DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.604/2010
Sh. Devender Yadav
S/o Sh. T. C. Yadav
R/o Sector-25,
Pocket 4, 171-172, 1st Floor,
Rohini, New Delhi-110085 ….Complainant
Versus
1. Oriental Insurance Company
9, Community Centre
Phase-I, Mayapuri
New Delhi
2. MD India Healthcare Services (TPA) Ltd.
E-98, 2nd Floor, Lajpat Nagar,
New Delhi-110024 ….Opposite Parties
Date of Institution : 06.09.10 Date of Order : 10.08.17
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
ORDER
The case of the complainant, in brief, is that somewhere around 2005 the complainant approached one of the agents of the OP for the purpose of getting himself as well as his family insured medically under the cover of medical insurance. Since the age of the complainant was below the mandate age and as such no prior medical examination was conducted on the complainant or on his family. It is stated that in furtherance of procedure for issuance of the medical policy, the complainant filled up all the requisite forms and handed over the same alongwith necessary documents to the agent of the OP No.1. The complainant paid the requisite premium and in turn the agent issued and handed over a cover note for the medical policy on behalf of the OP. The complainant has been paying the requisite premium demanded by the OP regularly and has paid approx. Rs.50,000/- and has never committed any default in making the said payments. On 26.04.2010, the complainant suffered a severe abdomen pain due to which he was rushed to Jaipur Golden Hospital at Rohini, New Delhi. It is submitted that the complainant had no previous history of any sort of disease prior to the present one. The complainant intimated the hospital staff that he is covered under the medical policy with the OP and also handed over the documents pertaining to medical policy to the staff of the Jaipur Golden Hospital. The hospital staff sent the documents of medical policy to the OP No.1 company for approval and the OP No.1 duly approved the claim of the complainant without any reservation. The complainant was diagnosed with acute pancreatitis. During the course of treatment the complainant was regularly collecting the prescription and requisite bills for the purposes of reimbursement from the OP No.1. It is submitted that after 3-4 days of the admission of the complainant in the hospital, the complainant was surprised when the hospital staff asked for deposit of interim payment. On enquiry the complainant was told that the OP No.1 has revoked/cancelled all the cashless benefits accrued to the complainant under the said medical policy. It is submitted that a surveyor of OP No.2 namely, Sh. Laxmi Narain Shukla came to the hospital and he informed to the complainant that the said cashless benefit has been revoked and further assured the complainant that the claim amount will be reimbursed to the complainant. It is submitted that the complainant in bonafide belief made all the payments of Rs.1,00,700/- to the Jaipur Golden Hospital and retained all the bills. He also incurred Rs.45,000/- towards medicines. It is submitted that after getting discharged from the hospital on 16.05.2010 the complainant submitted all the necessary bills and prescription in original with the OP No.2. The complainant was assured by the representative of OP No.2 that it will take a month for reimbursement of the amount. It is submitted that Sh. Laxmi Narain Shukla, surveyor of OP No.2 had telephonic conversation with the complainant in which he proposed to settle the claim to the tune of Rs.40000 – 50000 but, however, the complainant flatly refused the same. It is stated that the complainant time and again called the OP No.2 for enquiring about the status of his claim and personally visited the office of OP No.2 but no satisfactory reply was given to him. On 16.07.2010 the complainant wrote a letter to OP No.2 asking about the status of his claim but no reply was given to the complainant. On 09.08.10 the complainant wrote an email to the customer care of the OP No.2 in which he once again expressed his grievance regarding the disputed claim. On the very next day i.e. 10.08.2010 the complainant was shocked to receive a reply in which OP No.2 stated that the claim of the complainant is repudiated by operation of clause 4.8 of the terms and conditions of the policy. It is stated that clause 4.8 of the policy talks about the repudiation of the claimed amount by the OP if it is found that the patient is an alcoholic or the illness for which the policy amount is claimed is due to the excessive intake of alcohol by the patient. It is stated that the OP No.2 failed to give emphasis and completely overlooked the certificate dated 08.05.2010 issued by Dr. Sunil Jain, Consultant surgeon of the Jaipur Golden Hospital wherein the Surgeon had given his opinion that the current illness i.e. acute pancreatitis is not induced by the alcohol intake as the complainant used to take alcohol occasionally. It was categorically mentioned in the said certificate by the surgeon that there was no intake of alcohol prior to the attack of acute pancreatitis. Hence, pleading deficiency in service on the part of the OPs, the complainant has filed the present complaint for the following reliefs:-
- Direct the OPs to reimburse the claim amount of Rs.1,52,000/- to the complainant alongwith 18% interest till the date of realization,
- Direct the OPs to pay Rs.3,00,000/- to the complainant towards mental agony and harassment caused to the complainant,
- Direct the OPs to pay Rs.25,000/- to the complainant as litigation expenses.
In the written statement the OP No.1 has inter-alia stated that for the first time a fresh Mediclaim Insurance Policy bearing No.215502/48/2009/4285 (was taken) from one of the OPs office which is another independent office of the OP No.1 in March, 2009 without disclosing the OPs that the complainant is an alcoholic. The insurance was for one year w.e.f. 03.03.2009 to 02.03.2010 which was renewed for another year 03.03.2010 to 02.03.2011 under policy No.2155502/48/2010/4855 for himself, his wife and his dependent children for a capital sum insured of Rs.2,50,000/- for himself and wife and Rs.1,25,000/- for both the children. It is stated that a claim was reported on 26.04.2010 with TPA i.e. OP No.2 by the complainant intimating the OP No.2 that the complainant was admitted at Jaipur Golden Hospital for some pain in abdomen where he was managed and discharged on 10.05.2010 claiming cashless facility. It is submitted that OP No.2 granted the complainant cashless facility upto an amount of Rs.22,500/- first which was cancelled later on as eligibility of claim under the policy cannot be ascertained by the OP No.2. It is submitted that thereafter some papers were submitted by the complainant to the office of OP No.2 when the claim papers were scrutinized/processed by OP No.2 it observed that the complainant was an alcoholic and the claim falls within the exclusion clause 4.8 of the policy and OP No.2 accordingly repudiated the claim of the complainant as not payable and treated the same as “No claim” on account of Exclusion clause 4.8 and intimated the same to the complainant vide letter dated 10.08.2010. It is denied that the complainant had paid a sum of Rs.1,00,700/- to Jaipur Golden Hospital as no original bills for the same have been submitted by the complainant. It is denied that the surveyor of OP No.2 proposed to settle the claim for a sum of Rs.40,000/- to the complainant as alleged. OP No.1 has prayed for dismissal of the complaint.
OP No.2 has been proceeded exparte vide order dated 10.10.11 passed by our predecessors.
Complainant has filed a rejoinder and it is denied that since the Complainant was an alcoholic, he was having these symptoms of abdomen pain and had concealed this material fact before taking the insurance cover.
Complainant has filed his own affidavit in evidence. On the other hand, affidavit of Sh. Rajender Kumar, Divisional Manager has been filed in evidence on behalf of the OP No.1.
Written arguments have been filed on behalf of the complainant and OP No.1.
We have heard oral arguments on behalf of the complainant and have also gone through the file very carefully.
The only question to be decided in this case is, whether the repudiation of claim of the complainant by applying the provisions of clause 4.8 of the terms and conditions of the policy in question by the OP was justified.
The copy of the terms and conditions governing the policy in question has been filed in evidence on behalf of the OP. Para 4.8 inter-alia provides that the OP company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any disease arising out due to misuse or abuse of alcohol or use of intoxicating substances. According to the OP, the complainant suffered with acute pancreatitis because of alcohol intake and, hence, repudiation of the claim in question by virtue of the provision contained in clause 4.8 of the terms and conditions was quite justified.
We do not agree so far as the facts of the present case are concerned. It is, no doubt, true that use of alcohol may be one of the reasons for causing the disease acute pancreatitis. In the present case, according to the discharge summary of the complainant he used to take alcohol occasionally. We have gone through the medical literature on the subject and we find that it is not every quantity of the alcohol which may cause acute pancreatitis. It is only the heavy intake/use of the alcohol for a long term which may cause the said disease i.e. acute pancreatitis. In the present case, the OP has not filed any medical expert opinion on the record to even show that the complainant had suffered from the said disease due to intake/use of alcohol. In para 11 of his affidavit the OP’s witness has stated that OP No.2 TPA had also taken expert advice by a qualified doctor before taking the decision of repudiating the liability as per clause 4.8 of the contract of insurance. However, no such expert advice obtained from a qualified doctor has been filed on the record. Therefore, we hold that the repudiation of the claim in question of the complainant by the OP No.1 was not at all justified which amounts to deficiency in service on the part of the OPs.
In view of the above discussion, we allow the complaint and direct the OP No.1 to pay Rs.1,00,700/- to the complainant towards medical expenses alongwith interest @ 6% p.a. from the date of filing of complaint till the date of realization and Rs.20,000/- in lumpsum towards mental agony and cost of litigation within 30 days from the date of receipt of copy of this order failing which OP No.1 shall become liable to pay Rs.1,00,700/- to the complainant alongwith interest @ 9% p.a. from the date of filing of the complaint till realization. Since the claim of the expenses incurred on the purchase of medicines is not covered under the mediclaim policy in question we do not award any amount on purchase of medicines by the complainant.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 10.08.17
