Order-15.
Date-29/07/2015.
Complainants Nitesh Kumar Singh by filing this complaint has submitted that complainant purchased one Individual Health Insurance Policy – 2010 covering his family vide Policy No. 030300/48/13/97/00008769 having its validity from 25.03.2014 to 24.03.2015 and that policy was renewed in each year by the op no.1 on payment of requisite premium.
During the validity period of the said policy on 31.07.2014 complainant as per advice of the doctor, took admission to Institute of Neurosciences, Kolkata for diagnosis of Subarachnoid Haemorrhage with Multiple Contusions and was under treatment of the doctor of the said Hospital till 06.08.2014.
During the aforesaid period from 31.07.2014 to 06.08.2014 in the said hospital total expenditure amounting to Rs. 61,044/- has been paid by the complainant.But after discharge from the said Hospital, complainant after obtaining all the medical papers submitted along with claim form on 18.08.2014 for settlement of the claim of the complainant before the op no.2.
Thereafter op no.2 vide letter dated nil repudiated the claim with a remark that the patient had a history of heavy drinking on the night before admission.So, they are unable to sanction the cashless authorization.The said repudiation letter of the ops was made mechanically and with preconceived notion without considering the treatment papers and report etc. op repudiated the claim though no such drug has been taken by the patient at the time of admission or prior to that and such sort of repudiation is not only arbitrary, uncalled for and for such negligent and deficient manner of service on the part of the op and arbitrary decision of the op, complainant has filed this complaint for redressal and relief and for directing the op to release the mediclaim amount against such treatment cost when policy was valid for that period.
On the contrary op by filing written statement submitted that no doubt complainant purchased a policy i.e. Individual Health Insurance Policy – 2010 having Hospital Benefit for himself, his wife and son for total sum insured value of Rs. 1,00,000/- with such terms and conditions, limitations and exceptions thereof and the relevant policy was valid for the period from 25.03.2014 to 24.03.2015.
No doubt during subsistence of the said policy, the TPA received a pre-authorisation of cashless request form issued by Institute of Neuroscience, Kolkata dated 31.07.2014 for disbursement of medical expenses of complainant and as per said prayer so treatment sheet commencing from 31.07.2014 to 05.08.2014 as issued by the said Hospital was considered and daily progress notes containing 14 pages for the period from 31.07.2014 to 05.08.2014 issued by the said Hospital in the name of the complainant were also considered and after considering the entire treatment sheet and pathological report it was found that complainant is a chronic alcoholic and prior to admission to the Hospital on the preceding night he took excess liquor/alcohol and under intoxication he fell down and sustained head injury and was admitted in the hospital and the MRI of brain shows frontal impact and considered all those the TPA did not consider the claim and rejected it and denied also cashless authorization and ultimately when the claim was made by the complainant after discharge from the Hospital that was also considering and rejected as per policy condition No. 4.6.So, there was no ground for considering the claim of the complainant for which it was repudiated.
Moreover Insurance Policy is a contract by and between the insured and insurer and terms and conditions of the policy are binding upon both the parties equally and any deviation from the said Insurance Policy tantamounts to reconstruction and/or recasting of the policy absolving this op from any liability whatsoever and in the present case it is evident from the treatment sheets issued by the hospital that complainant is chronic alcoholic and is alcoholic dependant and under influence of intoxication and consequent to that he fell down and sustained injury and it is a pure case of alcoholic abuse as per Clause 4.6 of policy which is part of the Exclusion Clause.So, reasonably and logically the claim was repudiated as such there was no deficiency of service and for which the complaint should be dismissed.
Decision with reasons
On an in depth study of the complaint and written version and also relying upon the argument as advanced by the Ld. Lawyers of both the parties and further on proper assessment of the Insurance Policy of the Mediclaim Treatment Sheet supplied by the complainant and op, it is clear rather admitted that complainant is a bonafide Mediclaim Policy Holder having Policy No. 030300/48/13/97/00008769 and it was valid from 25.03.2014 to 24.03.2015 and fact remains that for some ailments, complainant as per doctor’s advice was admitted to Institute of Neuroscience, Kolkata on 31.03.2014 and was treated up to 06.08.2014 from the bill supplied by the said Institute and for the said treatment complainant paid expenditure/cost amounting to Rs. 61,044/- no doubt.
It is also admitted fact that complainant prayed for cashless benefit and that was rejected by the op and thereafter complainant submitted the entire claim after his discharge on 18.08.2014 for settlement of the claim of the complainant that was also rejected and repudiated on the ground that Clause 4.6 of the terms and conditions of the Policy is applicable in this case on the ground that complainant is a chronic alcoholic.
Now the question is whether the repudiation is justified.In this regard it is to be mentioned that complainant purposefully did not submit the treatment sheets, only submitted discharge summary.But anyhow op supplied entire mediclaim treatment sheet after collecting it from the said Hospital and from that treatment sheet, it is clear that complainant is a chronic alcoholic and further a known alcoholic and it is specifically noted in the said History that complainant is aged about 22 years, run a business, married person having one daughter, aged about 18 months and 2-3 times daily he takes Beer and also Whisky 2-3 times and 2 units in each occasion and he has been regularly drinking and for last one year he had been taking 3 units of Whisky in each case plus Beer till late night and he starts drinking from 11:00 A.M. and till late night and on the very date of admission also he took alcohol and patient is depending upon alcohol and he has become an alcoholic dependents and he fell down practically for his psychological problem and doctor advised for his treatment for psychological therapy and to meet psychiatrist in OPD Clinic as soon as possible and this is the report of doctor of Institute of Neuroscience, Kolkata dated 05.08.2014 and in fact due to taking alcohol, he fell down and sustained such injury and other co-related diseases.
About those documents, complainant has no denial and has not denied about that.In fact Ld. Lawyer for the complainant finding no other alternative to defend the complainant’s case submitted that he has no habit to take any drug and it is not a case of drug abuse.But in this regard we want to say without any hesitation that Clause 4.9, the Exclusion Clause as per terms and conditions of the policy is applicable, failing in respect of a person who has suffering from any injuries for drug abuse and also for alcoholic reason.Op has not stated that complainant is a drug addicted.Probably the Ld. Lawyer for the complainant failed to interpret the word ‘drugs and alcohol’.But as per observation and findings of the doctor dated 05.08.2014, it is clear that even prior to admission at night hours he took alcohol and fell down from the stair and sustained injury and that is fact which is confirmed by the treatment sheet of the Hospital what has not been denied by the complainant by any means.
At the same time from the report of the doctor, it is proved that he has been suffering from psychological dis-balancement for which he is further advised not to take alcohol and to take help of one psychiatrist in OPD Clinic for psychological therapy and treatment for recovering from such sort of illness.
So, it is found that complainant is not only a chronic alcoholic but also suffering from psychological problem due to some sort of financial deficiency for his low income, though he is married.
So, considering the above fact and also pathological report of the complainant, it is clear that complainant is not a drug addicted person, but he is a confirmed chronic alcohol and he takes drink daily from morning to late night and just last night from the time of admission he took alcohol and considering that report of the doctor it is found that complainant passes his days by in taking alcoholic continuously i.e. Beer, Whisky from morning to late night for which he suffered from alcohol related diseases and in fact in the present instance he fell down from stair at the relevant time he was completely under intoxication.So, invariably for such treatment and for his psychological problem, complainant is not entitled to get any relief against his Mediclaim Policy as per Clause 4.9, but it would not be 4.6 and against Clause 4.9 it is specifically mentioned if any injuries or suffering was caused due to use of intoxication drugs and alcohol insured is not entitled to and in this case it is found that complainant’s psychological suffering, mental sufferings and sufferings from other diseases are due to his status as a alcoholic person.
Doctor report supports that fact and doctor advised to completely reject the alcohol and for the psychological problem, he should be treated by a psychiatrist continuously that means he is a patient of psychological disorder also.So, as per Clause 4.9 of the terms and conditions of the policy, no doubt the op rightly rejected the claim of the complainant when complainant as insured and op as insurer are jointly guided by the terms and conditions of the policy and in the Exclusion Clause 4.9, it is specifically mentioned and rightly that was rejected and reasons for rejection was rightly stated in letter by the op and considering all the documents collected by the op from the Hospital as complainant did not supply all documents we are confirmed that complainant is nothing but an alcoholic person and his days start with alcohol and ends with alcohol.So, complainant has been suffering physically and mentally due to his alcoholic habits and he is a chronic alcoholic.
So, Clause 4.9 (Exclusion Clause) is applicable in this case and that was rightly applied by the op and there was no error in this regard and for that reason we are confirmed that there is/was no deficiency and negligence on the part of the op and their repudiation against the claim of the complainant is no doubt justified, legal and applying judicial mind and in the above fact and circumstances that was decided rightly and against that in fact complainant has nothing to say in view of the fact Exclusion Clause is equally applicable to the present complainant.In this regard we want to say that already Supreme Court and National Commission have confirmed by so many judgements that Insured and Insurer are strictly governed by the policy conditions and no exception and relaxation can be made on the ground of equity by any Forum and for violation of the terms and conditions of the policy, no doubt rejection was rightly made by the op for which complainant is not entitled to get any relief from this Forum.
After proper study of the entire complaint and also our findings, we find that in the complaint, truthful chapter, that is, complainant’s daily life, his behavioural science, mode and manner of leading life, his general habits and vices are not reflected and complainant tried to convince this Forum that he is an innocent.But this Forum is not telling that he is not an innocent.But we have gathered that the present complainant started his life at this stage at the age of 22 with all vices for embracing the end of his life and truth is that many youthful boys after marrying at early stage fails to maintain his family accordingly and ultimately suffer from mental depression for want of fund or for poor income and for not maintaining the family and in the present case that is the history of the present complainant and truth is that prior to purchasing of the policy he is a known alcoholic and he does not love anything in the world, not even his wife and daughter but he is lover of the alcohol whole day and now alcohol is first friend, alcohol is his first lover, but he does not know alcohol is the all cause of his frustration of life and ultimately cause of illness and death of life.
But we do not know whether after this treatment he has changed his behaviour or not.But we are requesting the complainant to leave those chapter forever and lead a life by embracing the philosophy of Lord Buddha for leading a peaceful life along with his beloved wife and daughter to enjoy a cordial family atmosphere by chanting mantras ‘Good Bye Alcohol’.
In the light of the above observation, the complaint fails.
Hence, it is
ORDERED
That the complaint be and the same is dismissed on contest without any cost.
