DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.273/2012
Sh. Bhim Bahadur
S/o Sh. Lal Bahadur
DSO-1, GS Dhaula Kaun,
New Delhi-110010 ….Complainant
Versus
1. Medsave Healthcare (TPA) Ltd.
Through its Regional Manager
F-701-A, Lado Sarai, Mehrauli,
New Delhi
2. United India Insurance Company Ltd.
Through its Divisional Manager
5R/4, Gobind Bhawan, NIT
Faridabad, Haryana ……Opposite Parties
Date of Institution : 25.05.12 Date of Order : 09.02.16
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Briefly stated, the case of the Complainant is that he had purchased a medical insurance policy bearing No.040500/48/10/14/00002916 for the period from 09.12.10 to 08.12.11. Unfortunately, he suffered pain in his abdomen and was admitted to Sunil Hospital on 03.04.11. He remained in the hospital for 4 days and thereafter he was discharged on 07.04.11. He submitted the claim No.20110405B001R4C044 and completed all the formalities but his claim was rejected by the OP vide letter dated 07.06.2011 and the reasons were arbitrary and unreasonable in nature. He approached the OPs many times but the OPs did not pay any heed on his request and rejected claim without any fault on his part despite the fact that he was admitted to the hospital on 03.04.11. Hence, pleading deficiency in service on the part of OPs, the complaint has been filed with the following prayers:-
- Direct the OPs to release the claim amount of Rs.25392/- alongwith upto date interest to the Complainant.
- Direct the OPs to pay a compensation of Rs.50,000/- to the Complainant for causing mental agony, pain and harassment to the Complainant.
- Direct the OP to pay Rs.10,000/- to the Complainant as litigation charges and other expenses.
OP No.1 has been proceeded exparte vide order dated 18.09.12 passed by our predecessors.
OP No.2 in the written statement has stated that the Complainant had taken the mediclaim policy bearing No.040500/48/10/10/14/00002916. His discharge summary was issued by the Sunil Hospital clearly stating that “the patient Mr. Bhim Bahadur aged 40 years old male admitted with c/o pain in abdomen, vomiting after taking alcoholic in morning then blood comes by mouth with mild fever and since morning and K/C liver abscess at the time of admission and further treatment was given and during the course of the treatment it was confirmed that the problem arose to the Complainant was because of taking the alcoholic substance in the morning the excess of the same resulted in the vomiting and blood started coming out and was taken to the hospital”. Complainant was a known case of Liver Abscess. The Complainant was taken to hospital for treatment which was excluded vide exclusion clause 4.8 of the policy.
As per the exclusion clause 4.8 “Convalescence, general disability, “run down” procedure, venereal diseases, intentional self-injury /suicide/accident due to and or use, misuse or abuse of drugs/alcohol or use of intoxication substance or such abuse or addiction etc.”.
OP No.2 has further stated that the claim of the Complainant was not payable and therefore, the claim was repudiated and intimation to this effect was given to the Complainant vide letter dated 07.06.11. OP No.2 has prayed for dismissal of the complaint.
Complainant has filed his own affidavit in evidence while affidavit of Dr. D. K. Sharma, Divisional Manager has been filed in evidence on behalf of the OP.
Written arguments have been filed on behalf of the parties. We have heard the arguments of the Complainant and have also gone through the file very carefully.
CW-1/A is the copy of insurance policy issued by the OP No.2. The OP No.2 vide letter dated 07.06.11 (Ex.CW1/B) informed the Complainant that his claim was repudiated according to exclusion clause No.4.8 of the policy. The hospital issued a discharge summary dated 07.04.11 (copy Ex. CW-1/C).
It is not in dispute that the Complainant had an insurance policy of OP No.2. The Complainant fell sick on 03.04.11 and admitted in the hospital upto 07.04.11. In the discharge summary, the attending doctor has stated “the patient Mr. Bhim Bahadur aged 40 years old male admitted with c/o pain in abdomen, vomiting after taking alcoholic in morning then blood comes by mouth with mild fever and since morning and K/C liver abscess”.
In view of the above, it transpires that the OP No.2 has repudiated the claim as per clause 4.8 as per the terms and conditions of the policy as mentioned above. At the time of discharge, the doctor mentioned that the Complainant has a liver abscess and he was hospitalized for the treatment of vomiting after taking alcohol in the morning. The Complainant has not mentioned anywhere in the complaint or filed any document that he was sick due to not take alcohol. Hence, the Complainant has failed to prove any deficiency in service on the part of OP No.2. Therefore, we dismiss the complaint with no order as to costs.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 09.02.16.
(NAINA BAKSHI) (N.K. GOEL) MEMBER PRESIDENT
Case No. 273/12
09.02.2016
Present – None
Vide our separate order of even date pronounced, the complaint is dismissed. Let the file be consigned to record room
(NAINA BAKSHI) (N. K. GOEL) MEMBER PRESIDENT
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