DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

Received by way of transfer                                            Consumer Complaint No.150 of 2018

                                              Date of institution: 01.03.2018

                                              Date of Decision:18.07.2022

1. Gurjot Bhatia son of Sh. H.S. Bhatia, resident of 494, Model Town, Ludhiana
2. Mnhar Bhatia, son of Sh. Gurjot Bhatia, Resident of 494, Model Town, Ludhiana 

…….Complainants

Versus

1. Max Bhupa Health Insurance Company Limited. B-I/I-2, Mohan Cooperative Industrial Estate Mathura Road, New Delhi-110044,

IInd Address: Plot No.88, Second Floor, Kunal Tower, Mall Road, Opposite Axis Bank, Ludhiana 141001

                                     ……..Opposite Party

QUORUM:     

HON’BLE MR. RANJIT SINGH, PRESIDENT.

                       HON’BLE MRS. RANVIR KAUR, MEMBER

PRESENT:

Sh.Ankur Ghai, Adv. counsel for complainant

Sh. V.S. Mand, Adv. For OP

ORDER

SH. RANJIT SINGH, PRESIDENT

The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Party on the ground that the complainant No.1 had taken out Max Bhupa Health Insurance from Opposite Party. The complainants have been issued the policy bearing No.30130005201604 with commencement date of 27.9.2016 and valid upto 26.9.2017. The policy was for sum insured of Rs.25,00,000/- and the complainant Nos.1 & 2 were the persons insured under the policy. The complainants had paid the premium dues Rs.15,072/- to the opposite party for the issuance of the policy. It is further alleged that before issuance of the policy, the opposite party has completed all their legal and medical formalities. Unfortunately, the complainant No.2, whose also insured under the policy met with an accident on 19.11.2016 during the validity of the policy. The complainant No.2 was driving his vehicle bearing No.PB-10-BU-4605 Hyundai Accent car on the night of 19.11.2016 when the complainant No.2 was going to meet his friend when around 10.30 PM near Verka Milk Plant Ferozpur Road, Ludhiana, the vehicle was involved in an accident. The accident was not because of any negligence or default of the complainant No.2. However, the complainant No.2

suffered injuries. The DDR was duly registered bearing No.07 dated 20.11.2016 at the police station PAU, Ludhiana. It is further alleged that the complainant No.2 is had valid driving license. Even on the date of occurrence i.e. night of 19.11.2016, the complainant No.2 have valid driving license duly issued on 28.01.2016 and valid till 27.1.2016. The complainant No.2 who is duly insured under the policy being son of complainant No.1 was initially taken to Deepak Hospital, Sarabha Nagar, Ludhiana, on 19.11.2016 at around 11.15 PM approximately and after being given initial medical aid was adviced to be taken to big hospital. Thereafter, the complainant No.2 was admitted in CMC Ludhiana on 20.11.2016. He was diagnosed with Closed Fracture Shaft of Left Humerus Distal 1/3^rd Radial Nerve Injury. The complainant No.2 was initially admitted under Neurosurgery in view of Low GCS. Once cleared he was taken up for ORIF + Planting Left Humerus and radial never exploration on 21.11.2016 suture line dressing was done which was clean and dry. Physiotherapy with elbow mobilization exercise and dynamic cockup exercises were started. The complainant No.2 was discharged by the hospital on 26.11.2016 with follow ups in OPD.  While at CMC Hospital, the complainant No.2 in the intervening night of 19.11.2016-20.11.2016 was also made to undergo bio chemistry test for blood alcohol count. In the test revealed Blood Alcohol Count to be 24.5 Mg/Dl. The permissible limits remain upto 30 Mg/Dl. The complainant had to incurred huge expenditure for the treatment at the CMC Hospital as well as Deepak Hospital. The complainant had to incur expenditure qua the treatment/admission at Deepak Hospital, Treatment at CMC as well as for medicines etc. and physiotherapy sessions. Thus, the complainant had to incur total expenditure of Rs.1,82,457/- on the treatment of complainant No.2. The complainant submitted their claim with the OP bearing No.22643 dated 16.1.2017, however, the OP rejected the claim for the reason clause -4, i.e. treatment related to addictive conditions and disorders, or from any kind of substances abuse or misuse. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-

1. To direct the OP to make the payment of Rs.3,28,957/- (principal amount of Rs.1,82,457/- with interest @ 12% per annum Rs.21,500/- from January, 2017 till date 
2.  To pay compensation of Rs.1,00,000/- on account of mental harassment, which the complainant has to face due to irresponsible attitude of the OPs.
3. To pay Rs.25,000/- as litigation expenses.

2. In reply, the OP has filed written reply taking preliminary objections; that complaint is not maintainable ; that the policy under question health companion was issued by the OP company on the basis of the information provided by the proposer in the proposal form. The OP company has acted strictly as per the policy terms and conditions and have acted within the four corners of the statutory provisions, no case of deficiency in service can be said to have arisen and as such the present complaint is liable to be dismissed. As per the terms of the policy contract if the policy is not suitable, the policy holder may get his/her policy reviewed by returning the policy and policy documents within 15 days from the day the policy holder received the policy. The insurance company will return the premium paid to the policy holder after making certain deductions specified therein. In the present case, the policy along with policy documents was dispatched to the policy holder and the same was duly received as admitted. The complainant after the receipt of the subject policy and policy documents did not approach the replying OP and got his subject policy reviewed/cancelled within free look period implying that the complainant duly accepted the subject policy and its documents with its terms and conditions. The policy holder never approached the replying OP with any grievance pertaining to the subject policy and its terms and conditions. The complainant is bound by the policy contract and given up relinquish/waved his right by not exercising the free look provision. Rest of allegations leveled by the complainant against the answering OP have been denied and prayed for dismissal the complaint.

3.     In support of the complaint, the complainant has tendered various documents. On the other hand, the OP also tendered certain documents in support of their version.

4.     We have heard the learned counsel for the parties and have gone through the record of the file, carefully.

5.     The contract of insurance between the complainant and OP is not denied the factum of accident during the subsistence of insurance is undisputed. The issue of dispute between the parties is narrowed down, whether factum of the complainant of having consumed alcohol, warrants the cancellation of the insurance disentitling the complainant of the insurance amount.

6.     The claim of the OP that the complainant did not disclose that he used to take alcohol does not behold legally. The reasons for the same being firstly consumption of the alcohol itself is not banned. Secondly, it being a matter of common sense the insurance companies usually subject the prospective buyer of the insurance to medical examination thereby the OP was free to subject the prospective buyer to the medical test to know whether he is habitual of consuming alcohol before entering into contract of insurance. The OP has not rebutted the claim of the complainant, the consumption of the alcohol within limits at the relevant time.

7.     In the light of aforesaid scenario the claim of the OP regarding non disclosing by the complainant being consumer of alcohol and the factum of his (complainant) having consumed alcohol (undisputedly within permissible limits) disentitling the complainant of the insurance amount does not behold legally.

8.     Consequently, the complaint of the complainant succeeds. Complainant is entitled to Rs.3,28,957/- a insurance along with interest @ 9% per annum from the date its becoming due. The OP is further directed to pay Rs.50,000/- as compensation and Rs.20,000/- as litigation expenses. The OP is further directed to comply with the said order within a period of 30 days from the date of receiving the certified copy of this order. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

July 18, 2022

(Ranjit Singh)

(Ranvir Kaur)

RBT/ CC No.150 of 2018

Present:    Sh.Ankur Ghai, Adv. counsel for complainant

               Sh. V.S. Mand, Adv. For OP

Vide our separate detailed order of today, the complaint stands allowed. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

July,18 2022

(Ranjit Singh)

(Ranvir Kaur)