ORDER

Per M.A. Alam , President

1. The complainant has filed this complaint on 1/5/2015.  She alleged that she and her husband Mr. Ved Prakash were joint mediclaim policy holders since 9 years.  On 2/9/2014 she was not feeling well and contacted Dr. V.P. Sacher of Sir Ganga Ram Hospital. On 5/9/2014 she took prescribed medicines-tablet of Aplrax -0.5 mg and Pacimol Tablet Corex Cough Syrup before taking breakfast. After few hours she got half senseless and hospitalized.  In the discharge slip doctor describe the patient was drossy and she tried to commit  suicide. On 7-9-2014  she claimed mediclaim from the OP for payment and it was denied on 24-9-2014 as this was a case of suicide. Therefore, she prayed that she be given Rs. 67,485.81/- towards hospital payment and  Rs. 6,00,000/- for the harassment caused to her.

2.  OP has admitted that complainant was covered under mediclaim policy with the OP for the period 06-09-2013  to 05-09-2014 and denied other allegations made in the complaint. OP filed preliminary objections that this is a case of suicide and is covered under Exclusion Clause 4.8 of the terms and conditions of the insurance policy and  there is no deficiency in service on the part of the OP. Hence, complaint be dismissed with cost.

3. In support of her complaint the complainant filed her affidavit along with documents Ex-1 to Ex -37.  In support of reply, the OP filed affidavit of Mr Mahesh Mehta Senior Divisional Manager and document policy Ex. RW1/1.  The complainant filed rejoinder to the reply and explained the objections filed by OP are baseless. Both the parties filed their written arguments.

4. We have heard the arguments and considered the evidence led by the parties on this argument and in this matter  points to be considered are  as under:-

1. Whether complainant is a consumer?
2. Whether ,there is any deficiency in service on the part of the OP?
3. Relief?

5. As OP has admitted that the complainant is holder of mediclaim policy Ex 31 which was valid from the period 6-9-2013 to 5-9-2014 therefore, it is proved that complainant is a “consumer”.

6.  It is evident from the affidavit of the complainant that she took one tablet of Alprex 0.5 mg and pacimol tablet Corex Cough Syrup before taking breakfast and after few hours and she got half senseless and these medicines were prescribed by Dr. V.P. Sachar vide prescription Ex. 1.   Discharge summary of the hospital Ex. 2 clarifies that on examination the complainant was drowsy and not obeying verbal commands therefore the history may be narrated by someone else and not by  the complainant.    Whatever the history written by the treating doctor it may be narrated by the attendant  of complainant  without any documentary  proof in support. Evidence led by the complainant is unchallenged  Clause 4.8 of the terms and conditions of the policy Ex. 1(Ex. RW1/2)  is as under:-

 “Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-injury/suicide, all psychiatric and psychosomatic disorders and diseases / accident due to and or use, misuse or abuse of drugs / alcohol or use of intoxicating substances or such abuse or addiction etc.”

7.Without support of any evidence regarding suicidal attempt by the complainant, this above clause 4.8 of Ex-1 is not applicable in the case and mediclaim of the complainant filed by OP was is unjustified. Looking at the above facts and circumstances of this case we are of the opinion this is not a case of suicide and is not covered under clause 4.8 of the terms and conditions of the policy Ex. RW1/11 and mediclaim of the complainant was filed wrongly by the OP.  Hence, there is deficiency in  service on the part of the OP who refused the claim lodged by the complainant.  Complainant filed payment of the hospital charges Ex. 34  for Rs. 61,735.81 paid by the complainant.

We , therefore, allow the complaint and direct it as under;-

1. Pay to the complainant a sum of Rs. 61,736.85 /- as hospitalization charges.
2. Pay to the complainant a sum of Rs. 10,000/- for harassment caused to the complainant.
3. Pay to the complainant a sum of Rs. 5000/- as cost of litigation.

This order shall be complied with by OP within a period 30 days failing which an additional interest of Rs. 10% per annum will be payable on whole above amount from the date of this order till payment to the complainant. Copy of this order be made available to the parties free of cost as per law and a copy be kept on separate file.  File be consigned to record room.

Announced in open sitting of the Forum on.....................