BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 225 of 2017
Date of Institution : 8.9.2017
Date of Decision : 24.1.2019.
Mahender Singh (aged about 44 years) son of Sh. Kaushal Singh, resident of House No.651, Sector-20, HUDA, Sirsa, District Sirsa.
……Complainant.
Versus.
1. ICICI Lombard General Insurance Company Limited, IRDA Regn. No.115, ICICI Lombard House, 414, Veer Savarkar Marg, Near Sidhi Vinayak Temple, Prabhadevi, Mumbai- 400025 through its Managing Director/ Authorized Signatory.
2. ICICI Lombard General Insurance Company Limited, Regional Office: The Statement, 4th Floor, Plot No.149, Industrial Area, Phase-1, Next to Hometel Hotel, Chandigarh through its Regional Manager.
3. ICICI Lombard General Insurance Company Limited through its Authorized Agent Aashish Jain S/o Sh. Baldev Raj, R/o Gali Dr. Inderjeet Wali, Mohalla Jail Ground, Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. ISSAM SINGH SAGWAL …… MEMBER.
Present: Sh. Vijay Sharma, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite parties no.1 and 2.
Opposite party no.3 exparte.
ORDER
The case of the complainant in brief is that complainant in order to secure his family from loss of expenses of treatment as well as to get financial help for securing the health of his family was desired to get a health insurance policy and as such he purchased a Health Smart Insurance Policy bearing No.4128i/HSM/88751987/01/000 dated 4.6.2016 for the period of two years w.e.f. 4.4.2016 to 3.4.2018 for annual insured sum of Rs.10,00,000/- and additional insured sum of Rs.2,00,000/-, which was purchased by complainant from op no.3 who is authorized agent of ops no.1 and 2. The above said policy is the renewal policy as previously the complainant purchased the policy from ops in the year 2014 for the period of two years. It was assured to the complainant by the ops that all the expenses to be incurred on the medical treatment will be borne by the company as the policy is cashless on some hospitals and reimbursement policy for other hospitals. That on 2.3.2017, the complainant was suffering from vomiting, decrease of urine output and fever etc. since 2-3 days and he visited JCD Super Specialty Hospital & Trauma Centre, Barnala Road, Sirsa and he was referred to higher centre and then immediately he was hospitalized in Fortis Escorts Hospital, Jaipur with the above said complaints. The treatment was given by the doctors and after treatment, the complainant recovered and thereafter he was discharged on 11.3.2017. That an amount of Rs.2,42,020/- was incurred by the complainant on medical treatment alongwith hospitalization charges in the said hospital. Apart from it, thereafter the complainant has further incurred an amount of Rs.16,272/- on his treatment as per prescription of the doctor and in this way he has incurred total sum of Rs.2,58,292/- on his treatment from said hospital. That at the time of admission of complainant in Fortis Escorts Hospital, the family members of complainant informed the ops and all the medical reports and other documents including bills etc. were submitted to the ops. It is further averred that complainant has applied for claim of the amount incurred by the complainant on his treatment bearing claim No.220100399095, but the ops put off the complainant with one pretext or the other and finally they have refused the claim of complainant vide Ref. No.88751987 dated 20.7.2017 with the false reason that “Any expenses incurred on treatment of illness due to use, misuse or abuse of intoxicating drugs or alcohol will not payable, hence rejected.” Whereas the complainant is not a habitual drunkard and is not addict to intoxicating drugs, but the ops have rejected the claim of complainant on false and frivolous grounds. It is further averred that complainant has also become victim of malpractice of the ops as ops have procured false ground from the doctor to the effect that complainant is chronic alcoholic since 20 years, whereas he is not a chronic alcoholic from such period and doctor cannot predict the period of consumption of liquor by a patient. The complainant was diagnosed by the doctor JCD with the help of Global Imaging and Path Lab. and as per their report, the liver and kidney of complainant was normal. That ops have intentionally rejected the claim of complainant just to usurp the claim amount, for which he is legally entitled. It is further averred that complainant has approached the ops on many occasions and requested to pay his claim, but on every occasion, the ops have refused to admit his claim. That such act and conduct of the ops amounts to gross deficiency in service, due to which the complainant has been put to unnecessary harassment and mental tension. Hence, this complaint.
2. On notice, opposite parties no.1 and 2 appeared and filed written statement taking certain preliminary objections. It is submitted that contents of para no.3 of the complaint are correct to the extent that complainant had purchased the health policy and further it is also submitted that complainant paid the premium amount and also renewed it in time, but there are some terms and conditions alongwith the policy to which the complainant/ policy holder must follow strictly and in case of violation then it is clear violation of the terms and conditions of the health policy and in that case the claim shall be rejected by the insurance company. It is further submitted that complainant made a false and concocted story and also tried to give the colorful version just to grab the compensation on the false and fabricated grounds. As per the clarification received from the hospital, the etiology of liver disease is alcohol induced. In accordance with clause 3.4.v of Policy wordings, claims arising on account of or in connection with any alcohol or drug abuse shall be permanently excluded from the scope of cover under the policy. Hence the cashless facility is denied. Insured, at his discretion, may furnish all the necessary documents for probable reconsideration at the time of member re-imbursement. Initial AL stands null and void. Hence, the complainant violated the terms and conditions of the insurance policy and the complaint of complainant is liable to be rejected on this score alone. It is also submitted that complainant never disclosed the above mentioned facts at the time of purchase of the insurance policy in question. Remaining contents of the complaint are also denied.
3. Opposite party no.3 did not appear despite notice and was proceeded against exparte.
4. The complainant and ops no.1 and 2 led their respective evidence by way of affidavits and documents.
5. We have heard learned counsel for complainant as well as learned counsel for ops no.1 and 2 and have perused the case file carefully.
6. The complainant in order to prove his complaint has furnished his affidavit Ex.C1 in which he has reiterated all the averments made in his complaint. He has also furnished copies of policy documents Ex.C2, Ex.C3 and copy of acknowledgment of premium Ex.C4, copy of discharge summary Ex.C5, copy of HRCT scan of thorax Ex.C6, copy of policy card Ex.C7, copies of prescriptions slips Ex.C8, Ex.C9 and copy of repudiation letter dated 20.7.2017 Ex.C10. On the other hand, ops no.1 and 2 produced affidavit of Sh. Apurva Sharma, Legal Manager Ex.R1, copy of authorization letter to the hospital for the treatment and guarantee of payment dated 3.3.2017 Ex.R2, copy of denial of cashless access dated 8.3.2017 Ex.R3, copy of letter dated 13.3.2017 Ex.R4, copies of cashless authorixation request note Ex.R5, Ex.R6, copy of adhar card Ex.R7, Ex.R8, copy of certificate of Dr. Pratik Tripathi Ex.R9, copy of policy certificate Ex.R10, copy of tax certificate Ex.R11, copy of policy card Ex.R12, copy of claim form Ex.R13, Ex.R14, copy of address Ex.R15, copy of receipt Ex.R16, copy of document regarding file received Ex.R17, copy of claim form Ex,R18, copy of key information sheet Ex.R19, copy of policy wording Ex.R20, copy of details of insurance ombudsmen Ex.R21, copy of day care treatment Ex.R22, copy of certificate of Dr. Pratik Tripathi Ex.R23, copy of another certificate of doctor Ex.R24, copies of treatment record of JCD Super Speciality Hospital, Sirsa and Fortis Hospital Ex.R25 to Ex.R38, copy of ultrasound report Ex.R39, copy of statement of account Ex.R40, copy of document regarding file received Ex.R41 and copy of e-mail Ex.R42.
7. The perusal of the evidence of the parties reveals that it is undisputed fact between the parties that complainant had purchased a health smart insurance policy bearing No.4128i/HSM/88751987/01/000 dated 4.4.2016 for the period of two years w.e.f. 4.4.2016 to 3.4.2018 from ops no.1 and 2 through op no.3. It is further undisputed fact that on 2.3.2017 the complainant was suffering from vomiting, decrease of urine output, fever etc. and he visited JCD Super Specialty Hospital & Trauma Centre, Sirsa and he was referred to higher centre and was hospitalized in Fortis Escorts Hospital, Jaipur. According to complainant, an amount of Rs.2,42,020/- was spent by him on his treatment in Fortis Escorts Hospital, Jaipur and thereafter an amount of Rs.16,272/- was incurred on medicines as per prescription of the doctor of Fortis Hospital and in this way the complainant has incurred total amount of Rs.2,58,292/- on his treatment from the said hospital. Claim was lodged with ops but claim was repudiated on the ground that any expenses incurred on treatment of illness due to use, misuse or abuse of intoxicating drugs or alcohol will not be payable.
8. The bone of contention between the parties is qua taking of alcohol by the complainant. As per contention of the ops no.1 and 2, the complainant is a chronic alcoholic since last 20 years and he suffered problem in his liver and kidney due to use of excess alcohol. On the other hand, there is a specific plea of the complainant that he is not a chronic alcoholic from such period and doctor has mentioned totally false reason because the doctor cannot predict the period of consumption of liquor by a patient rather complainant was diagnosed by Doctor of JCD Super Speciality Hospital, Sirsa with the help of Global Imaging and Path Lab and as per their report, the liver and kidney of complainant were normal. The perusal of the discharge summary of Fortis Escorts Ex.C5 reveals that it is mentioned in the discharge summary in the history of present illness that patient was admitted in Fortis Escorts Hospital Jaipur in HDU with C/o recurrent vomiting associated with abdominal pain which is not associated with hemetemesis and c/o decrease urine output from last 3 days. C/O fever which is not associated with any chills and rigor. Fever was low grade and patient is chronic alcoholic since 20 years. As per discharge summary patient came in hospital with above mentioned complaints in MICU. But the perusal of discharge summary reveals that doctor has not given his opinion that disease is only due to excessive use of alcohol. Moreover, doctor has not placed on record any document from which he formed his opinion that complainant is a chronic alcohol habitual from the last 20 years. So, it cannot be presumed without any cogent and convincing evidence on record that complainant is a chronic habitual of alcohol from the last 20 years.
9. Though during the course of arguments, learned counsel for ops no.1 and 2 has strongly contended that as per clause 3.4 of the terms and conditions of the policy it falls within exclusions clause if illness is due to use, misuse or abuse of intoxicating drugs or alcohol and company shall not be liable to pay claim. No doubt, ops no.1 and 2 have placed on record copy of terms and conditions of the policy but they have not placed on record any document from which it could be presumed that this copy of terms and conditions was ever supplied to the complainant alongwith issuance of policy. Secondly, ops no.1 and 2 have not placed on record any copy of proposal form by which question was put to the complainant whether he takes alcohol or not. Moreover, it was legal obligation of the agent op no.3 of ops no.1 and 2 to make all required enquiries from the insured before submitting his application for issuance of proposal form for issuance of the insurance policy and further he should recommend the proposal form after making his inquiry and investigation qua use of alcohol by applicant/ insured. So, it appears that there is lapse on the part of ops and now ops cannot take benefit of their own lapses and are not justified in repudiating the claim of complainant. Non payment of claim to the complainant clearly amounts to deficiency in service on the part of ops.
10. In view of the above, we allow the present complaint and direct the opposite parties to pay claim amount to the complainant within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation and litigation expenses to the complainant within above said period of 45 days. In default, the ops shall be liable to pay interest @6% per annum on the claim amount from the date of order till actual realization. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:24.01.2019. Member District Consumer Disputes
Redressal Forum, Sirsa.
