Delhi

New Delhi

CC/326/2011

Gautam Sehgal - Complainant(s)

Versus

M/S. United India Insurance Company Ltd. - Opp.Party(s)

30 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./326/2011/                                       Dated:

In the matter of:

GAUTAM SEHGAL,

S/o Sh. Harish Sehgal,

R/o C-121, Ramprastha,

Ghaziabad,

Uttar Pradesh.

 

        ……..COMPLAINANT

VERSUS

 

UNITED INDIA INSURANCE CO. LTD.

503-504, 5^th Floor, 26, Kailash Building,

Kasturba Gandhi Marg,

Connaught Place,

New Delhi-110001.

               .... OPPOSITE PARTY

 

PRESIDENT: S.K. SARVARIA

ORDER

 

Repudiation of the insurance claim of the complainant by the OP insurance company has led the complainant file the present complaint under section 12 of The Consumer Protection Act, 1986. The case of complainant as disclosed in the complaint, in short, is that he is insured with the OP vide policy number 041200/48/10/41/00000047 PHS ID No. 20320010 and the parents of complainant are also covered for healthcare. On 20/12/2010 father of the complainant, Mr Harish Sehgal fell sick and was referred to Sant Parmanand Hospital, Civil Lines, Delhi, wherein he remained hospitalised from 20/12/2010 to 29/12/2010. The father of the complainant was diagnosed with “Acute Ulcerative Colitis”. The hospital charged the complainant Rs. 97,425/- towards hospitalisation expenses and medical bills for treatment of his father amounted to Rs. 26,253/– thus both totaling Rs. 1,23,678/–.

The complainant on 12/1/2011 raised insurance claim with the OP, but the same was repudiated vide OP’s Online Status Report on the grounds that discharge summary of hospitalisation from 11/4/2008 to 19/4/2008, the patient was known alcoholic for the last 25 years, and as per terms and conditions of policy alcohol and its related complications are not covered. Hence, the claim stands repudiated by OP insurance company.

        According to the complainant the disease of the father of the complainant was in no way related to either alcohol intake or alcoholism. The discharge summary of the hospital does not mention any instance of alcoholism and does not give any diagnoses upon that basis. It clearly states that patient Sh. Harish Sehgal was suffering from “Acute Ulcerative Colitis”. The OP has thus wrongly repudiated the claim.

The complainant has prayed for the following reliefs:

1. Direct the OP, namely, United India Insurance Co. Ltd. to pay Rs. 1,23,678/-towards the Medical Expenses incurred by the complainant, alongwith interest @12% p.a. from the date of payment of the Medical Expenses by the Complainant till date of realization.
2. Award damages in the amount of Rs. 3,00,000/- along with litigation expenses in the amount of Rs, 14,000/- to the complainant and against the OP; and
3. Grant any other relief as this Hon’ble Forum may deem fit in the interest of justice, equity and good conscience.

 

The notice of the complaint was issued to the OP insurance company who contested the complaint and filed written statement admitting that the said insurance policy for the period 1/4/2010 to 31/3/2011 was obtained by the complainant for himself and his parents. According to the OP, alcohol and its related complications are not covered under the policy. After receipt of the claim from the complainant the OP insurance company deputed Claim Department of Paramount Health Services TPA Private Limited to assess the claim of the complainant who submitted the report to the OP company stating that complainant had lodged a false claim. Thereafter, OP also examined the claim of the complainant and rightly repudiated the claim of the complainant. OP has denied that there was any deficiency in service on its part and has denied other facts stated in the complaint. The OP has prayed for dismissal of the complainant with heavy costs in favour of the OP company.

In support of his case, the complainant filed his affidavit in evidence. On behalf of the OP insurance company, the affidavit in evidence of Mr Shyam Singh, Divisional Manager of the OP insurance company is filed. The complainant has filed written arguments. No written arguments are filed by the OP insurance company. It is also to be noted that after hearing arguments on behalf of complainant this complaint case was reserved for final order on 15/4/2014, and in the meantime, some learned Members of this District Forum changed. So, the learned outgoing President of this District Forum on 30/11/2015 adjourned the matter for re-arguments on 15/5/2016. On 16/5/2016 none appeared for the OP and only learned counsel for complainant appeared, who addressed final arguments.

We have heard learned counsel for the complainant and have gone through the written arguments filed on behalf of complainant, record of the case and relevant provisions of law.

The basic facts in the pleadings and evidence are not disputed. Undisputedly, the complainant obtained the insurance policy for himself and for his parents being policy number 041200/48/10/41/00000047 PHS ID No. 20320010 from the OP and during its validity period his father, Mr Harish Sehgal fell sick and was hospitalised in Sant Parmanand Hospital, Civil Lines, Delhi from 20/12/2010 29/12/2010, for obtaining treatment for “Acute Ulcerative Colitis”. The hospital charged the complainant Rs. 97,425/- towards hospitalisation expenses and medical bills for treatment of his father amounted to Rs. 26,253/- thus totaling Rs. 1,23,678/-. These expenses are also not disputed by the OP insurance company in the pleadings. The complainant on 12/1/2011 raised insurance claim with the OP, but the same was repudiated vide OP’s online status report on the ground that discharge summary of hospitalisation from 20/12/2010 to 29/12/2010 shows the patient was known alcoholic for the last 25 years, and as per terms and condition of policy alcohol and its related complications are not covered.

 

 

In the backdrop of the above admitted position the only question which remains to be decided in whether the repudiation of the insurance claim of the complainant by the OP insurance company on the ground that in the discharge summary in 2008, the father of the complainant is shown as known alcoholic for the last 25 years is established on record or not, since this ground for repudiation is strongly objected on behalf of the complainant. There is no document or discharge summary produced by the OP insurance company either with the written statement or with the affidavit in evidence to show or justify its plea that in the discharge summary of 2008, the father of the complainant is shown as known alcoholic for the last 25 years. Further, in the discharge summary of Sant Parmanand Hospital in which the father of the complainant was hospitalised during 20/12/2010  to 29/12/2010, nowhere, it is stated that father of the complainant was alcoholic or was consuming alcohol for the last 25 years or suffered the disease in question on account of consuming alcohol. Therefore, we do not have any hesitation in holding that the repudiation of the medical reimbursement insurance claim of the complainant was an unjustified act on the part of OP insurance company, leading to the irresistible conclusion of deficiency in service on the part of OP insurance company. The complaint, therefore, deserves to be allowed. However, we find that though the complainant is entitled to reimbursement of the medical bills from the hospital in question, but the claim of damages in the sum of Rs. 3,00,000/- looks to be on quite higher side. So, it needs to be curtailed.

In view of the above discussion the complaint is allowed and we direct OP insurance company to reimburse the insurance claim of medical expenses incurred by the complainant for medical treatment of his father amounting to Rs. 1,23,678/– along with simple interest at the rate of 10% per annum from the date of filing of the complaint till realisation of the said amount. We also direct the OP insurance company to make the payment in the sum of Rs. 50,000/– to the complainant on account of mental agony and harassment suffered by the complainant and also clarify that this amount is inclusive of litigation cost. If the said amount is not paid by the OP insurance company within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 10% per annum from the date of this order till recovery of the said amount of Rs. 50,000/–. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

File be consigned to the record room.

Pronounced in open Forum on  30.5.2016

 

(S K SARVARIA)

PRESIDENT

 

                                           (H.M VYAS)

                                    MEMBER