If the terms and conditions are not acceptable to the policy holder he can apply for cancellation of the policy within 15 days from getting the policy which is called free look period. The complainant never applied for disbursement of claim to o.ps. as per the official record. The policy conditions as stated by the complainant is admitted and according to the hospital records of Sanjivan Hospital the complainant’s case is caused by consumption of alcohol which contradict the terms and conditions of the policy. At the time of signing of the proposal form the complainant did not disclose the fact of alcoholism. In view of the facts and circumstances as stated above, o.ps. prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant had the policy at the point of relevant of time.
- Whether the complainant became ill.
- Whether the complainant claimed the amount incurred by him towards his treatment.
- Whether the complainant will be entitled to get the relief as prayed for.
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant suddenly became ill on 23.5.13. Initially he was taken to a hospital and since he was not getting proper treatment there he was released from the said hospital and was admitted to Apollo Gleneagles Hospital. The treatment rendered to the complainant was for acute pancreatitis. After recovery the complainant claimed the amount towards his medical expenses. The o.ps. on 26.5.13 communicated the complainant that the claim cannot be disbursed because according to them the complainant had acute alcoholic pancreatitis. The complainant being a hazi and never addicted to drinking and he is engaged in religious activities, the allegation of alcoholic was a wrong allegation and the complainant will be entitled to get the claim as made by him.
Ld. lawyer for the o.ps. argued that the complainant became legitimate policy holder vide policy no.0189310057 on 4.11.10. The policy was named as Bajaj Allianz Family Care First. The medical documents received from Sanjivan Hospital shows that the complainant was admitted with abdominal pain and the complainant was previously alcoholic. Page 3 of the progress report it was clearly stated that the complainant was suffering from pancreatitis (alcoholic) and as per the clause 6® of the policy contract it was mentioned that the consumption of alcohol which contradicts the terms and conditions of the policy i.e. exclusion clause. The reimbursement was denied because of exclusion clause 6 ® of the policy contract. In view of the facts and circumstances as stated above o.ps. prayed for dismissal of the case.
Considering the submissions of the respective parties it is admitted that the complainant had one policy at the relevant point of time and the said policy was valid while he was admitted to hospital and it is also found from the materials on record that the complainant became ill for which he had to take admission in a hospital and subsequently he was shifted to Apollo Gleneagles Hospital. After release from the hospital the complainant claimed the reimbursement of the medical expenses incurred by him. The o.ps. after considering the exclusion clause 6(R) of the policy denied the reimbursement of the medical expenses since the complainant suppressed the fact of his addiction to alcohol. On perusal of the materials on record it appears that in the policy the terms and conditions were provided to the complainant and as per exclusion clause 6® of the said terms and conditions of the policy the insured will not be entitled to get any medical expenses for suffering from any disease arising out of consumption of alcohol. The terms and conditions of the policy are determined as per approval of IRDA. Accordingly the o.ps. had to deny the claim of the complainant and as such, we hold that there was no deficiency in service on the part of o.ps. and the complainant will not be entitled to get any relief as prayed for. Thus all the points are disposed of accordingly.
Hence, ordered,
That the CC No..414/2013 is dismissed on contest without cost against the o.ps.
Supply certified copy of this order to the parties free of cost.
