Order No. 23 dt. 15/11/2017
The fact of the case according to the complainant in brief is that the complainantfor his illness got admission to Woodland Hospital on 07.09.2011 for treatment of acute abdominal pain, loose motion and nausea under the care of Dr. S. K. Seal, General & Laparoscopic Surgeon. Complainant undertook a medical insurance policy with Star Health and Allied Insurance Company Limited, 75C, Park Street, Kolkata-700016 (o.p.1) under policy no.000893 in continuation of his early policy from United India Insurance Company Limited for the period from 28.10.2010 to 27.10.2011 against payment of Rs.8,466/- for health insurance covering of the complainant himself, the spouse and his children with coverage limit of Rs.5,00,000/-. Complainant had to stay in Woodland Hospital for treatment alongwith necessary investigation. After completion of treatment complainant was released on 11.09.2011 and he submitted an insurance claim with relevant papers for reimbursement claiming Rs.46,000/- as medical expenses issued by the Woodland Hospital. But the o.p. has repudiated the claim on 02.12.2011. Complainant again submitted a written petition dated 12.12.2011 vehemently challenging the so called observation of the op. Complainant thereafter issued another letter dated 22.06.2012 requesting to review the bonafide claim. Complainant produced a certificate issued by Dr. S. K. Seal, attending doctor, dated 20.06.2012 under his signature and R.N. refuting regular intake of alcohol by the complainant. Against the repudiation letter complainant issued a prayer seeking review of the claim of hospitalization but the o.p. company turned down the claim by issued a letter dated 13.12.2012 which was again confirmed by the o.p. company on 17.08.2012. Finding no other alternative thecomplainant lodged this complaint praying order against the o.p. for payment of Rs.46,000/- as medical expenses incurred in the Woodland Hospital along with compensation of Rs.35,000/- for deficiency in service or unfair trade practice with harassment and mental agony along with litigation cost of Rs.2,000/-.
O.ps. contested the case by submitting w/v where the Ld. Lawyer stated that complainant obtained Family Health Optima Insurance Policy for the period from 28.10.2010 to 27.10.2011 for the sum assured of Rs.5,00,000/- covering husband, wife and their two children. Complainant got admission on 07.09.2011 for treatment of acute pancreatitis and released on 11.09.2011. Ld. Lawyer contended that the treating doctor in a certificate dated 24.09.2011 mentioned that the complainant’s pancreatic problem is due to consumption of alcohol. As per exclusion no. 10 of the policy issued to the complainant, o.ps are not liable to make any payment in respect of any expense for treatment of general debility.Accordingly the claim was repudiated by the o.ps and the same was communicated videletter dated 02.12.2011 &13.01.2012.The complainant made a representation dated 22.06.2012 to the o.ps i.e. after more than six months from the date of repudiation attaching a certificate from Dr Sanjay Kumar Seal, the treating doctor who certified that the complainant had no history of intake of alcohol. It is mentioned here that surprisingly the same doctor vide his certificate dated 24.09.2011 had diagnosed the ailment of the complainant as acute pancreatic based on the background history of alcohol consumption.It is evident that only with the fraudulent intention and to manipulate the claim, the complainant has collected such certificate from the treating doctor and that too after six months from the date of repudiation. The o.ps had rightly communicated to the complainant vide its letter dated 17.08.2012 in response to his said representation confirming repudiation of the claim once again invoking Exclusion Clause No.11 of the policy without giving any weight-age to the subsequent certificate of the treating doctor.
Thus there is no iota of doubt that the proximate cause of the ailment of the complainant was due to consumption of alcohol and therefore not payable under the terms and conditions of the policy.
On the basis of the pleadings of the respective parties following points are to be decided:-
- Whether there was any deficiency in service on the part of the o.ps ?
- 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 fact
Considering the submissions of the respective parties and document on record it is an admitted fact that complainant obtained Family Health Optima Insurance Policy for the period from 28.10.2010 to 27.10.2011. Complainant got admission on 07.09.2011 for treatment of acute pancreatitis and released on 11.09.2011and he submitted an insurance claim with relevant papers for reimbursement claiming Rs.46,000/- as medical expenses issued by the Woodland Hospital. But the o.p. has repudiated the claim on 02.12.2011 citing exclusion clause no. 11 of the policy where the Company has stated that company is not liable to pay any hospital expenses if the admission and treatment of the patient is due to the habit of consuming alcohol or any kind of intoxicating drug. Again, the treating doctor in a certificate dated 24.09.2011 mentioned that the complainant’s pancreatic problem is due to consumption of alcohol. As per exclusion no. 10 of the policy issued to the complainant, o.ps are not liable to make any payment in respect of any expense for treatment of general debility. Accordingly the claim was repudiated by the o.ps and the same was communicated vide letter dated 02.12.2011 &13.01.2012.
The contract of insurance is based on the doctrine of utmost good faith and life assured was under an obligation to disclose each and every aspect with respect to his health at the time of submitting proposal form. Complainant did not do so. The treating doctor erroneously issued the certificate dated 20.06.2012 on the request of the complainant as it is evident from the certificate dated 24.09.2012 of the same doctor. The insured had not disclosed the fact of being alcoholic, thus the complainant had violated the very basic concept of insurance contract which is based on doctrine of utmost good faith. Hence, ops had rightly repudiated the claim of the complaint.
Hence, it is ordered,
that the case no. 588 of 2013 is dismissed on contest without cost against the o.p.s.
Supply certified copy of this order to the parties free of cost.
