BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.426 of 2016

Date of Instt. 03.10.2016

Date of Decision: 04.10.2017

Om Parkash Bhambri aged about 60 years son of Sh. Aishi Lal R/o H. No.163, Seth Hukam Chand Colony, Jalandhar.

..........Complainant

Versus

1. M/s National Insurance Co. Ltd., Head Office: 3, Middleton Street, Kolkatta, West Bengal, PIN 700071, Through its Chairman/Mg. Director.

2. M/s National Insurance Co. Ltd., Divisional Office I, BMC Chowk, G.T. Road, Jalandhar Through its Senior Divisional Manager.

….… Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Sh. Parminder Sharma (Member)

Present: Sh. Rohan Bhalla, Adv Counsel for the complainant.

Sh. RS Arora, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. The instant complaint presented by the complainant, wherein stated that he purchased one medi-claim policy bearing policy No.4033004815850000523 dated 27.03.2016 valid from 27.03.2016 to 26.03.2017, from the OPs and the said policy including the coverage of all kinds of risks of medical expenses, of medical treatment including major surgeries of the complainant and his family members as mentioned in the policy. The yearly premium of the policy was Rs.13,496/- and the complainant has paid the said premium to the OPs and the said policy is to cover the risk of medical treatment upto the tune of Rs.1,50,000/- of each insured member. The complainant has purchased this policy on 24.03.2010 and thereafter the complainant is regularly getting the renewal of the same from the OPs without any default. The complainant is regularly paying the annual premium and getting the renewal of the same. At the time of purchase of the policy, the concerned agent assured the complainant that during the validity of the policy, if the complainant will suffer any kind of medical problem including any kind of surgery, the OP is liable to pay all the hospital expenses, medicine expenses as well as other connected expenses to the complainant. Moreover, at the time of purchase of the policy, medical check-up as well as blood test was done by the empanelled doctor of the OP and after the complete check up, the OP issued the policy in question to the complainant.

2. That during the validity of the said policy, the complainant was having problem of heaviness in chest. Due to that reason, the complainant was admitted in Global Hospital, Jalandhar on 22.04.2016, where he was provided medical treatment by hospital authority and the doctors diagnosed as HTN, DM Type-2, CAD (Unstable Angina) and the complainant underwent successful PTCA and stunt was deployed at 12 ATM pressure. After the surgery, the complainant was discharged from the hospital on 24.04.2016. The complainant has paid a sum of Rs.1,70,367/- to the Global Hospital, Jalandhar for medical treatment, which include hospital expenses, medicines as well as other expenses. Thereafter, the complainant contacted the agent of the OPs and supplied all the medical bills of Rs.1,70,367/- to the said agent and who got the signatures of the complainant on one claim form, which was blank at that time. The complainant asked the said agent to complete the said form and explained all the medical expenses and the said agent assured the complainant that he will do the same at his own level. Inspite of completion of all the necessary formalities, OPs repudiated the claim of the complainant, vide letter dated 01.09.2016 by which the OPs declined the claim of the complainant on the ground that the complainant is chronic alcoholic, which is main contributory factor for causing diabetes and its complications leading to coronary artery disease and therefore disease due to alcohol falls under permanent exclusion of the policy. As per the OP, the claim of the complainant is not payable under Clause 4.21 of the policy. In fact, the complainant is not chronic alcoholic and moreover, the words chronic alcoholic is wrongly written by Duty Medical Officer. No such past history was ever given by the complainant to any doctor regarding the alcohol and when this wrong writing came into the knowledge of medical officer, who has attended and given treatment to the complainant, the said medical officer Dr. Anwar Khan admitted his error and the necessary correction has been made in the discharge summary of the complainant. The said doctor also issued a separate certificate after correction of the error. So, infact, the history has wrongly been mentioned by duty medical officer, which was later on corrected by the concerned doctor. Moreover, before this problem, the complainant was getting regular medical check up from different hospitals and there was not any medical problem to the complainant. So, the complainant never concealed any fact as mentioned in the repudiation letter. Moreover, the policy was firstly purchased in the year 2010 and thereafter, the said policy was regularly being renewed by the OP every year and there is not even a single complaint of heart problem of the complainant during long period of six years. At the time of purchase of the policy, OPs assured that the complainant needs not to bother anything, the entire amount of the treatment will be directly paid by the OPs to the complainant immediately after the submission of the claim by the complainant. The complainant had completed all the formalities, OP was lingering on the matter on one pretext or other, which resulted into deficiency in service on the part of the OPs. The complainant also suffered mental tension, harassment and agony due to non-payment of claim and as such the present complaint was filed with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the amount of claim i.e. Rs.1,70,367/- and also be directed to pay compensation of Rs.1,00,000/- for mental tension, harassment and agony and further be directed to pay litigation expenses to the tune of Rs.22,000/-.

3. Notice of the complaint was given to the OPs and accordingly both the OPs appeared through their counsel and filed written reply, whereby contested the complaint by taking preliminary objections that there is an attempt by the complainant by getting white-washed a grave incriminating fact from his surgeon Dr. Anwar Khan, who created forgery to help the complainant and therefore, the complaint is liable to be delegated to the Civil Court and further averred that the complaint is based on total misconception of the complainant. His conception is sadly that he could succeed by obtaining a letter from his doctor that he was not “Chronic Alcoholic” and as such the complaint of the complainant deserves to be dismissed. On merits, it is admitted that the complainant purchased insurance policy from the OP and it is also not denied by the OPs that the complainant submitted a medical claim but the same was repudiated by the OPs, vide letter dated 01.09.2016 under Exclusion Clause 4.21 of the policy, but the remaining allegations as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merit and the same may be dismissed.

4. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit Ex.CA and supplementary affidavit Ex.CB alongwith some documents Ex.C1 to Ex.C13 and then closed the evidence.

5. Similarly, counsel for the OP No.1 and 2 tendered into evidence two affidavits Ex.O1 and Ex.O2 alongwith document Ex.O3 i.e. Discharge Summary and also produced on the file Mediclaim Insurance Policy i.e. Ex.O4 and then closed the evidence.

6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

7. From the facts as enumerated in the complaint as well as written reply, it reveals that the issue in regard to purchase of the mediclaim insurance policy by the complainant on 27.03.2016 for the period of 27.03.2016 to 26.03.2017 and the said policy is to cover the risk of medical treatment upto the tune of Rs.1,50,000/- of each insured member and even submitting of mediclaim is also not denied by the OPs, rather these factum have been admitted.

8. Now issue in dispute is only, whether the medi insurance claim of the complainant has been rejected by the OP on a substantive ground or not. For concluding the above query, we have gone through the all documents, produced on file by both the parties and accordingly, we analyzed the documents i.e. Insurance Card, obtained by the complainant from the insurance policy for the year 2011, the same is Ex.C1. Further, complainant got insurance in the year 2012, 2013, 2014 and then the last insurance obtained by the complainant, which is under reference, on 27.03.2016 till 26.03.2017 and repudiation letter is Ex.C9, the said repudiation letter is a main and crucial document in this case and accordingly, we gave deep consideration to this repudiation letter Ex.C9 dated 01.09.2016, whereby the medical insurance claim wad declined, on the ground that as per personal history of the patient, patient is chronic alcoholic, which is the main contributing factor in causing diabetes and its complications leading to coronary artery disease. Therefore, disease due to alcohol falls under permanent exclusion of the policy as per Clause 4.21 of the policy and this repudiation letter is under challenge. In order to collect a truth, it is required to go through the document produced on the file by the OPs i.e. affidavit of Gurwinder Kaur, Deputy Manager Ex.O1 and further she again filed her supplementary affidavit Ex.O2, whereby the version of the complainant is categorically denied. Apart from that the OP has also brought on the file Discharge Summary and whole case of the OP is based upon discharge summary Ex.O3, issued by the Global Hospital, where from the complainant got his treatment, no doubt in the said discharge summary, the personal history recorded by the doctor is as under:- “Chronic Alcoholic” and also recorded that Diabetes Mellitus:Yes; Hypertension: Yes, making a base of this discharge summary Ex.O3, the repudiation letter Ex.C9, issued by the OP, whereby rejected the claim of the complainant but as per the version of the complainant, the Duty Medical Officer of Global Hospital inadvertently recorded the remarks in the discharge summary chronic alcoholic, whereas the complainant is not a chronic alcoholic and when this factum has brought to the notice of the treating doctor i.e. Dr. Anwar Khan, who rectified this mistake by giving an other certificate, which is Ex.C8, wherein categorically described by the said doctor, which is as under:-

“Regarding the sentence of Chronic Alcoholic in column personal history was written by mistake by duty medical officer. So, after coming in right, chronic Alcoholic has been cut off from the personal history of the patient. Kindly note down”.

9. Apart from this certificate, issued by the doctor, who also submitted his affidavit Ex.CB, whereby reasserted the factum as detailed in the clarification certificate Ex.C8. It is natural phenomenon that man can commit a mistake but the same can be rectified, if came to the notice of the man and similarly happened in this case, as the duty medical officer recorded the remarks in personal history “Chronic Alcoholic”, but when these remarks have been deleted by the Senior Medical Officer Doctor Anwar Khan, who was giving treatment to the complainant, then we can conclude that the said word is considered to be excluded from the discharge summary Ex.O3, if so then, the complainant is not proved to chronic alcoholic and moreover, diabetes and hypertension is not a critical disease, in the fast running life, these type of diseases i.e. diabetes and hypertension are common to so many peoples. So, accordingly we find that the claim of the complainant is illegally and arbitrarily rejected by the OP because the word 'Chronic Alcoholic' is deleted from the summary report. Apart from that the complainant has been continuously getting an insurance from the OP since 2010 and he obtained 4-5 time insurance policy and if there was any heart disease or alcoholic habit, then the complainant must get a treatment from any other hospital, but no such evidence has been collected by the OP from any other hospital. So, in the absence of any medical evidence of other hospital that the complainant is alcoholic, diabetic and hypertension, is not proved and in support of above observation, we like to made a reliance a pronouncement of Hon'ble State Commission, cited in 2008(1) CPC 675, title “Life Insurance Corporation of India Vs. Smt. Sukhwinder Kaur”. On the same point, we take an opportunity to refer an other pronouncement of Hon'ble National Commission, cited in 2012(2) C.P.J 65, title “Life Insurance Corporation of India and another Vs. Sudesh”, wherein his Lordship held as under “question of repudiation under insurance policy, on the ground of concealment/suppression of information would have arisen only if there was evidence to show that insured had undergone hospitalization for any disease in near proximity of time when policy was obtained and had not disclosed it, insurance company can not take disadvantage of its own acts of commission or omission”. Further, we like to refer an other pronouncement of Hon'ble National Commission, cited in 2005(2) C.P.J 32, title “Surinder Kaur and others Vs. LIC of India and Others”, wherein his Lordship held as under “Doctors opinion based on hospital history, not sufficient, no treatment record prior to proposal produced by any doctor nor any reference of any doctor was received by hospital, repudiation on basis of hospital record unjustified”.

10. In view of above detailed discussion, itself emerged that the case of the complainant is proved and accordingly the complaint of the complainant is partly accepted and OP No.1 and 2 are directed to pay the insured amount of Rs.1,50,000/-, complainant is not entitled to get more than insured amount and further OPs are directed to pay compensation of Rs.20,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. Complaint could not be decided within stipulated time frame due to rush of work.

11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Parminder Sharma Karnail Singh

04.10.2017 Member President