Order dictated by:
Sh. Charanjit Singh, President
- Mr.Satbir Singh complainant has filed the present complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant got Health Benefit mediclaim Insurance for himself and his family from the opposite party having policy No. 10073768, copy of cover note is annexed with the complaint, as such he is consumer as provided under the Act and is competent to invoke the jurisdiction of this Forum. The complainant unfortunately fell ill and was to be hospitalized at Med Card Multi Speciality Hospital, Amritsar from 20.4.2016 to 2.5.2016 and treatment cost of the said hospitalization came to Rs. 1,07,027/-. The opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis and the sum insured is for Rs. 3 lacs. Opposite party instead of making the said payment repudiated the genuine claim of the complainant vide letter dated 2.6.2016 on the ground that the complainant was habitual alcoholic which infact was totally wrong and against the true facts. The aforesaid act of the opposite party in repudiating the genuine claim of the complainant amounts to deficiency in service, malpractice , unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
- Opposite parties be directed to pay the amount of Rs. 1,07,027/- alongwith interest @ 12% p.a. from 2.5.2016 till realization ;
- Compensation to the tune of Rs. 50000/- alongwith adequate litigation may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version taking certain preliminary objections therein inter alia that the complainant has concealed the true and material facts from this Forum as in the case the claim of the complainant has been repudiated on the ground that it falls under exclusion clause 4.3(a)(XXIV) for permanent exclusion i.e.
Clause 4.3 Permanent Exclusion
- Any claim in respect of any Insured person for arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions:-
(XXIV) Act of self destruction or self inflicted injury, attempted suicide or suicide while seen or unseen or illness or injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.
The complainant was admitted for the treatment of Pancreatitis which is directly related to the complainant’s past history of excessive consumption of alcohol. Hence, the claim was denied and was duly mentioned in repudiation letter dated 2.6.2016. As per indoor case papers of the hospital, the complainant had a second attack of pancreatitis. Also the etiology of pancreatitis is mentioned to be ethanol in the progress notes of Medcard Multi Speciality Hospital which shows that the pancreatitis is caused due to alcohol. Therefore, the claim was repudiated on the ground that it falls under exclusion clause 4.3(a)(XXIV). The opposite party has procured the independent opinion of the expert Dr. C.H.Asrani in which it was stated that “after perusal of available medical documents and collating his past history with credible reference as well as treating doctor’s own proclamation on the etiology, the patient’s episode of acute pancreatitis is attributable to his history of ethanol consumption.”. It is worthwhile to mention here that the cashless claim was lodged by the complainant and as per the details filled in pre-authorization form the complainant was suffering from HTN since 10 years, therefore, cashless facility was denied on 20.4.2016 for non disclosure of hypertension since 10 years. On merits opposite party has taken the similar pleas as such there is no need to reproduce the same . While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh. Deepinder Singh,Adv. Counsel for the complainant tendered into evidence affidavit of the complainant Ex.C-1, copy of policy Ex.C-2 & Ex.C-3, copies of medical bill Ex.C-4 and copy of discharge summary Ex.C-5 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for the opposite party tendered into evidence affidavit of Sh. Ramneek Sachar Ex.OP1 alongwith documents Ex.OP2 to Ex.OP14, affidavit of Dr. Gurpreet Singh Ex.OP15 and affidavit of C.H.Asrani Ex.OP16 and closed the evidence on behalf of the opposite party.
5. We have heard the Ld.counsel for the parties and have carefully gone through the record on the file.
6. Ld.counsel for the complainant has vehemently contended that complainant got Health Benefit mediclaim Insurance for himself and his family from the opposite party having policy No. 10073768, copy of cover note is Ex.C-2 and Ex.C-3 on record. During the subsistence of the policy period, the complainant unfortunately fell ill and was to be hospitalized at Med Card Multi Speciality Hospital, Amritsar for the period from 20.4.2016 to 2.5.2016 and incurred an expenditure of Rs. 1,07,027/-. In this regard complainant has placed on record copy of inpatient bill Ex.C-4. The opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis and the sum insured is for Rs. 3 lacs. Opposite party instead of making the said payment repudiated the genuine claim of the complainant vide letter dated 2.6.2016 on the ground that the complainant was habitual alcoholic which infact was totally wrong and against the true facts.
7. On the other hand Ld.counsel for the opposite party has repelled the aforesaid contention of the Ld.counsel for the complainant on the ground that the claim of the complainant has been repudiated on the ground that it falls under exclusion clause 4.3(a)(XXIV) for permanent exclusion i.e. Act of self destruction or consumption , use, misuse or abuse of alcohol and Pancreatitis. It has further been contended that the complainant was admitted for the treatment of Pancreatitis which is directly related to the complainant’s past history of excessive consumption of alcohol. Hence, the claim was denied and was duly mentioned in repudiation letter dated 2.6.2016. Not only this the cashless claim was lodged by the complainant and as per the details filled in pre-authorization form the complainant was suffering from HTN since 10 years, therefore, cashless facility was denied on 20.4.2016 for non disclosure of hypertension since 10 years. But however, from the appreciation of the facts and circumstances of the case, it was admitted by the opposite party that the cashless claim was denied on 20.4.2016 for non disclosure of hypertension since 10 years , copy of denial letter is Ex.OP6, but later on the claim lodged by the complainant for reimbursement of the medical expenses was repudiated by the opposite party on the ground of Act of self destruction or consumption , use, misuse or abuse of alcohol and Pancreatitis, copy of repudiation letter is Ex.OP14 on record. But we are not agreed with these different grounds as the opposite party itself not sure whether the complainant was suffering from Hypertension or he was habitual of alcohol. To prove his case the opposite party has placed on record affidavit of his own expert doctor Dr. C.H.Asrani, who is on the panel of the opposite party and it is obvious that the doctor who is on the panel of the opposite party has to give report in favour of the Insurance company and not in favour of the complainant .Perusal of both the letters, it stands proved on record that the opposite party is relying upon the discharge summary of Med Card Multispeciality Hospital Ex.OP10. But no affidavit of the doctor who has written the discharge summary has been produced on record. As such in the absence of the affidavit of the doctor who has written the discharge summary , no evidentiary value can be placed upon the discharge summary . Reliance in this connection has been placed upon National Insurance Company Limited Vs. Sardar Kulbir Singh 2010(3) CPC 488 (NC) wherein it has been held in para 11 as under:-
“Affidavit of the Doctor who had prepared the discharge summry has not been filed. It is not disclosed in the discharge summary as to on whose information the doctor had recorded the fact that the respondent was suffering from Chronic Stable Angina for the last 10 years. No reference has been made to any previous medical record in the discharge summary to show that the respondent was suffering from Chronic Stable Angina for the last 10 years. The discharge summary does not disclose as to on what basis it has been stated that the respondent was suffering from Chronic Stable Angina.”
Further reliance has been placed upon Manikant Vs. New India Assurance Co.Ltd. 1(2012) CPJ 88 (NC) of the Hon’ble National Commission wherein it has been held that the surveyor did not appear in court and subject himself to cross examination nor was any affidavit filed by him to prove his report . Producing a document in court does not by itself constitute proving the document. It has to be backed by credible evidence. In the instant case, no evidence was led to prove the surveyor’s report in the absence of which the surveyor’s report has little evidentiary value. The ground of repudiation of the claim is that complainant was admitted for the treatment of pancreatitis which is directly related to the complainant’s past history of excessive consumption of alcohol. No doubt that alcoholism is one of the most common causes for pancreatitis, but every case is to be decided on the basis of evidence . Whereas no past history of the complainant was produced on record by the opposite party to prove that the complainant was suffering from this disease of Pancreatitis .Reliance in this connection has been placed upon Bajaj Allainz Life Insuance Company Ltd. Vs. Sowbhagyalaxmi and Ors. 2013(1) CPC 128 that repudiation of claim on ground of pre-existing disease was unfounded on report of investigator which was not supported by any evidence or affidavit. Hon'ble National Commission in case LIC of India and Others Vs. Kunari Devi 2009(2) CPC 107 has held that only evidence relied upon by the insurance company was the history recorded in hospital's bed head ticket which cannot be treated as a material evidence. Petitioner could not produce any evidence showing any proof of treatment taken by deceased insured from any doctor, repudiation of the claim was held not sustainable. Our own Hon'ble State Commission in case Life Insurance Corporation of India & Anr. Vs. Murti Devi 2012(3) CPC 375 has held that where petitioner has not produced any record of medical treatment of the insured to prove that he had taken medical treatment from any doctor regarding disease prior to the insurance policy. It cannot be held that complainant has suppressed any material fact . Examination of doctor who checked patient prior to obtaining of policy, some treatment papers, some prescriptions, etc., should have been produced by the opposite party. The Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) has held that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party firstly in declining the cashless facility and secondly not settling the claim on false and frivolous ground for such a long period, amounts to deficiency in service. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC) is fully attracted. It was held that
“Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
8. On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9. In view of the above discussion, we allow the present complaint with costs and direct the opposite party to settle the claim of the complainant to the tune of Rs. 1,07,027/- alongwith interest @ 6% p.a. from the date of lodging of the claim till realization. Opposite party is also directed to pay litigation expenses of Rs.5000/- to the complainant. Compliance of this order be made within a period of one month from the date of receipt of copy of this order ; failing which complainant shall be entitled to get the order executed through the indulgence of this Forum. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
