Complainant Naresh Kumar Goel through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that opposite party may kindly be directed to pay Rs.1,20,414/- alongwith interest @ 12% per annum from the date of the death of Varun Goel. Opposite party be also directed to pay Rs.50,000/- for harassment, mental agony and deficiency in service alongwith Rs.15,000/- as litigation expenses to him.

2. The case of the complainant in brief is that his son Varun Goel has purchased a National Medi-claim Policy from the opposite party vide policy No.401211/48/13/8500500812 and paid an amount of Rs.6,199/- as premium which was effective from 24.03.2014 to 23.03.2015 and covers all the medical risks to Varun Goel. He was nominee of Varun Goel and as such he is consumer of the opposite party. His son was ill and he was admitted to the Fortis Escorts Hospital at Amritsar on 30.10.2014 with the diagnosis of “Acute Asthmatic” Unfortunately Sh.Varun Goel died in the Hospital with the cause of “Cardio Pulmonary Arrest” on 01.11.2014. He had spent Rs.1,20,414/- on his treatment and the claim was lodged with the opposite party. Due to his utter surprise, the opposite party has made his genuine claim as ‘No Claim”. This amounts to deficiency in service on the part of the opposite party. He has next pleaded that previously also he was admitted in the Fortis Escorts Hospital and the claim was paid by the opposite party on the opinion of the specialist doctor of Fortis Escorts Hospital, but in the present case the cause of death was not related to the reasons given in the no claim letter. Opposite party was requested to pay the genuine claim to him but of no use. Hence this complaint.

3. Upon notice, the opposite party appeared and filed its written version through its counsel, taking the preliminary objection that the complaint filed by the complainant is not maintainable; the complaint is absolutely false, frivolous; no cause of action has ever arisen in favour of the complainant against the opposite party to file the present complaint, hence the complaint under reply is an abuse of the process of law and as such the same is liable to be dismissed, with exemplary cost. On merits, it was submitted that one Mr.Varun Goel got National Mediclaim policy bearing No.401211/48/13/8500000812 effective from 24.03.2014 to 23.03.2015 from the opposite party. Mr.Varun Goel son of Naresh Goel died and claim was lodged by Naresh Kumar Goel father of deceased Varun Goel before opposite party regarding expenses on treatment of deceased Varun Goyal. The Claim file was sent to PARK MEDICLAIM TPA PVT.LTD. THIRD PARTY ADMINISTRATOR-HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI for investigation and admissibility of claim. That Dr.A.K.Batra MEDICAL DIRECTOR OF PARK MEDICLAIM TPA PVT. LTD. VIKRANT TOWER, RAJENDRA PLACE NEW DELHI vide its letter dated 31.12.2014 declared that the claim of the complainant is not admissible as “Mr. Varun Goel was hospitalized at Fortis Escorts from 30.10.2014 to 01.11.2014 with diagnosis Septicemia with Cirrhosis of liver, Portal, Hypertension, Cholelithiasis with Multi Organ Dysfunction with Metabolic Acidosis. On going through the death summary and other documents wherein it has been stated that there are episodes of bringe drinking for almost 1 year. Mr.Varun Goel is covered under National Mediclaim Policy. National Mediclaim Policy does not cover the expenses on treatment arising out of illness/disease/injury die to misuse or abuse of drugs/alcohol or use of intoxicating substance vide exclusion clause 4.21. Hence, the claim is not admissible.” Thereafter the opposite party vide its letter dated 12.01.2015 closed the claim file of the complainant reason peril/cause of loss not covered in the policy duly conveyed to the complainant. So, the opposite party is not liable to pay any claim to the complainant as per the terms and conditions of the policy vide EXCLUSION CLAUSE 4.21 of the policy. All other averments made in the complaint have been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4. Counsel for the complainant tendered into evidence affidavit of complainant Ex.CW1/A along with other documents Ex.C1 to Ex.C7 and closed his evidence.

5. Counsel for the opposite party has tendered into evidence affidavit of Parveen Chadda Branch Manager Ex.OP-1, alongwith other documents Ex.OP-2 to Ex.OP-7 and closed the evidence.

6. We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen at the impugned ‘repudiation’ dated 31.12.2014 (Ex.C4) by the TPA (Third Party Administrator) of insurance death-claim (Ex.OP2) dated 16.12.2014 pertaining to the DLA’s Mediclaim Policy (Ex.C1/Ex.OP7) for the assured sum/amount of Rs.2,50,000/- per the applicable policy (Ex.C1) on the grounds that his ailment(s) pertain to excessive consumption/misuse/abuse of Drugs and Alcoholic and thus the related medical treatment(s) are not payable/reimbursable vide the Policy’s Exclusion (Ex.OP7) Clause 4.21.

7. We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and accompanying affidavit (Ex.OP1) on the grounds as mentioned out in paragraph ‘4’ of the written statement being in violation/contravention of the terms of the Policy (Ex.OP7). Further, the impugned repudiation has been based upon the Fortis Death Certificate (Ex.OP3), Death Summary (Part of Ex.OP2) and Investigation Report (Ex.OP6) in which the ‘immediate-cause’ of death has been mentioned as: ‘Cardio Pulmonary Arrest’ with ‘antecedent-cause’ as: ‘Cirrhosis of Liver + HTN with Septicemia with CRTIS’ etc and further remarks as: ‘Known case of cirrhosis of Liver’ coupled with ‘Bronchopneumonia plus Acute Respiratory Distress Syndrome’ etc and upon its perusal the TPA have concluded that ‘death’ of the DLA has been caused by ailments resulting out of excessive consumption/misuse of ‘alcohol’ etc with no other independent/cogent evidence of the same; and that surely indicates that the ‘claim’ has been repudiated on flimsy grounds for collateral reasons. Firstly, the TPA cannot legally repudiate/settle a mediclaim on its own; it can simply put forth its recommendatory opinion for consideration by the OP insurers while deciding the same. The OP insurers are desired to settle the claim per the overall evidence available on cogent grounds and on hearsay conjectures and presumptions. The case-history with the hospital is nothing more than a ‘recital’ as narrated by the accompanying attendant and must be held in the light of some independent cogent ‘proofs’ to impart it the legal authenticity and acceptability to settlement of the mediclaim. We find that the instant impugned repudiation has not been in resonance with the contracted terms of the Policy and the present complainant shall be entitled to statutory relief. Lastly, we set aside the impugned repudiation in favor of its fresh settlement.

8. Finally, we partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ in full pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.

9. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

(Naveen Puri)

President.

ANNOUNCED: (Jagdeep Kaur)

January 19, 2018 Member.

*MK*