Delhi

New Delhi

CC/436/2013

Raaj Sharma - Complainant(s)

Versus

M/S. Royal Sundaram Alliance Insurance Company Ltd. - Opp.Party(s)

23 May 2016

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI),

 ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

 NEW DELHI-110001

Case No.C.C./436/2013                                 Dated:

In the matter of:

SH. RAAJ SHARMA

E/o Pink Apartments,

Flat No. 196, Sector-18 B,

Dwarka,

New Delhi-75

        ……..COMPLAINANT

 

VERSUS

Royal Sunderam Alliance Insurance Co. Ltd.,

1505-1506, 15^th Floor, Ambadeep Building,

14, K.G. Marg, Connaught Place,

New Delhi-110001

 

               .... OPPOSITE PARTY

 

PRESIDENT: S.K. SARVARIA

ORDER

The repudiation of the medical claim of the complainant by the OP insurance company has led the former to file the present complaint against the latter under Section 12 of The Consumer Protection Act, 1986. The complaint has claimed the following reliefs against the OP insurance company:

(a)       Rs.90,357/- and interest thereon at the rate of 18% p.a.

 

 

(b)       Rs.50,000/- as compensation for the harassment, inconvenience, frustration and           mental agony suffered by the complainant.

(c)        Award costs of the complaint in favour of the complainant and against the OP.

(d)       Rs.25,000/- towards costs of the litigation, fees of advocats, legal notice and other expenses.

 

            The notice of the complaint was issued to the OP insurance company who contested the complaint and filed reply disputing the claim of the complainant and praying for dismissal of the complaint. In support of his case, the complaint has filed his affidavit in evidence and on behalf of the OP insurance company, the affidavit in evidence of Mr G. Vinay Parkash an officer and authorised representative of the OP insurance company is filed. Both parties have filed written arguments also.

 

The parties, instead of addressing oral arguments have relied upon the written arguments. We have carefully read the written arguments filed on behalf of the parties, record of the case and have gone through the relevant provisions of law.

 

The basic facts are not in dispute. Admittedly OP had issued a Health Shield Standard Insurance Policy bearing No. HIQ0000424000100  to the complainant for the period commencing from 11/5/2002 10/5/2012, It is also not disputed that on 7/11/201, the complainant was admitted at Medanta Medicity Hospital run by Medanta Medicity Global Health Private Limited and was discharged from the said hospital on 9/11/2011. The medical expenses incurred by the complainant in the sum of rupees, 90,357/- are also not disputed on behalf of the OP insurance company.

 

            In the backdrop of the above admitted position the case and contention of complainant is that he was admitted to Medanta the Medicity Hospital on 7/11/2011 as he suffered from bleeding of the gums and was treated there and was discharged on 9/11/2011, during the validity period of the said insurance policy. The OP on the other hand, has repudiated the claim of the complainant and has taken the defence that the medical claim of the complaint was repudiated as the complainant had history of chronic alcoholism and the treatment availed by the complainant was for liver disease and esophageal varices which is the problem generated by alcoholism. Therefore, the complainant is not entitled to any claim from the OP insurance company.

 

We have given the careful thought to the above controversy after carefully perusing  the record of the case and find the contention of the OP insurance company well founded. Health Shield Standard Insurance Policy issued by OP to the complainant is Exhibit R. 1. The Health Shield Standard Insurance Policy issued to the complainant is subject to the terms and condition appended to it.  In the  Policy Schedule, according to Exclusion Clause (D 24) use of intoxicating drugs, alcohol and the treatment of alcoholism, drug abuse, et cetera and medical conditions resulting from or related to such abuse or addiction is excluded from the policy coverage. Now the discharge summary, dated 9/11/2011 issued by Medanta the Medicity run by Medanta Global Health Private Limited shows, against the heading Diagnosis, that  the complainant had acute GI bleed under evaluation. He is shown to suffer from alcoholic liver disease and had alcohol dependence. The report of Santosh Memorial Clinic and Shivganga Hospital also shows complainant is chronic alcoholic. Therefore, the case of complainant is directly covered in the Exclusion Clause D 24 and his claim is rightly repudiated by the OP insurance company.

 

There is yet another point which makes the present complaint liable to be dismissed. The complainant in the complaint has alleged that he was admitted to the hospital in question on 7/11/2011 and was discharged on 9/11/2011 as he was suffering from bleeding of the gums and he suddenly became unconscious and had bruises on his body. The medical record and discharge summary of the complainant, referred before, clearly shows that the complainant had acute GI bleed under evaluation. He is shown to suffer from alcoholic liver disease and had alcohol dependence. Therefore, present complaint is based upon the false claim of the complainant by concealing the actual disease for which he took treatment from the hospital in question.

 

In view of the above discussion, we do not find any merit in the present complaint. The complaint is dismissed with costs of Rs. 5000/- to be paid be complainant to OP Insurance Company. A copy of this order reach be sent to both parties by registered post free of cost. This order be sent to server (www.confonet.nic.in ).

 

The file be consigned to the record room.

Announced in open forum on 23/5/2016

 

 

(S K SARVARIA)

PRESIDENT

 

                                            (H M VYAS)

MEMBER