BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.384 of 2014

Date of Instt. 03.11.2014

Date of Decision :24.04.2015

Mrs.Madhu Kaura wife of Late Shri Ravi Kaura R/o H.No.EG890, Mohalla Gobind Garh, Jalandhar City.

..........Complainant

Versus

National Insurance Company Limited, Branch Office II, 89, Mahavir Marg, BMC Chowk, Jalandhar through its Senior Branch Manager.

.........Opposite party

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.KC Malhotra Adv with Ms.Harleen Kaur Adv., counsel for complainant.

Sh.RS Arora Adv., counsel for opposite party.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act against the opposite party on the averments that law abiding citizen complainant above named obtained mediclaim insurance policy (individual) covering risk to reimburse/indemnify expenses to the insured person expenses incurred for hospitalization and for medical/surgical treatment at any hospital/nursing home and for any disease or suffer from any illness/ailments, disease or injury sustained from opposite party through its authorized agent for the period stated in the policy schedule dated 18.8.2013 by renewal effective from 25.3.2013 to 24.3.2014. The complainant has been continuously and un-interruptly insured herself and her son Umesh Kaura under mediclaim insurance policy (individual) since year 2010 without any gap/break and stings by opposite party. The policy No.401104/48/12/8500000779 was allotted. Insured persons covered by policy for medical benefit insurance policy are complainant and her son Umesh Kaura as under:-

2. The cover note and policy schedule of policy was issued in the name of complainant. The total amount of renewal premium of Rs.8060/- as consideration was paid to the opposite party through its authorized agent/representative which was accepted after satisfying the continued insurability and without questioning the credentials of the insured person without any demur and strings. The product name for hospitalized benefit was mediclaim insurance policy (individual). The opposite party issued/delivered to the complainant cover note and policy schedule of mediclaim. Insurance policy only from the inception of the risk coverage and on its renewal. The policy document was not issued/delivered to the complainant by opposite party during the whole of the period of the policy. Umesh Kaura co-insured was hale and hearty, remained in good health with normal and active life and participated in day to day activities/affairs of business without any trace of illness or disease before the policy was obtained by renewal. There was no outward symptoms or signs and past history of any ailment or disease and nothing was wrong with his physical condition and his health profile was good throughout. To misfortune and ill luck of the complainant Umesh Kaura son, co-insured was taken ill on 31.7.2013 and remained admitted from 31.7.2013 to 30.8.2013 in Dayanand Medical College and Hospital, Ludhiana. He expired on 30.8.2013 due to natural death at prime of his youth. It was God's Will. After discharge from the hospital, the complainant made a claim for Rs.3,80,336/- expenses incurred for reimbursement for hospitalization and on account of medicine incurred for medical treatment including medicines for reimbursement and treatment expenses to opposite party to settle the claim. Duly completed claim on prescribed claim form, bills and receipts and discharge certificate alongwith clinical test reports were submitted to opposite party. All the formalities and requirements which ever were asked for were completed and complied with for settlement and reimbursement of mediclaim. However, the complainant is entitled to claim amount for Rs.1,25,000/- sum insured regardless of the amount of Rs.3,80,336/- spent by the complainant. To utter surprise and dismay of the complainant, opposite party vide letter dated 12.11.2013 unilaterally, arbitrarily on whims and fancy repudiated mediclaim reimbursement for Rs.1,25,000/- cryptically on the purported ground the claim is not payable as per exclusion clause 4.8 of insurance policy as the disease is caused by misuse/abuse of alcohol. Opposite party has wrongly, perversely, unilaterally, repudiated the mediclaim in oppressive manner the genuine and legitimate claim. However, no such exclusion clause 4.8 of policy was ever made known to the complainant/insured persons and the policy document containing such purported exclusion clause was not ever issued/delivered to the complainant during the subsistence of mediclaim insurance policy by renewal and from inception. The mediclaim so made is not hit by any such hidden clause and oppressively against the complainant. The repudiation of mediclaim is neither germane to the facts nor warranted in any manner due to misinterpretation and misreading of exclusion clause 4.8. Even otherwise opposite party has misconceived, misinterpreted and misread purported exclusion clause 4.8 of insurance policy which inter-alia stipulate "accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances". The cause of death was natural and unrelated to accidents due to misuse of drugs/alcohol or use of intoxicating substances. On such like averments, the complainant has prayed for directing the opposite party insurance company to pay her the claim amount of Rs.1,25,000/- alongwith interest. She has also claimed compensation and litigation expenses.

2. Upon notice, opposite party appeared and filed a written reply pleading that the deceased did not die a natural death as alleged but died due to the abuse of alcohol (Excluded under clause 4.8) and he could not be saved of his Alcohol Liver Disease by all the doctors of three hospitals where he remained admitted one after the other from 1.6.2013 to 30.8.2013. Mention in the complaint of first two hospital (1.6.2013 to 30.7.2013 and 30.7.2013 to 31.7.2013) is smoke screened. The misrepresentation and commission of fraud on the opposite party is clear therefore on these allegations, the complainant is liable to be relegated to the Civil Court. Not a single word has come from her in the complaint about the admission of the deceased in Talwar Hospital and Kidney Hospital before the deceased took the admission in the DMC Hospital, Ludhiana where he died. If there could be blatant concealment of a fact which otherwise is obvious to all concerned, the concealment of earlier treatments, at and before the date of taking the insurance, could not be ruled out. Not a word has come in the complaint by way of challenge or denial over the report of the doctors (which reports otherwise, one and all, are doubly handy with the complainant one in original and the other through RTI). From the reports, the high daily alcoholic intake is the identifiable cause of cirrhosis liver. The nearest evidence available is the reports of the doctors of the deceased coming to the hospitals for the treatment of cirrhosis of liver, but saying that he did not die of cirrhosis of liver but died a natural death is far-fetched. He died at the age of 30 and the expectancy of life in Punjab is 70 years. It is submitted that the complainant has not given any other reason for his early death in contradiction to what has been the diagnostic cause emerging from the reports of the doctors. The Alcoholic Liver Disease visits only those who are the hard drinkers and not the non-alcoholics. It is wrong that any wrong interpretation is given to by the insurance company to the clause which stipulated "accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances". The focus of the complainant is on the use of word accident in the clause limiting it to the vehicular accidents whereas the accident has the multi-meaning:- a mishap, misfortune, unfortunate incident, injury, disaster, tragedy, calamity, casualty, catastrophe, an event that is without apparent and deliberate cause. It is further submitted that the accidents are physical and non-physical. Non physical examples of accidents are unintentionally revealing of a secretive disease. The clause with the use of the word accident due to abuse of the alcohol fully covers the death which occurred in the present case to the deceased due to his secretive disease coming to reveal itself on complete failure of the liver by the abuse of alcohol. It denied other material averments of the complainant.

3. In support of her complaint, learned counsel for complainant has tendered into evidence affidavits Ex.CA and Ex.CB alongwith copies of documents Ex.C1 to Ex.C217 and closed evidence

4. On the other hand, learned counsel for opposite party has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O6 and closed evidence.

5. We have carefully gone through the record and also heard the learned counsels for the parties.

6. The facts involved in the present case are not much disputed. It is not disputed that complainant and her son Umesh Kaura(since deceased) were covered under the mediclaim policy obtained by the complainant from the opposite party insurance company. The sum insured in the case of Umesh Kaura (since deceased) was Rs.1,25,000/-. Ex.O3 is death of summary of Umesh Kaura (since deceased) issued by DMC Hospital, Ludhiana on 30.8.2013 and from the perusal of death summary it is evident that Umesh Kaura was suffering from ALD i.e Alcoholic Liver Disease, Cirrhosis. He remained admitted in above hospital from 31.7.2013 and died on 30.8.2013. From the evidence on record, it is evident that Umesh Kaura (since deceased) was admitted in DMC Hospital, Ludhiana due to Alcoholic Liver Disease where he died. Before DMC Hospital, Ludhiana, he remained admitted in Talwar Hospital and Kidney Hospital. After his death, the complainant lodged the claim with opposite party insurance company but opposite party insurance company repudiated her claim as per condition No.4.8 of the terms and condition which are attached with Ex.O5. Condition No.4.8 of the terms and condition of the policy provide as under:-

" Convalescence general debility Run Down condition or rest cure, congenital external disease or defects or anomalies, sterility, infertility/sub fertility or assisted conception procedures, venereal disease, intentional self injury, suicide, all psychiatric and psychosomatic disorders/diseases, accidents due to misuse or abuse of drugs/alcohol or use of intoxicating substances".

7. Ex.O6 is information given by opposite party insurance company to the complainant regarding repudiation of her claim and as per this letter the claim has been repudiated as per exclusion clause 4.8 of the insurance policy as disease was caused by misuse/use of alcohol. Counsel for the complainant contended that opposite party insurance company has mis-interpreted the clause or condition 4.8 of the policy. He further contended that death in this case can not be termed as accident due to misuse/use of drug/alcohol or any other intoxicating substance. Counsel for the opposite party insurance company contended that accident has a vast meaning and it even cover the death in the present case which was due to Alcoholic Liver Disease. We have carefully considered the contentions advanced by learned counsel for both the parties. An event without apparent cause is normally described as accident but disease is not an accident. In our opinion, in the present case, the death of the above said insured due to Alcoholic Liver Disease can not be termed as accident on account of use/misuse of alcohol. So, in our opinion, the opposite party insurance company has after wrongly relying upon condition No.4.8 of the policy has repudiated the claim. It may be mentioned here that the claim was not repudiated by insurance company that the insured has concealed any pre-existing disease at the time of taking the policy for the first time. Moreover, opposite party insurance company has not produced the proposal form or the treatment record of the deceased before taking of the policy for the first time to show that the deceased has suppressed the pre-existing disease i.e Alcoholic Liver Disease. Moreover, the claim has not been repudiated by opposite party on this ground.

8. In view of above discussed circumstances, we are of the opinion that opposite party insurance company has wrongly repudiated the claim of the complainant.

9. Consequently, the present complaint is accepted and opposite party insurance company is directed to pay Rs.1,25,000/- being the sum insured to the complainant alongwith 9% interest from the date of repudiation of her claim till the date of payment. It is clarified that interest amount is being granted by way of compensation. The complainant is awarded Rs.3000/- on account of litigation expenses. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

24.04.2015 Member Member President