Ms. Rekha Rani, President

Sh. Vikram Kumar Dabas, Member

Mrs. Manju Bala Sharma, Member

ORDER                        January 2018                 

Sh. Vikram Kumar Dabas, Member

1.       The complainant had purchased a policy of insurance from OP 1 on 24.09.2012  for a period of 1 year.  It covered the complainant and its family from accidents and various diseases.  The policy was renewed from time to time and  was valid up to 23/09/2014.  On 25.03.2014 the complainant fell ill and was admitted to Pushpanjali Medical Centre, Delhi.  He was discharged on 29.03.2014  and had incurred a sum of Rs. 48335/- as expenses on his treatment.  The complainant had

lodged a complaint with OP 1 for reimbursement of the said amount.  OP 1, however, repudiated the claim on the plea that the Complainant had obtained policy

of Insurance without disclosing the fact that he was suffering from chronic Liver disease  (ALD – Alcoholic Liver Disease).  The complainant had alleged deficiency in service on the part of OP 1 and has preferred this complaint before this Forum.     

OP 1 has contested the complaint & filed written statement wherein it has taken a preliminary objection that this complaint is not maintainable and is liable to be dismissed as the complainant had obtained the insurance policy by concealment/suppression of material facts.  It has claimed that the complainant was suffering from chronic liver disease prior to the inception of the policy which he had obtained without disclosing the said facts in the proposal form.  OP 1 has stated that in the discharge summary dated 29/03/2014 it had been clearly mentioned that the patient had a past history of ALD and was a follow up case of ethanol consumption.  OP 1 has claimed that the claim lodged by the complainant was also repudiated as per clause 4.3 (A) (25) of the policy terms & conditions, as per which any illness attributable to consumption of alcohol was not covered under the policy.   

OP 1 has contested the complaint on merits.  OP 1 has admitted that it had issued a Policy of Insurance in respect of the complainant and his family which was valid up to 29/09/2014.  It has, however, reiterated that the policy was obtained by suppression of facts and the claim was repudiated under clause 4.3(A) permanent exclusion.  It has prayed that since the complaint is without merit the same be dismissed. 

In the affidavit of evidence the complainant has reiterated the contents of the complaint.  In the evidence filed by way of affidavit the OP has corroborated

the contents of the written statement.  OP has also filed an affidavit of Dr. S. Vijay in support of its case, wherein he had stated that an expert medical opinion was also taken from an independent doctor i.e. Dr. C.H. Asrani.    

We have heard arguments advanced at the bar and have perused the record.

We have gone through the proposal form, a copy of which has been placed on record by the OP Insurance company.  On page 2 of the policy under the head – ‘pre-existing disease details.   We have noticed the fact that under the aforesaid head the insured had declared that he did not suffer from any illness or disease listed there including Liver disease.  We have then gone through the discharge summary issued by Pushpanjali Medical Centre dated 29/03/2014 where under the head ‘past history’ it has been mentioned that the patient had a history of (ALD- Alcoholic Liver Disease).  Under the head ‘history of present illness’ it has been mentioned that the patient was a follow up case of chronic ethanol consumption.  He was diagnosed as a case of ALD, Anaemic Pancytopenia and folic acid deficiency.  The condition of the patient was therefore due to chronic alcoholic consumption.  OP 1 has also placed on record an affidavit of  Dr. S Vijay who has also supported the case of OP1.  Dr. S. Vijay has also obtained an expert medical opinion from Dr. C H Asrani which also support the case of OP1.  In particular, we have been taken through the opinion of Dr. C H Asrani which reveals as follows :

Opinion required :

Q 1.  Please opine on the aetiology behind insured’s current hospitalization.

Insured was diagnosed to have pancytopenia and folic acid deficiency and both were due to his alcoholic liver disease caused by chronic ethanol consumption.   

Q 2. Does the appended claim fall under purview of any exclusion clause of the policy?

Yes. The claim falls under item xxiv) of clause 4.3 listing Permanent Exclusions, which is ‘’.......  illness or injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.’’

Q3.  Is the claim admissible?

No, claim is not admissible.  Insured had a history of chronic ethanol (alcohol) consumption and was a k/c/o ALD and the hospitalization was for alcohol related complications viz. Pancytopenia and folic acid deficiency.

          We have considered the contentions raised on both sides and we are convinced that OP 1 had rightly repudiated the claim lodged by the complainant.  The medical history placed on record of the complainant proves that he was a chronic case of liver disease.  He had not disclosed this fact in the proposal form despite being specifically asked about the same.  He had, therefore, obtained the policy of insurance by suppressing the facts which he was bound to disclose.  A contract of insurance is a contract based on utmost good faith i.e. doctrine of uberimma fide.  The complainant is therefore not entitled to the benefit of the policy.   Even otherwise the complications with which the complainant was

suffering were due to chronic consumption of alcohol.   The claim was therefore rightly repudiated under clause 4.3 (A) of the policy terms and conditions.  

In view of the foregoing discussion the complaint has no merits and is dismissed.  There is no order as to costs.

Copy of this order be sent to the parties as per law.  File be consigned to record room. 

Announced on this           day of ___________, 2018