CONSUMER DISPUTES REDRESSAL FORUM (CENTRAL)
ISBT KASHMERE GATE DELHI
CC/152/2018
No. DF/ Central/ Date
Mrs. Neelam Grover
W/o Late Bharat Bhushan Grover
R/o BJ-16, Shalimar Bagh West,
New Delhi. …..COMPLAINANT
VERSUS
National Insurance Company
DAB, Jeevan Vikas Building,
2nd Floor, 30-31A,
Asaf Ali Road, Delhi-110002. …..OPPOSITE PARTY
Quorum : Ms. Rekha Rani, President
Ms. Manju Bala Sharma, Member
Dr. R.C. Meena, Member
ORDER
Ms. Rekha Rani, President
Instant complaint was been filed by Mrs. Neelam Grover (in short the complainant) under Section 12 of the Consumer Protection Act, 1986 as amended inter-alia pleading therein that complainant is the wife of Late Sh. Bharat Bhushan Grover, insured deceased who had insurance policy of National Insurance Company(in short OP) for the assured sum of Rs.5,00,000/-. The deceased was suffering from Chikungunya. He was admitted in Fortis Hospital, Shalimar Bagh. He was prescribed medicines for Chikungunya. On being admitted in the hospital, TPA was informed. Vide letter dated 20.10.2016 TPA informed the hospital that the deceased would not be allowed cashless facility. The said letter stated “On scrutiny of the claim documents it has been found that the patient is having Pancytopenia with MOD, ACRAL Cutaneous Ulceration due to Methotrexate overdosing and history of Inavdvertent overdosing of Methotrexate due to erroneous intake of Methotrexate. According to exclusion clause 4.21 Drug Abuse: Treatment Arising out of misuse or abuse of drugs are not payable under the policy terms and conditions. Hence the cashless is denied.” Such findings were given by OP without going through the medical history of the deceased. The deceased passed away in the ICU on 24.10.2016. Complainant made a payment of Rs. 6,37,959/- to the hospital. Family of the deceased tried to reach out to the OP but no one from OP side was willing to help. Ultimately on 20.11.2017, LRs of complainant approached Insurance Regulatory and Development Authority of India (IRDA). On 15.12.2017 they responded with the same reason as given by TPA for rejecting the claim. Hence, instant complaint was filed seeking direction to the OP to pay to the complainant a sum of Rs. 6,37,959/- as hospitalization expenses, 5,00,000/- as compensation for causing pain and mental agony and NBC be paid to the legal heirs of the deceased.
OP remained absent despite being served and so they were proceeded ex-parte.
OP repudiated the claim vide letter dated 12.12.2017 for the reason that ‘the Patient Mr. Bharat Bhushan Grover had history of inadvertent use of methotrexate so developed its complications.Therefore the claim falls under exclusion clause 4.21 of ‘National Medicalim Policy’-Treatment arising out of illness/ disease/ injury due to misuse or abuse of drugs/alcohol or use of Intoxicating substances.Therefore in the light of above facts, we are closing the file as “NO CLAIM”.Folitrax (Methotrexate) was prescribed by a qualified doctor namely Dr. Sunil Khetrapal (M.B.B.S., M.D.(Medicine), M.A.M.S.(Aus.), F.C.G.P.) vide prescription dated 26.09.2016 and was therefore taken by the deceased for the treatment of his ailment.OP has failed to appear and contest the claim despite service.Nothing is placed on record to prove that it is a case of drug abuse or misuse.Repudiation of the claim is thus not justified.OP is directed to pay Rs.5,00,000/-, the sum insured along with interest @ 9% per annum from the date of filing of the complaint till realization, Rs. 25,000/- as compensation for causing mental harassment and Rs. 25,000/- towards litigation expenses.Copy of this order be sent to the parties as statutorily required. File be consigned to record room.
Announced on Day of 2019.
