DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (CENTRAL)ISBT KASHMERE GATE DELHI

COMPLAINT CASE NO. 133/2019

No. DC/ Central/

vs.

Coram:       Ms. Rekha Rani, President

                    Shri Vyas Muni Rai, Member

                   Ms. Shahina, Member (Female)

ORDER

Ms. Rekha Rani, President

1. Smt. Naintara Thakur (in short the complainant) filed the instant complaint under section 12 of the Consumer Protection Act, 1986 pleading therein that her husband purchased a National Mediclaim Policy vide policy no. 3613035001710003206 from National Insurance Company Ltd. (in short OP2) which was valid from 06.03.2018 to 05.03.2019.

Her husband was admitted in Rajiv Gandhi Cancer Institute and Research Center, Sector-05, Rohini, Delhi-110085 from 24.07.2018 to 26.07.2018, 07.09.2018 to 12.09.2018 and 19.10.2018 to 24.10.2018 for treatment of Squamous Cell Carcinoma of Lung with Multiple Brain Metastasis, who died on 26.11.2018.

An amount of Rs. 1,88,402/- and an amount of Rs. 5,02,645/- (total amount of Rs. 6,91,047/-) was spent on his treatment.

2. Complainant filed claim vide claim no. MD14553873 for Rs. 1,88,402/- and vide claim no. MD14370287 for Rs. 5,02,645/- (total amount of Rs. 6,91,047/-.

All the original documents were supplied to the OP as directed by them on 28.11.2018 and 11.09.2018. However, OP repudiated the claim on 06.10.2018. The repudiation of the claim is arbitrarily. Hence, instant complaint was filed seeking direction to OP to pay to the complainant an amount of Rs. 6,91,407/- and Rs. 5,00,000/- for causing harassment and mental agony.

3. Notice of complaint was issued to OP who appeared and contested the claim. Both sides filed evidence by way of affidavits. They also filed Written Submissions.
4. We have perused the material available on record. We have also heard Ld. Counsel for both sides.
5. OP has submitted that deceased husband of the complainant was treated for Squamous Cell Carcinoma of Lung with Multiple Brain Metastasis and that on scrutiny of claim documents it was observed that there was history of known-smoker and accordingly the claim was repudiated as per Clause 4.21 of the Insurance Policy as  treatment arose out of illness/ decease/ “due to misuse or abuse of drugs/ alcohol and use of intoxicating substance.” It is submitted that since deceased was smoker the claim was rightly repudiated as per terms of the insurance policy.
6. The claim is further resisted on the ground that the complaint has been filed with regard to medical claim and hospitalization expenses of late Mr. Veer S.S. Thakur by his widow, Ms. Naintara Thakur without making any other legal heirs as party to the present complaint. Further, it is stated that no succession certificate in favour of Ms. Naintara Thakur, none any no-objection certificate issued by any of the legal heirs has been placed on record and as such the claim is stated to be non-maintainable.

7.   It is submitted on behalf of the complainant that she is co-insured in the insurance policy in question. Copy of the policy is placed on record which indicates that Ms. Naintara Thakur, Wife of Mr. Veer S.S. Thakur was co-insured along with the complainant. Her name is clearly mentioned in the very first page of the policy. As such, she is entitled to file the instant complaint.

8. Ld. Counsel for OP has not placed on record any scientific evidence on record to indicate that smoking invariably causes cancer. It is a known fact that a smoker may not necessarily be afflicted with this decease and it is also true that a non- smoker may have this decease.

9. Ld. Counsel for complainant has also placed on record copy of a certificate issued by Rajiv Gandhi Cancer Institute and Research Centre which is signed by Dr. Vineet Talwar, Dr. Varun Goel and Dr. Prasanta Dash, bearing no. RGCI&RC/MRD/1794 dated 17.10.2018 and counter signed by COO& Medical Superintendent, Dr. Sunil K. Khetarpal which reads as follow:-

“This is to certify that Mr. Veer SS Thakur, 68Yrs Male CR. No. 237576 a diagnosed case of Ca lung with Brain mets is under treatment at this hospital since 06.07.2018. According to hospital record he gave the history of smoking but quit 2years back. On re interrogation in follow up he stated that the history of smoking, quit 4 years back.”

10. In view of above discussion the repeatation of claim of the complainant was not justified. The complaint is allowed and OP is directed to pay a sum of Rs. 1,88,402/- on account of claim filed vide claim no. MD14553873 and a sum of Rs. 5,02,645/- on account of claim filed vide claim no. MD14370287 total amount a sum of Rs. 6,91,047/-. along with compensation of Rs. 15,000/- within a period of 30 days from the date of receipt of copy of this order failing which the said amount shall be payable at the rate of 6% interest per annum from the date of filing of the complaint i.e. 11.06.2019  till the date of payment/ realization.
11. Copy of this order be sent to the parties as per rules. File be consigned to record room.

Announced on this  29^th  July of 2022.