Haryana

Karnal

CC/466/2019

Rohit Gupta - Complainant(s)

Versus

National Insurance Company Limited - Opp.Party(s)

Deepak Bhandari

18 Jul 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 466 of 2019

                                                        Date of instt.25.07.2019

                                                        Date of Decision:18.07.2022

 

Rohit Gupta son of Shri Raman Kumar, resident of House no.874, Sector-13, Urban Estate, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     National Insurance Company Ltd. Dhanwanti Building, G.T. Road, opposite Bus Stand, Karnal-132001 through its Branch Manager.

 

2.     Medsave Health Insurance TPA Ltd., SCO-66, 2^nd floor, Sector-40C, Chandigarh.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Shri Vineet Kaushik……Member

      Dr. Rekha Chaudhary…….Member

                   

 Argued by: Sh. Deepak Bhandari, counsel for the complainant.

                   Sh. Lal Singh Lote, counsel for OP no.1.

                    OP no.2 exparte (vide order dated 07.11.2019)

 

                    (Jaswant Singh President)

 

ORDER:   

                

                   The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased one mediclaim policy from the OPs, vide policy no.420501/48/11/8500000553, valid from 20.02.2012 to 19.02.2013, sum insured Rs.2 lacs, premium Rs.2592/-. The complainant continued the said policy till today and paid its premium as under:-

i.      Policy no.420501/48/12/8500000446 w.e.f. 20.02.2013 to 19.02.2014, sum insured Rs.2 lacs, premium Rs.2592/-

ii.     Policy no.420501/48/13/8500000388 w.e.f. 20.02.2014 to 19.02.2015, sum insured Rs.2 lacs +Rs.2 lacs (for wife), premium Rs.5593/-

iii.     Policy no.420501/48/14/8500000319 w.e.f. 20.02.2015 to 19.02.2016, sum insured Rs.2 lacs, premium Rs.3108/-.

iv.     Policy no.420501/48/15/8500000414 w.e.f. 20.02.2016 to 19.02.2017, sum insured Rs.5 lacs (Rs.2.75 lacs for self +Rs.2.25 lacs for wife) premium Rs.6553/-.

v.     Policy no.420501/48/16/8500000413 w.e.f. 20.02.2017 to 19.02.2018, sum insured Rs.5 lacs (Rs.2.75 lacs for self +Rs.2.25 lacs for wife) premium Rs.6553/-

vi.     Policy no.420501501710000113 w.e.f. 20.02.2018 to 19.02.2019, sum insured Rs.11.05 lacs (Rs.5,68,750/- for self +Rs.5,36,250 for wife) premium Rs.11,711/-.

vii.    Policy no.4205015011810000253 w.e.f. 20.02.2019 to 19.02.2020, sum insured Rs.16.05 lacs (Rs.5,43,750 for self +Rs.5,61,250 for wife+ Rs.5,00,000/- for daughter) premium Rs.16,774/-

vii.    Policy no.420501501810000265 w.e.f. 20.02.2019 to 19.02.2020, sum insured for top up for Rs.10 lacs (Rs.5 lacs for self +Rs.5 lacs for wife) premium Rs.3510/-.

 

In the mid of July, 2018, complainant was suffering from Jaundice and was diagnosed by the Cygnus Hospital, Karnal. All the reports were normal, however, Cerum Bilirubin was high. Complainant took the treatment from the said hospital upto 20.09.2018 but when he could not get any relief, then he got himself examined from ILBS, Vasant Kunj, New Delhi and remained under the treatment of Dr. S.K. Sarin upto 01.02.2019. During the said period, complainant remained as Indoor Patient from 05.10.2018 to 09.10.2018 and after that complainant remained outdoor patient and spent a sum of Rs.1,72,282/-on his treatment. Thereafter, complainant informed the OPs and submitted the entire treatment record and expenditure bills etc. on 12.12.2018 and lastly on 03.01.2019. However, OPs postponed the matter on one pretext or the other and ultimately, OP no.2 repudiated the claim of the complainant, vide letter dated 28.01.2019 on the ground that expenses on treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances is an exclusion under the policy terms and conditions.

Rejection Reason:-     Recommended for rejection as the ailment is outcome of Alcoholic history of patient.

The rejection of the clam of the complainant is based on surmises and conjectures. The disease like Jaundice can be developed in any common man and there may be other facts for developing the Jaundice in the human being. Even otherwise, complainant is getting the medical policies since 2012 and every time, he was examined through the doctor of the OPs and no such type of disease was ever found in the complainant. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that complainant is addicted to misuse or abuse of drugs/alcohol or of intoxicating substances which against the terms and conditions of the insurance policy. It is further pleaded that all the ingredient has been explained in details at the time of obtaining mediclaim policy. It is further pleaded that complainant has submitted his medical bills on 02.11.2019 instead of 10.10.2018. It is further pleaded that after consulting the medical records, the OP no.2 has intimated to the OP, vide letter dated 11.01.2019 for rejection “as the ailment is outcome of alcoholic history of patient and the claim is recommended for rejection and confirm to enable us to close the matter at the earliest” and in such circumstances the OP is unable to pay the mediclaim.  It is further pleaded that the complainant’s treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances is an exclusion under the policy terms and conditions and as such the complainant is not entitled to compensation. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             OP no.2 did not appear despite service and opted to be proceeded against exparte, vide order dated 07.11.2019 of this Commission.

4.             Parties then led their respective evidence.

5.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of insurance policies dated 20.02.2012 to 19.02.2013,

20.02.2013 to 19.02.2014, 20.02.2014 to 19.02.2015, 20.02.2015 to 19.02.2016, 20.02.2016 to 19.02.2017, 20.02.2017 to 19.02.2018, 20.02.2018 to 19.02.2019, 20.02.2019 to 19.02.2020 Ex.C1 to Ex.C8, copy of top up insurance policy 20.02.2019 to 19.02.2020 Ex.C9, copy of top up payment receipt dated 25.02.2019 Ex.C10, copy of rejection letter dated 11.01.2019 Ex.C11, copy of medical bills Ex.C12 to Ex.C52, copy of discharge summary dated 01.02.2019 Ex.C53,  copy of reports dated 25.09.2018, 16.04.2019, 01.02.2019, 30.10.2019 Ex.C54 to Ex.C57, copy of consultant records dated 10.10.2018, 09.11.2018 Ex.C58 and Ex.C59, copy of discharge summary dated 05.10.2018 Ex.C60, copy of lab. report dated 25.09.2018 Ex.C61, copy of Endoscopy report Dated 23.08.2018 Ex.C62, copy of consultant record dated 24.09.2018, 20.09.2018, 06.07.2018 Ex.C63, Ex.C65 and Ex.C66, copy of lab report dated 06.10.2018 Ex.C64 and closed the evidence on 23.02.2021 by suffering separate statement. 

6.             Learned counsel for OP no.1 has tendered into evidence affidavit of Reena Basak, Administrative Officer Ex.OPs1, copy of letter dated 11.01.2019 of Medsave Health Inst. TPA Ltd. Ex.OPs2, copy of claim form submitted on 02.11.2018 Ex.OPs3, copy of insurance policy Ex.OPs4, copy of discharge summary dated 25.09.2018, 05.10.2018, 05.09.2018, 01.10.2018, 01.10.2018 respectively Ex.OPs-5 to Ex.OPs-10 and closed the evidence on 24.12.2021 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased the medical insurance policy from the OPs in the year 2012, which was continuously renewed till 2020. In the mid of July, 2018, complainant was suffering from Jaundice. Complainant took the treatment from the Cygnus Hospital hospital upto 20.09.2018. Thereafter, he got himself examined from ILBS, Vasant Kunj, New Delhi and remained under the treatment of Dr. S.K. Sarin upto 01.02.2019. During the said period, he spent a sum of Rs.1,72,282/-on his treatment. Complainant submitted all the medical record and bills to the OPs and requested for reimbursement of abovesaid amount, but OPs did not pay any heed to the request of complainant and repudiated the claim of the complainant, vide letter dated 28.01.2019 on the false and frivolous ground and lastly prayed for allowing the complaint.

9.             Per contra, learned counsel for OP no.1 while reiterating the contents of written version, has vehemently argued that complainant is addicted to misuse or abuse of drugs/alcohol or of intoxicating substances which against the terms and conditions of the insurance policy and in such circumstances the OP is unable to pay the mediclaim and OP has rightly repudiated the claim of complainant and lastly prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, complainant had purchased the medical insurance policies from the OPs on 20.02.2012 and same was continuously renewed upto 19.02.2020.

12.           In the mid of July, 2018, complainant was diagnosed by the Cygnus Hospital, Karnal as he was suffering from Jaundice and complainant took the treatment from the said hospital upto 20.09.2018  and lateron he remained under the treatment of Dr. S.K. Sarin upto 01.02.2019 at ILBS, Vasant Kunj, New Delhi.

13.           The claim of the complainant has been repudiated by the OPs, vide letter Ex.C11/Ex.OPs2 dated 11.01.2019 on the ground that expenses on treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances is an exclusion under the policy terms and conditions. The claim of the complainant was recommended for rejection as the ailment is outcome of Alcoholic history of patient.

14.           The onus to prove its version lies upon the OPs, but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. OPs have relied upon the discharge summaries Ex.OPs-5 to Ex.OPs-10. On perusal of said discharge summaries, it is nowhere mentioned that ailment is outcome of Alcoholic history of patient. It is not proved on record on what basis OPs have came to the conclusion that complainant was alcoholic. The policy in question had been taken by the complainant in the year 2012 and premium was regularly paid by the complainant and same was continuously renewed by the complainant by increasing sum insured in the policy in question. There is nothing on the file to prove that ailment is the result of alcohol.  The repudiation of claim of complainant is only on the basis of presumption and assumption. Thus, the repudiation letter is totally arbitrarily, unjustified, biased, based on the presumptions and assumptions.  

15. Further,Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 

 16.          Keeping in view the ratio of the law laid down in the abovesaid judgments, facts and circumstances of the complaint, we are of the considered view that act of the OP no.1 amounts to deficiency in service and unfair trade practice. 

17.           The complainant has claimed for Rs.1,72,282/- and in this regard he has placed on record bills Ex.C12 to Ex.C52/-. The said medical bills neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the said amount alongwith interest, compensation on account of mental tension and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.1 to pay Rs.1,72,282/- (Rs.one lakhs seventy two thousand two hundred eighty two only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and  Rs.5500/- towards the litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated:18.07.2022     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                           Member                          Member