ORDER

DR. VIKRAM DABAS

Late Sh. Alok Goyal was holder of a mediclaim policy which was valid till 

30.6.2013. the present complaint was filed by his legal heirs.  It is the case of 

the complainants that late Sh. Alok Goyal was a patient of Hepatitis C since 

2003 and was admitted in Vedanta Hospital , Gurgoan on 11.9.2012 for 

stomach varices bleeding caused due to H.C.V. related C.L.D.   Late Alok Goyal 

had expired on 30.10.2013 . the complainants have filed a claim with the OP for 

reimbursement of the expenses incurred on the treatment of the disease  and 

had claimed a sum of Rs. 5,00,000/- as per the terms and conditions of the 

insurance. The OP had , however, repudiated the claim. The complainants have 

alleged that this act of repudiation was illegal an unjust. 

The Ops have contested the complaint and have filed a written statement. It is 

claimed that the complaint is not maintainable as there is no deficiency in 

service on the part of the Ops.   Paras no. 1 to 3 of the preliminary submission 

of written statement is relevant for the purpose of disposal of this complaint and 

PRELIMINARY SUBMISSION:- 

1.That admittedly, the complainant 

was Mediclaimpolicy holder vide policy 

no.271400/48/2013/1574 with the 

insurance cover for a sum of 

Rs.5,00,000/-(Rupees five lacs only) 

valid upto 30.06.2014. The said 

mediclaim was issued subject to the 

Page 2 of 5

terms and conditions which are 

applicable as per Standard Mediclaim 

2. That the complainant preferred the 

reimbursement claim for multiple 

hospitalizations of the complainant at 

Medanta from 11.09.2012 

to01.06.2013.However, the discharge 

summary from11/09/2012 to 

20/09/2012 clearly reveals that the 

Complainant was diagnosis with"CLD-

HCV/Ethanol(Alcohol related to CLD 

with recurrent bleed". The copy of the 

said discharge summary was

already placed on record as Annexure 

It is submitted that as per exclusion 

clause 4.8 of the policy, "Individual 

claim policy does not cover the 

expenses related to use/misuse. and 

abuse of alcohol". Thus, the claim of 

the complainant is not admissible as 

per terms and condition of the policy.

3. That it is pertinent to mentioned 

here that prior to the submission of 

re-imbursement claim, the 

complainant had also preferred two 

cashless claims numbered 

OICDR2/3934 & OICDR2/4968 the 

Page 3 of 5

same policy for hospitalization

11.09.2012 to 20.09.2012 and on 

15.01.2013 which were declined on 

20.09.2012 and 16.01.2013 

respectively under clause "expenses 

related to  use/misuse/abuse of 

Alcohol being not payable vide 

exclusion clause 4.8". The 

respondents subsequent to the denial 

of cash less claims of the 

complainants also carried out the 

verification of the inpatient records of 

the Lt. Sh. Aloke Goyal. It is submitted 

that the Lt. Sh. Aloke Goyal. had 

history of alcohol consumption 120-

150 ml/day in a weeks. The copy of 

the said record is annexed herewith 

for the kind perusal of this Hon'ble 

          The Op has contested the complaint on merits and have reiterated that 

the claim was not payable as per exclusion clause no. 4.8 of the policy. 

      We have heard arguments advanced at the bar and have perused the 

     The sole question for our consideration is whether OP1 was justified in 

repudiating the claim lodged by the complainant. OP1 has contended that the 

claim was not payable as per exclusion clause 4.8 of the terms and conditions of 

the policy of insurance purchased by the complainant. The OP has relied upon 

Page 4 of 5

the terms and conditions of the Happy family floater  policy. This was not the 

policy which was purchased by the complainant. He  had purchased an 

individual mediclaim policy. Reliance on clause 4.8 of the Happy family floater  

policy was, therefore, misconceived and cannot be made the basis of the 

   Secondly, the OP has repudiated the claim on the ground that it was a case of 

alchol abuse on the part of the deceased.  We have gone through a certificate 

dated 3.10.2012 issued  by  the treating doctor namely Dr. A.S. Soin  who has 

certified that the deceased was suffering from HCV related chronic liver disease 

. As per the above certificate the deceased was suffering from Hepatitis C virus 

and his condition was not related to any abuse of alcohol. The primary cause for 

the illness was Hepatitis C which is also evident from subsequent discharge 

summaries issued by the Hospital and also the death summary of the patient 

placed on record of this case. From the above discussion we are of the 

considered opinion that in the facts and circumstances of the case, repudiation 

of the claim was unjustified and uncalled-for. We hold OP guilty of deficiency in 

service and direct it as under:-

1. Release to the complainant the claim on the amount spent on the treatment 

of the deceased subject to the maximum of sum insured i.e. Rs 5,00,000/-.

2. Pay to the complainants a sum of Rs. 50,000/- as compensation for pain and 

3.Pay to the complainants a sum of Rs. 5,000/- as cost of litigation.

   The OP shall pay this amount within a period of 30 days from 

the date of this order failing which they shall be liable to pay 

interest on the entire awarded amount @ 10% per annum.  IF the 

OP fails to comply with this order, the complainant may approach 

this Forum for execution of the order under Section 25/27 of the 

Consumer Protection Act. 

Copy of the order be made available to the parties as per 

rule.   File be consigned to record room. 

Announced in open sitting of the Forum 

on.....................