BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 275 of 2015

Date of Institution: 04.05.2015

Date of Decision: 13.07.2016  

1) Mrs.Radhika Soni widow of Vikas Soni, 2) Mrs.Radhika Soni widow of Vikas Soni being the natural guardian of minor daughter Harshita Soni, Legal heirs of the deceased Vikas Soni resident of House No. 2147, Bazar Sikri Bandan, Katra Dullo, Amritsar. Aged 38 years.

Complainants

Versus

National Insurance Company Limited, Kolkata through its Chairman/ Managing Director/ Principle Officer, service through its Branch Office at D-26, Court Road, Amritsar through its Branch Manager. 

Opposite Party

Complaint under section  12 & 13 of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainants: Sh.Deepinder Singh, Advocate

              For the Opposite Party: Sh. S.K.Davessar, Advocate

Coram

Sh.S.S.Panesar, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.S.S. Panesar, President.

1.       Smt.Radhika Soni and her minor daughter Harshita Soni, have brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainants are the legal heir of deceased Vikas Soni, who had taken the Health Plus Medical Expenses Policy from Opposite Party for himself and the complainants vide policy No. 401900/48/13/8500002223 covering the risk period w.e.f. 26.11.2013 to 25.11.2014. The copy of the policy document is annexed. The complainants are the consumers as provided under the Act and  are competent to invoke the jurisdiction of this Forum. Deceased Vikas Soni unfortunately fell ill and was to be hospitalized at Dayanand Medical College & Hospital, Ludhiana for the period 16.10.2014 till 29.11.2014 where his total hospitalization bill come to Rs.5,67,668/- and the deceased was insured for Rs.2 lacs, with Opposite Party, the claim with all the relevant documents were filed with Opposite Party and the same was duly  acknowledged by Opposite Party. To the utter shock of the complainants, the Opposite Party disallowed the genuine claim of the complainants vide their letter dated 26.2.2015 on the frivolous ground that the insured  deceased was  Alcoholic Addict and the treatment taken thereof is not payable to him.  It is pertinent to mention over here that the Opposite Party before going into the treatment taken by said deceased repudiated the claim on the flimsy grounds, it is worthwhile to mention over here that the said deceased as never a Alcoholic Addict as mentioned by the Opposite Party in its repudiation letter dated 26.2.2015 and moreover, no such terms and conditions were communicated to said deceased and the complainants. Said repudiation of the genuine claim of the complainants without ascertaining the correct facts  by the Opposite Party is the arbitrary act of the Opposite Party. The complainants have prayed for the following reliefs vide instant complaint:-

a)       Opposite Party be directed to pay the amount of Rs.2 lacs alongwith interest @ 12% per annum from 29.11.2014 till realization.

b)      Opposite Party be directed to pay the compensation of Rs.1 lac to the complainants.

c)       Opposite Party be directed to pay the adequate costs of litigation.

d)      Any other relief to which the complainants are found entitled to under the law, equity and justice be also allowed.   

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written statement taking certain preliminary objections therein inter alia that the complainants have not come to this Forum with clean hands and in fact, they have suppressed the material facts from this Forum and as such, the present complaint merits dismissal on this simple score only. It is pertinent to mention over here that Vikas Soni was admitted at Dayanand Medical College & Hospital, Ludhiana for Alcohol Cirrhosis and Alcoholic Hepatitis on 16.10.2014 and was discharged on 29.11.2014. As per discharge summary, Vikas Soni was a known case of Alcoholic Liver Disease with Cirrhosis. As per the terms and conditions of the policy, the expenses related t o treatment of disease caused by Alcoholic Addiction are not payable and as such, as per the insurance coverage, the claim is inadmissible and after considering the facts and circumstances and insurance coverable, even the Dedicated health Care Services TPA (India) Private Limited as well as Opposite Party rightly arrived at the conclusion that the claim is inadmissible and is not payable and as such, the impugned claim was rightly repudiated and even in respect thereof repudiation letter dated 26.2.2105 is self explanatory and the complainants were apprised vide said repudiation letter regarding repudiation of the said claim and as such, it becomes quite evident that the relief sought is not available to the complainant as envisaged under the law. On merits, it is denied that any alleged genuine claim of the complainants is denied on fictitious grounds, as alleged. It is denied that the claim was repudiated on flimsy grounds. It is denied that the deceased was never an Alcoholic Addict. It is denied that terms and conditions were not communicated to the deceased and the complainants, as alleged.  It is denied that the Opposite Party is liable to pay any compensation of Rs.1 lac as alleged, rather the present complaint being false, frivolous, vexatious, merits  dismissal  with special costs as envisaged under the law and a prayer for dismissal of the complaint with cost was made.

3.       In his bid  to prove their case, the complainants tendered into evidence affidavit Ex.C1, copy of insurance cover Ex.C2, copy of repudiation letter Ex.C3, copy of bill details Ex.C4, copy of discharge summary Ex.C5, details of previous medical policies Ex.C6, copy of medical bils Ex.C7 and   and closed his evidence.

4.       To rebut the evidence of the complainants, the Opposite Party tendered into evidence the affidavit of Sh.R.L.Mehta, Divisional Manger Ex.OP1, copy of letter dated 26.2.2015 Ex.OP2, lette dated 14.2.2015 Ex.OP3, letter Ex.OP4, copy of discharge summary Ex.OP5, copy of insurance policy document alongwith terms and condition Ex.OP6.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record. We have also gone through the written submissions submitted on behalf of both the parties as well.

6.       On the basis of evidence on record, ld.counsel for Opposite Party has vehemently contended that it is not disputed that Vikas Soni deceased was holder of Sampooran Aroya Bima Policy covering risk period w.e.f. 26.11.2013 to midnight of 25.11.2014. Copy of the insurance policy alongwith its terms and conditions accounts for Ex.OP6. The relevant term and condition 2.1.8 states that in case of use of alcohol etc. the claim is not payable. Vikas Soni was admitted in Dayanand Medical College & Hospital, Ludhiana for Alcohol Cirrhosis and Alcoholic Hepatitis on 16.10.2014 and was discharged on 29.11.2014. As per discharge summary Vikas Soni was a known case of Alcoholic Liver Disease with Cirrhosis. It is important to mention here that even in this case complainants have also placed on record  discharge summary of Dayanand Medical College & Hospital, Ludhiana, copy whereof is Ex.C5. From the perusal of the discharge summary placed on record itself shows that Vikas Soni was a known case of Alcoholic Liver Disease with Cirrhosis. The impugned claim was repudiated by Opposite Party vide repudiation letter dated 26.2.2015, copy whereof is Ex.C3/Ex.OP2 on record. The impugned claim was repudiated by the Opposite Party as the medical treatment obtained by Vikas Soni was admittedly for Alcohol Cirrhosis and Alcoholic Hepatitis on 16.10.2014. Since the medical expenses related to treatment of disease caused by Alcoholic Addiction, hence those were not  admissible/ payable under clause 2.1.8 of the terms and conditions of the insurance policy.  The contents of repudiation letter dated 26.2.2015 have not been controverted by the complainants but rather vague pleas have been taken that claim was rejected on the bass of frivolous and flimsy grounds and further plea was taken that deceased was never Alcohol Addict. But this alleged plea of the complainant was false on the very face of  it as the same is contrary to the contents of discharge summary. Not only that, the contents regarding treatment & problem suffered by Vikas Soni, as per discharge summary, have not been controverted in the complaint. Keeping in view the facts and circumstances of the case, ld.counsel for the Opposite Party has vehemently contended that the claim has rightly been repudiated as per the terms and conditions of the insurance coverage and as such it can not be contended that there is any lapse or deficiency in service on the part of Opposite Party, rather the boot is on the other leg. Ld.counsel for the Opposite Party has relied upon the ruling M/s.Suraj Mal Ram Niwas Oil Mills (P )Ltld. Vs. United India Insurance Company Limited & Anr. 2010(3) Apex Court Journal 714 SC wherein it has been laid down that there must be strict compliance with the terms and conditions of an insurance policy, and the appellant having breached a fundamental condition of the policy, the respondent is not liable to pay any amount to them. In support of the contention that in a contract of insurance, rights and obligations are strictly governed by the terms of the policy and no exception of relaxation can be given on the ground of equity, learned counsel relied on the judgements of this Court in Deokar Experts Private Limited Vs. New India Assuracne Company Limited 2008(140 SCC 598.

7.       On the aforesaid contentions, it has been argued before this Forum that the claim has been rightly repudiated and the complaint may be rejected  with costs accordingly. 

8.       But however, from the perusal of the evidence on record it becomes evident that Vikas Soni deceased was hospitalised at Dayanand Medical College & Hospital, Ludhiana for the period w.e.f. 16.10.2014 uptil  29.11.2014. Charges for hospitalization and treatment bill came to be Rs.5,67,668/- while a sum insured was Rs.2 lacs under the policy. However, the claim was repudiated vide letter dated 26.2.2015 Ex.C3  on frivolous ground that the deceased was Alcoholic Addict and the treatment taken thereof is not payable. Opposite Party in its stand before the Forum has reiterated that the deceased took the treatment of Alcohol Cirrhosis and Alcoholic Hepatitis. Though the Opposite Party has claimed that the deceased was alcoholic and was suffering from Alcoholic Liver Disease, yet the record produced by the Opposite Party, more particularly record of DMCH, Ludhiana Ex.OP6 reveal that the patient was suffering from NASH (Non Alcoholic Steato Hepatitis). The diagnosis and treatment was done for NASH which is a medico-legal  term. When elaborated it means  Non Alcoholic Steato Hepatitis. NASH  is a liver disease which is not due to consumption of alcohol. As such, the deceased was non alcoholic in nature. Opposite Party did not call for any medical specialist, who treated the insured on some earlier date on account of some alcoholic disease. Reliance has been placed on Bed Head Ticket only for reaching the conclusion that the insured was alcoholic. Moreover, it is settled law  that Bed Head Ticket cannot be made a basis for reaching the conclusion for pre-existing disease rather further evidence has to be brought to prove the pre-existing disease.  Reliance in this connection can be had on LIC of India & Anr.Kamla Devi 2009(3) CPC page 244 NC, wherein it has been laid down that LIC’s counsel relied basically on the Bed Head ticket wherein it is mentioned that the insured was consuming alcohol for a decade in high doses. This statement of history of the deceased was not given  by the insured because insured was admitted in an unconscious state. There is no certificate to this effect by the doctor indicating how he elucidated this information. Accordingly, this record  cannot be relied upon as admission of the insured that he was consuming too much alcohol for a decade. Further reliance can be had on Life Insurance Corporation of India-Appellant Vs. Smt.Sukhwinder Kaur 2008(10 CPC page 675, wherein it has been held that moreover, taking liquor is not a disease. Almost everybody takes liquor with few exceptions. Again it varies whether one takes liquor in larger quantity or takes only small dose like medicine; whether one takes regularly or occasionally. This report does not clarify these details. If consumption of liquor was a disease, the insured would not have survived for 15 years. In this casealso there is no  evidence to show as to whether the insured was taking liquor in large quantity nor the period from which he was taking liquor, has been proved through evidence on record.  The only evidence adduced is the Bed Head Ticket which clearly states that insured was suffering from NASH (Non Alcoholic Steato Hepatitis)  which is non alcoholic disease and the same was not due to consumption of alcohol. In such a situation, the Opposite Party has wrongly applied clause 2.1.8 to repudiate the claim of the complainant. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted,  wherein it  was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 has held to the following effect:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.       

The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

Although the amount spent by the insured for the treatment came out Rs. 5,67,668/-, but the complainants have claimed sum assured of Rs.2 lacs only as medical claim under the insurance cover which the complainants are entitled to recover from the Opposite Party. Consequently, the instant complaint succeeds and the complainants are allowed a sum of Rs.2 lacs alongwith interest @ 9% per annum in equal share from the date of filing the complaint until and unless full and final recovery. The costs of the litigation are assessed at Rs.2000/-. Since the complainant No.2 is minor, her share of the amount be kept in some nationalized bank in the shape of an FDR for the period, till the minor attains the majority. Compliance of this order be made within 30 days from the date of receipt of copy of the order, failing which, the complainant shall be at liberty to invoke the jurisdiction of this Forum to get the order executed.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated: 13.07.2016.                                                     (S.S.Panesar)                                                                                         President

                                          (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member

hrg