Punjab

Faridkot

CC/18/185

Hardev Singh - Complainant(s)

Versus

Oriental Insurance co. Ltd - Opp.Party(s)

Ashu Mittal

04 Sep 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :             185 of 2018

Date of Institution:    16.11.2018

Date of Decision :       4.09.2019

 

Hardev Singh aged about 50 years, son of Jalour Singh, c/o Ms Dev Bros., Faridkot Road, Kotkapura, Tehsil Kotkapura, District Faridkot.

...Complainant

Versus

 

1. Oriental Insurance Company Limited, Branch Office Kotkapura Tehsil Kotkapura, District Faridkot.
2.  Oriental Insurance Company Limited, A-25/27, Asaf Ali Road, New Delhi, 11002 through its MD.

     .....Opposite Parties

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt Param Pal Kaur, Member.

 

Present: Sh Ashu Mittal, Ld Counsel for Complainant,

              Sh Vinod Monga, Ld Counsel for OPs.

 

ORDER

(Ajit Aggarwal, President)

                                         Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim for Rs.68,370/-with interest and for

 

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further directing OPs to pay Rs.25,000/- as compensation for deficiency in service, harassment, inconvenience, mental agony alongwith litigation expenses.

2                                        Briefly stated, the case of the complainant is that vide Insurance Policy bearing no. 233702/48/2017/37, complainant was insured with OPs for a sum of Rs. Four Lakhs for a period from 6.04.2016 to midnight of 5.04.2017 and during this period he suffered from liver problem  and remained admitted in Premier Gastroenterology Hospital, Jalandhar from 14.11.2016 to 18.11.2016. He spent Rs.68,370/-on his treatment and thereafter, he completed all formalities and submitted all the bills and other relevant documents to OPs for reimbursement of his claim.  Vide letter issued in February, 2017, OPs demanded some documents, which were duly supplied by complainant to them, but thereafter, vide letter dated 5.05.2017, they repudiated the claim of complainant as No Claim on pretext that complainant had a history of alcohol consumption and is not entitled for reimbursement. Due to non settlement of claim by OPs, complainant has been suffering great economic problems and hardships. Complainant made many requests to Ops to settle his claim, but all in vain. This act of OPs amounts to trade mal practice and deficiency in service and it has caused harassment and mental agony to complainant for which he has prayed for directions to OP to pay Rs.25,000/-as compensation alongwith Rs.11,000/-as cost of litigation besides the main relief. Hence, the present complaint.

3                                       The counsel for complainant was heard with regard to admission of the complaint and vide order dated 20.11.2018, complaint was admitted and notice was ordered to be issued to the opposite parties.

 

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4        On receipt of the notice, OPs filed written statement wherein averred that there is no deficiency in service on the part of answering OPs as claim of complainant was duly processed and considered, but it was found to be not admissible as the medical policy does not cover expenses incurred for treatment of all diseases due to use of alcohol vide exclusion clause 4.8 and therefore, claim of complainant was declared as No Claim and same was conveyed to him. In view of terms and conditions of the policy in question, complainant is not entitled for any relief and therefore, present complaint is liable to be dismissed. However, on merits OPs have denied all the allegations of complainant being wrong and incorrect, but admitted before the complainant that complainant alongwith his wife was insured with them for the period from 6.04.2016 to midnight of 5.04.2017 for Rs. 4 lakhs against policy in question. It is also admitted that complainant submitted a claim for his treatment for the period from 14.11.2016 to 18.11.2016 from Premier Gastroenterology Hospital, Jalandhar. Vide letter dated 7.02.2017, complainant was required to submit some documents and in certificate dt 22.07.2017 submitted by him and from in ward history of hospital, it was clear that complainant was suffering from Ch Cirrhosis for the past approximately 3 years and was alcoholic. Claim was processed and being found not admissible, it was declared no claim vide letter dated 5.05.2017 and same was duly conveyed to complainant. It is averred that claim of complainant was rejected as per terms and conditions of the Policy under clause 4.8 of Insurance Policy as treatment expenses for the disease occurring due to use of alcohol are not payable under policy of insurance. Ld counsel for OPs further asserted that there is no deficiency on their part and prayed for dismissal of complaint with costs.

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5                                                 Parties were given proper opportunities to prove their respective case. The complainant tendered in evidence his affidavit Ex.C-7 and documents Ex C-1 to 6 and then, closed his evidence.

6                                               In order to rebut the evidence of the complainant, the ld Counsel for OPs tendered in evidence, affidavit of Vikas Kataria Ex OP-1 and documents Ex OP-2 to Ex OP-12 and then, closed the same on behalf of OPs.

7                                              We have heard the learned counsel for the parties and have very carefully gone through the affidavits and documents on the file.

8                                                 From the careful perusal of record and keeping in view evidence and documents placed on record by respective parties, it is observed that case of the complainant is that complainant was insured with OPs under Policy in question for a sum of Rs. Four lakhs  for a period from 6.04.2016 to 5.04.2017 and during this period of insurance, he fell ill and remained admitted in Premier Gastroenterology Hospital, Jalandhar from 14.11.2016 to 18.11.2016 and spent Rs.68,370/- on his treatment. He lodged claim with OPs, but they repudiated the same on the ground that complainant had history of alcohol consumption, which amounts to deficiency in service and trade mal practice and has caused harassment to him. Grievance of the complainant is that despite repeated requests, OPs did not pay any heed to his genuine requests for processing his claim and rejected the same as No Claim. On the other hand to controvert the pleadings of complainant, OPs stressed mainly on the point that complainant was an alcoholic and due to consumption of alcohol, he was suffering from Ch. Cirrhosis disease for about three years and claim of complainant is not admissible as per terms and conditions and exclusion clause 4.8 of the Insurance Policy. It is

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observed that there is not denial regarding insurance of complainant with OPs for Rs.4 lakhs. It is also admitted that complainant was hospitalized and he remained under treatment during the subsistence of policy in question. It is also admitted that complainant gave due intimation regarding treatment to them and lodged his claim for the purpose of reimbursement. The only plea taken by OPs is that complainant was  an alcoholic and due to this reason they repudiated the claim of complainant.

9                                From the careful perusal of record placed on record by complainant it is observed that complainant was neither an alcoholic nor had any addiction for drugs. In document Ex 2 which is copy of discharge summary dated 18.11.2016 issued by Premier Gastroenterology Institute, Jallandhar it is specifically mentioned that cause of admission in hospital is Cirrhosis Liver.  Further from the perusal of document Ex C-5 which is copy of certificate issued by Dr Amit Singhal, DM (Gastro) AIIMS, Premier Gastroenterology Institute, Jallandhar, it is clearly mentioned that patient denies any history of alcohol consumption. It is also specified that for last three years complainant was suffering from Ch Liver Cirrhosis and with effect from past approximately two years, he was under treatment of Dr Amit Singhal. This document is of vital importance as it certified by concerned doctor fully authenticating the pleadings of complainant that he was not an alcoholic. No where in any documents it is mentioned that complainant was in habit of taking tobacco or alcoholic substances. It is observed that there is no personal history /habit of smoking, tobacco chewing, alcohol, drugs etc or any other addiction to complainant. It is clearly written  that complainant suffered from Cirrhosis Liver and there is no report that complainant was having any personal history or habit of smoking, tobacco chewing, alcohol, drugs etc or any other addiction. Thus, in the light of these documents, how can OPs even

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presume or come to conclusion that complainant is an alcoholic or is a drug addict and thus, there is no ground for rejection of genuine Mediclaim of complainant. Repudiation of claim of insured complainant by OPs totally on false grounds amounts to deficiency in service and trade mal practice. Ex C-1 is the copy of insurance policy proving the fact that he was insured with OPs. Thus, complainant has placed on record sufficient and cogent evidence to prove his pleadings. Moreover, there is not even an iota of doubt over the authenticity of documents produced by complainant and it is made out that complainant was not having any past history of alcohol or tobacco chewing or any other kind of drug addiction. It is observed that OPs have wrongly denied the claim of complainant and it amounts to deficiency in service on their part.

10                                      From the above discussion and evidence produced by the complainant, we are of considered opinion that Ops have wrongly and illegally repudiated the claim of complainant on false grounds of terms and conditions of Policy. The present complaint is hereby accepted and complainant is entitled for insurance claim on account of expenditure incurred by him on his treatment during the period of insurance. OPs are directed to pay Rs.68,370/- to complainant for the treatment undertaken by him at Premier Gastroenterology Institute, Jallandhar for the period from 14.11.2016 to 18.11.2016 alongwith interest at the rate of 9 % per anum from 5.05.2017 the date, when they repudiated the claim of complainant vide letter dt 5.05.2017 Ex C-3 till final realization. Ops are further directed to pay Rs.5000/- as consolidated compensation for harassment and litigation expenses to complainant. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under

 

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Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost as per law. File be consigned to record room.

Announced in Open Forum

Dated : 4.09.2019         

 

(Param Pal Kaur)                     (Ajit Aggarwal)

                    Member                                                President