BEFORE THE ADDITIONAL BENCH DISTRICT CONSUMER DISPUTES REDRESSAL FORUM AT

MYSURU.

Consumer Complaint (C.C.)No. 1273/2016

Complaint filed on 07.06.2016

Date of Judgement.06.12.2017

PRESENT                      :         1. Shri Ramachandra  M.S.,  B.A., LL.B.,

                                                   PRESIDENT

2. Shri  Thammanna,Y.S., B.Sc., LL.B., 

                                       MEMBER

Complainant/s       :                Mr. Rajashekara Murthy,

                                                S/o S. Basvaiah

                                                Aged about 47 years,

                                                R/at No.31 , near Anthony

                                                Church , Gayathripuram,

                                                2^nd Stage, 2^nd Phase,

                                                Mysuru.

(Smt. Shivanna., Advocate)

V/s

Opponent        /s             :       1.The Branch Manager,

                                                Star Health And Allied-insurance

                                                Company Ltd.,

                                                Sri Lakshmi Arcade, 1^st Floor,

                                                # 14, 8^th Cross, 4^th main,

                                                Panamaniah Hospital road,

                                                Saraswathipuram, Mysuru.

                                                2. The Manager,

                                                Star Health and Allied-insurance

Company Ltd.,

# 1, New Tank Street,

Valluvar Kottam High Road,

Nungambakkam,

Chennai-600034.

(Sri. B.N.Shashidhara., Advocate)

           SHRI RAMACHANDRA . M.S.,

           PRESIDENT

                                                                           JUDGEMENT

The complainant filed the complaint Under Section 12 of Consumer Protection Act, 1986 against the opposite party seeking for relief of insurance claim amount   and other relief.

2. The brief facts of the complainant that the an intermediary named Mr. Arokyaraji the employee of the 1^st opposite party, approached the complainant, for the introduction of the Family health Optima insurance plan At the time of introduction of the policy the aforesaid intermediary never informed  the complainant that known alcoholic persons are not covered under the above policy on the aforesaid introduction, the complainant proposes to the policy no P/141116/01/2016/001607  on 10.07.2015 the period of above insurance is from 10.07.2015 to 09.07.2016.

3. On 01.12.2015 the complainant was  met with jaundice, therefore he was taken the medical consultation as inpatient at, chitra’s  Hospital, Mysuru, from 01.12.2015 to 04.12.2015 and thereafter at Srinivasa speciality consultation centre, Mysuru and thereafter inpatient at Vikram Hopital, Mysuru from 10.12.2015 to 12.12.2015 and thereafter also taken  further medical treatment. Therefore, the complainant claimed the medical charges under the policy.

4. But, on  12.12.2015 the opposite party no.2 has issued a letter to the Vikarm Hospital , Mysuru stating that, the claim of the insured-patient is not admissible under the above insurance policy for the reasons that “Viral Markers are Ngative and patient is a known alcoholic, as per out medical opinion , the present hospitalization is related to the management of an ailment which is as a result of alcoholic intake. This is not covered as per the policy’’.

5. The complainant has spent more than Rs. 70,000/- towards medical treatment and other charges against the aforesaid ailment, Neither at the time of introduction of the policy nor at the time of proposal of the policy the opposite party no.1 or party no.2 are not questioned the complainant about the alcohol. Neither have they intimated the complainant that the known alcoholic persons are not covered under the above policy, No Where in the medical records of the complainant, is it stated that the aforesaid ailment of jaundice is as a result of alcoholic intake. Intentionally with a mala fide intention he opposite parties have rejected the claim of the complainant. The aforesaid act of the opposite party no.1 and 2 are amounts to deficiency in service on their part. Hence this complaint.

6. Notice to the opposite party duly served represented by counsel filed version.

7. The complainant and opposite party filed chief examination affidavit and filed documents arguments heard,  reserved for orders.

8. Heard arguments.

9. The points that arise for our consideration are;

1. Whether the complainant proves that there is deficiency in service on the part of opposite party by not paying insurance claim amount  and thereby proves that he is entitle for the relief sought?
2. What order?

10. Our answer to the above points is as follows;

      Point No.1:   In the affirmative

Point No.2: As per final order for the following;

REASONS

11. Point no.1 :-  That the complaint obtained Family Health Optima Insurance plan policy on 10.07.2015 from opposite party company in policy no P/141116/01/001607. The paid of insurance is from 10.07.2015 to 09.07.2016 subsequently complainant suffered jaundice  for which he has taken treatment at charitra Hospital, Mysuru as in patient from 01.12.2015 to 04.12.2015 and thereafter he was admitted to as inpatient to Vikarm Hospital, Mysuru, from 10.12.2015 to 12.12.2015 for further treatment. Therefore the complaint claimed the medical charges of Rs. 70,000/-  under the policy which came to be repudiated by the opposite party company hence this complaint. Here all the above facts is established by complainant with material documentary evidence and these facts is also not disputed by opposite party company. The dispute is only that complaint is not eligible for the insurance claim amount. For the reason, that the aliment suffered by him is due to alcoholic intake as per the doctor opinion the opposite party contends that as this is not covered as per the conditions of policy. They repudiated the claim also denied the entire allegation of complaint.

12. Further that the initial and primary burden of proof lies on the complainant that the ailment was due to regular intake of alcohol when this is not covered under the policy they cannot settle the claim of complainant, the burden of proving the said facts lies on the person who alleges same facts against the complainant. Here in this complaint opposite party company has taken up some defence that has to be established by him with cogent and convincing material evidence. Opposite party has not made any attempt to prove his contention and thereby he has miserable failed to discharge the burden of proof lies on him. Thereafter that the opinion expressed by doctor , patient is known alcoholic as per medial opinion this opinion of doctor is not supported by any detailed medical  report and also to arrive at the conclusion  that the  patient is A known Alcoholic what are the tests have been made and on which report basis they have given report of that the ailment suffered by complainant is due to intake of alcohol. All these questions remained un answered and that stray opinion expressed by doctor without any supporting detailed report has no evidentiary value in the eye of law. That such opinion need not be considered, it has no implication  on the merits of case. For these facts it is observed that opposite party has failed to support his defence and in our view the repudiation of complaint claim is not justified and it is held to be bad in law.

13. That the complainant in support of his claim has relied on Judgment rendered by National Consumer Commissioner Delhi, in Rev No 1571/13 between Ranvir Sigh Alias Ranbir Kaur Vs Life Insurance Corporation of India on perusal of facts and principles of the above ruling we held that principles laid down by the Hon’ble National Commissioner is aptly applicable to the complaint on hand by applying the same we can safely come to the conclusion that the repudiation of claim is illegal and bad in law.

14. Further the complainant has prove his case beyond reasonable doubt and also deficiency of service on the part of opposite party. Under such circumstance the complaint is liable to be allowed. Accordingly we answered point no.1 in the affirmative.

15. Point no.2:- From the above discussion we hereby proceed to pass the following :-

ORDER

1. The complaint is hereby allowed in part.
2. The opposite party is directed to pay sum of Rs. 70,000/- within 60 days of this order with interest at the rate of  15% p.a. from date 12.12.2015  till payment made.
3. The opposite party is directed to pay of Rs.. 5,000/-  towards deficiency in service and Rs. 3,000/- towards cost of proceedings to the complainant within 60 days of this orders.
4. In default to comply the above order opposite party shall pay interest on the said amount of 8,000/- at the rate of 12% p.a. from the date of order till payment made.
5. In case of default to comply this order, the opposite party shall     undergo imprisonment and also liable for fine under section 27 of  the CP Act, 1986.
6. Give the copies of this order to the parties, as per Rules.

(Dictated to the stenographer transcribed , typed by her, transcript corrected by us and then pronounced in open court on the 06^th December   2017)  

Shri Thammanna Y.S.,                                 Shri Ramachandra M.S.,    

Member.                                                          President.