Punjab

StateCommission

A/12/16

ICICI Lombard General Insurance Company Ltd. - Complainant(s)

Versus

Mahesh Aggarwal - Opp.Party(s)

R.S.Dhull

26 Feb 2015

ORDER

                                                               FIRST ADDITIONAL BENCH

 

STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION, PUNJAB, SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.

 

First Appeal No.16 of 2012

                                                Date of Institution:  05.01.2012.

                                                Date of Decision:           26.02.2015.

 

1.      ICICI Lombard General Insurance Co. Ltd., Sutehri Road Near         Manvata Mandir, Hoshiarpur through its Manager.
2.      ICICI Lombard General Insurance Company Limited Health    Care, TGB Mansion 6th Floor, Plot No.6-2-2012 Khaitarabad,   Hyderabad-500004 (Andhra Pradesh) now at SCO No.507,        Sector 70, Mohali through its Legal Manager Inderjit Singh.

                                                         …..Appellants/opposite parties

Versus

 

1.      Mahesh Aggarwal, son of Muni Lal Aggarwal,

2.      Partik Gupta, son of Mahesh  Aggarwal, both C/o M/s Mahesh         and sons Shiv Bhawan, Old Pansarian Bazar, near Sarafan          Bazar, Hoshiarpur.

                                                               ….Respondents/complainants

                                                    

Appeal against order dated 28.11.2011 passed by the District Consumer Disputes Redressal Forum, Hoshiarpur.

Quorum:-

     Shri J. S. Klar, Presiding Judicial Member.

             Shri Vinod Kumar Gupta, Member.

Present:-

 

     For the appellants       :     Ms. Meenu Sharma, Legal Manager

For the respondents    :     Sh. Parveen Kumar, Advocate.

     . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

J. S. KLAR, PRESIDING JUDICIAL MEMBER:-

                   The appellants (the opposite parties in the complaint) have directed this appeal against the respondents herein (the complainants in the complaint), impugning order dated 28.11.2011 passed by the District Consumer Disputes Redressal Forum Hoshiarpur (in short, “the District Forum”), partly accepting the complaint of the complainant and directing the appellants to pay Rs.93,480/- besides Rs.5000/- for mental harassment and as costs of litigation. The instant appeal has been preferred against the same by the OPs now appellants.

2.           The complainants have filed the complaint under Section 12 of the Consumer Protection Act, 1986 (in short "Act") against the OPs on the averments that complainant no.1 Mahesh Aggarwal is holder of health insurance policy issued by OPs and complainant no.2 Partik Gupta is also covered under the said policy, which was issued on 31.12.2010 for the period 12.12.2010 to 11.12.2011. The policy was the renewed policy and previous number was 4034i/FHR/05057875/00/000. That complainant no.2 Parteek Gupta was admitted in DMC Hospital Ludhiana on 05.04.2011 and remained there till 15.04.2011, vide discharge slip Annexure-A2. That it was a cashless policy and the claim was lodged with the OP no.1 within time, but he same was rejected by the OPs, vide letter dated 02.05.2011 on the false ground. That complainant was made to incur the medical expenses upto the extent of Rs.1,10,000/- due to rejection of the insurance claim by the OPs. The repudiation of the insurance claim by the OPs is unjustified. The complainant has, thus, prayed that OPs be directed to pay the amount of Rs.1,70,000/- along with interest @ 24% besides costs of litigation of Rs.12,000/-.
3.           Upon notice, OPs filed joint written reply, raising preliminary objections that complaint is not maintainable. That complainants, being beneficiaries are guilty of suppression of the material facts at the time of getting the insurance policy from the OPs. The jurisdiction of District Forum Hoshiarpur was also challenged. On merits, the complaint was contested on the ground that the renewal of the policy was done by the complainants by concealing the fact and there was false representation on the part of the complainants misleading the OPs to lead to the renewal of the policy. The contract of insurance is not legally tenable, because the renewal of the policy was got done by the complainants by suppressing the material facts. That it was discovered that complainant no.2 was suffering from Acute Pancreatitis (alcohol induced), which means that the said treatment was done for alcohol abuse. That vide clause 3.4 of the insurance policy, the claim arising out of alcohol abuse is excluded from the scope of contract of insurance. The insurance claim of the complainants was rightly rejected by them. The OPs prayed for dismissal of the complaint of the complainants.
4.           The complainants tendered in evidence, the affidavit of Mahesh Aggarwal Ex.C-1 along with documents Ex.C-2 to C-54 and Ex.Mark-C3 and closed the evidence. As against it, the OPs tendered in evidence affidavit of Gurpreet Singh Bhullar, the authorized signatory of OPs Ex.OP-1 along with documents Ex.OP-2 to OP-5 and closed the evidence thereafter. On conclusion of evidence and arguments, the District Forum Hoshiarpur partly accepted the complaint of the complainants, as stated above. Dissatisfied with the order of the District Forum, the OPs now appellants have preferred this appeal against the same.
5.           We have heard the learned counsel for the parties and have also examined the record of the case. The affidavit of Mahesh Aggarwal complainant no.1 is Ex.C-1 on the record. This affidavit is in support of the plea of the complainants, as contended in the complaint. Deficiency in service on the part of the OPs has been alleged in this affidavit and the documents Ex.C-2 to Ex.C-43 have been relied upon in this regard. It was stated in this affidavit that complainant no.2 was again admitted in Dayanand Medical College and Hospital Ludhiana on 02.07.2011 and was discharged on 18.07.2011 and was subjected to surgery, vide Mark C-3. That their insurance claim has been rejected on imaginary grounds on the basis of discharge slip. The copy of insurance policy Ex.C-2 is on the record for the period from 12.12.2010 to 11.12.2011. Ex.C-3 is the case summary & discharge slip on the record of complainant no.2 Parteek Gupta. He was admitted there on 05.04.2011 and discharged on 14.04.2011. The history of present illness is recorded as pain in abdomen for one day. It is recorded in the history course that patient was presented as case of acute pancreatitis, conservative management in the form of I/V fluids, I/V ciplox Metrogyl, PPI's, Drotin was given for 5 days subsequently, but pain subsided and patient was passing stools, NJFT was removed and he was orally started in the form of liquids diet & subsequently semisolid diet. Patient had deranged RFT's at the time of admission possibility ARF, which was subsequently improved. Patient is pain free right now for 4 days & taking orally and is being discharged. The discharge slip of complainant no.2 is Ex.Mark C-3 on the record, he was admitted in hospital on 02.07.2011 and discharged on 18.07.2011. It is recorded, being the history of present illness pain in abdomen for one month. It is recorded in the hospital course that large cyst was found in the lesser sac (intrapancreatic). On the basis of case summary & discharge slip, the OPs rejected the insurance claim of the complainants on the ground that acute pancreatitis is on account of alcohol induced. OPs relied upon Ex.C-4 to the effect that as per evidence available – in discharge summary submitted during cashless- acute pancreatitis (alcohol induced), as per course of hospitalization- presented with c/o – acute pancreatitis, conservative management- as per part-II of schedule permanent exclusion clause 3.4 V treatment related to alcohol abuse is not payable, hence rejected. The claim lodged by complainant no.2 Parteek Gupta with the OPs is Ex.C-5 on the record. Ex.C-3 is discharge slip of Parteek Gupta complainant no.2 issued by the Dayanand Medical College & Hospital Ludhiana, recorded in diagnosis HTN with acute pancreatitis and deranged RFT's (resolved). Ex.Mark C-3 is another case summary & discharge slip of Parteek Gupta complainant no.2 on the record issued by the Dayanand Medical College & Hospital Ludhiana. Ex.C-7 is the treatment advised slip on the record. Ex.C-7 and C-8 are the payment receipts in the name of complainant no.2 issued by the DMC Hospital Ludhiana. Ex.C-9 is the payment receipt of Scanning on the record. The other bills regarding purchase of medicines during the treatment at DMC Hospital Ludhiana are
   Ex.C-10 to C-42 on the record. Ex.C-43 is bill progress chart.
    Ex.C-44 to Ex.C-47 are the payment receipts issued by the DMC Hospital Ludhiana in the name complainant no.2 Parteek Gupta. Ex.C-48 is the Individual Health Insurance Policy. Ex.C-49 is the letter regarding repudiation of insurance claim, Ex.C-50 is the free health check-up coupon. Ex.C-51 is the policy terms and conditions. Ex.C-52 is health insurance endorsement on the record.
6.           The OPs mainly relied upon the discharge summary Ex.C-6 issued by the DMC Hospital Ludhiana of Parteek Gupta, where it was diagnosed to be a case of HIN with acute pancreatitis (Alcoholic induced) with deranged RFT's (resolved). The OPs brought the case under the exclusion clause of insurance contract and rejected it. The OPs also relied upon Ex.OP-2, the insurance policy document, clause 3.4 (V) excludes the alcohol or drug abuse from the insurance claim. The OPs submission is that since the complainant was a case of alcohol induced, which contributed to pancreatitis and such exclusion clause 3.4 (V) of the contract of the insurance, the claim was rejected. Ex.OP-3 is the case summary & discharge slip, which has been produced on the record by the complainant in this case. In the hospital course, complainant was presented as a case of acute pancreatitis. The submission of the OPs now appellants is that the complainants concealed the material fact of complainant no.2 being a case of alcohol abuse at the time of renewal of the policy, hence, the contract of insurance stood repudiated.
7.           We have considered the above evidence thoughtfully in this case. The submission of the complainants is that in discharge summary Ex.C-3 and Ex.Mark C-3 in the hospital course, only acute pancreatitis is recorded and there is no mention of any alcohol abuse therein. It was argued by complainants that complainant no.2 was insured with OPs and he was suffering from acute pancreatitis. The word acute means, it was not chronic and it developed suddenly. The complainant no.2 was operated upon, vide Ex.Mark C-3, he was admitted on 02.07.2011 to 18.07.2011. The photocopy of the case summary Ex.C-3 is on the record that complainant no.2 Parteek Gupta was admitted in DMC Hospital Ludhiana on 05.04.2011 and discharged on 14.04.2011. It is nowhere recorded that complainant no.2 is a case of alcohol abuse or suffered from induced alcohol. Even in the hospital record, there is no mention of complainant no.2 being a victim of alcohol. Use of expression of alcohol induced in discharge summary, vide Ex.C-6, this impression has been scored out. The OPs has not summoned the original discharge summary on the record to come to this conclusion. Since in the course personal history of the complainant no.2, there is no mention of any alcohol abuse and the word alcohol has been scored out on the photo copy of Ex.C-6 and the original discharge summary report has not been summoned by the OPs to rebut it nor any medical experts evidence is on the record that it was a case of excess use of alcohol. Mere taking of alcohol is no ground to reject the claim and reference may be made to the judgment of this Commission in "LIC of India & Anr.   Versus  Sukhwinder Kaur" 2008(1) CPC-675. We find that there was no proof of nexus of acute pancreatitis with use of alcohol on the record. No expert has been examined nor any affidavit tendered by the OPs of the expert witness to prove that acute pancreatitis was on account of any alcohol solely. The personal history of complainant no.2 nowhere recorded him as alcoholic. The District Forum righty found the OPs deficient in service and awarded the amount of Rs.93,480/- as established on the record for his treatment. We are unable to disagree with the findings of the District Forum under challenge in this appeal. There is no ground to interfere with the order of the District Forum in this appeal.
8.           In the light of our above discussion, we do not find any merit in this appeal and the same is hereby dismissed.
9.           The appellants had deposited an amount of Rs.25,000/- with this Commission at the time of filing this appeal. This amount with interest, which accrued thereupon, if any, be remitted by the registry to complainants now respondents in this appeal by way of a crossed cheque/demand draft after the expiry of 45 days. The remaining amount shall be paid by the OPs now appellants to the complainants within 30 days from the date of receipt of the copy of this order.
10.           Arguments in this appeal were heard on 24.02.2015 and the order was reserved. Now the order be communicated to the parties. The appeal could not be decided within the statutory period due to heavy pendency of court cases.

                                                                          (J. S. KLAR)

                                                         PRESIDING JUDICIAL MEMBER

                   

                                                                   (VINOD KUMAR GUPTA)

                                                                              MEMBER

 

February 26, 2015.                                                             

(MM)