Haryana

StateCommission

A/523/2016

UNITED INDIA INSURANCE CO. - Complainant(s)

Versus

ROHTASH KUMAR YADAV - Opp.Party(s)

RAM AVTAR

01 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA,PANCHKULA

                                                 

First Appeal No.523 of 2016

   Date of Institution:08.06.2016

Date of Decision: 01.07.2016

United Insurance Company ltd., Divisional Office, Hoshiarpur now through its Deputy Manager, United India Insurance Company Limited SCO No.123-124, Sector 17, Regional Office, Chandigarh.

     …..Appellant

                                                Versus

 

1.Rohtash Kumar Yadav, r/o village Khentawas P.S.Farrukh Nagar, District Gurgaon.

2.EMEDITEK (TPA) Services Limited Corporate Office, 45 Nathupur Road, DLF Phase-III, Gurgaon through its authorized signatory.

3.Authorised person of Artemis Hospital, Artemis Medicare Services Pvt. Limited, Artemis Health Institute, Sector 51, Gurgaon.

         …..Respondents

 

CORAM:   Mr. R.K.Bishnoi, Judicial Member.
                   Mrs.Urvashi Agnihotri, Member.

 

Present:-    Mr.Ram Avtar, Advocate for the appellant.

 

 

                                      O R D E R

 

URVASHI AGNIHOTRI, MEMBER:

 

United Insurance Company Ltd. – OP is in appeal against the Order dated 04.01.2016 passed by the learned District Consumer Disputes Redressal Forum (for short ‘District Forum’) Gurgaon allowing the reimbursement of the medi claim of the complainant amounting to Rs.27,940.54 alongwith interest @ 9 % p.a. from the date of filing of the complaint i.e. 27.09.2010 till its realization and Rs.2000/- as litigation expenses.

2.                Briefly stated, the complainant obtained cashless medi claim policy No.221500/48/09/06/000761 from OP and obtained card No.UI-FMCP/11277419 on 19.10.2009. During the subsistence of the insurance policy, the complainant fell ill and remained hospitalized in Artemis Health Institute, Sector 51, Gurgaon during the period from 19.10.2009 to 21.10.2009 and he incurred Rs.27940.54 on his treatment. The cashless facility was denied by the insurance company for which the complainant submitted his claim with the OP after discharge under claim No.UI/FMCP/102009/0078. But the Ops No.1 & 2 failed to reimburse the claim and ultimately repudiated the claim vide letter dated 22.12.2009. Aggrieved against this act of the OP, the complainant approached the District Forum claiming reimbursement of his medi claim to the tune of Rs.27,940.54/- alongwith interest, compensation and litigation expenses.

3.                Opposing the claim, the OP pleaded that they had rightly repudiated the claim as there were two discharge summaries relating to the complainant. In one discharge summary there was mention of alcohol but in the subsequent discharge summary there was no mention of alcohol. Neither the second nor alleged subsequent discharge summary was sent to the OP.
There was no occasion for the doctor to issue second discharge summary. Thus, the claim was rightly repudiated in view of Exclusion Clause and specific terms and conditions of the Insurance Policy, hence there was no deficiency in service on the part of OP No.1.

The complainant was admitted vide AHI ID No.GN000069021/IP No.10257086 on 19.10.2009 and was discharged on 21.10.2009 and the complainant has paid a sum of Rs.27,904.54. Therefore, in view of the facts and circumstances mentioned above, there is no deficiency in service on the part of the OP and as such, he is not entitled for any claim. However, the learned District Forum rejected the pleas raised by the OP and accepted the complaint vide order dated 04.01.2016 by granting the aforesaid relief.

4.                Against this order, the OP has filed Appeal before us contending that the learned District Forum has accepted the complaint without any legal justification. The appellant reiterating their submissions as made before the District Forum pleaded that in one of the two discharge summaries specific  mention of alcohol has been made in the following terms:-

                   On this basis the OP pleaded that by virtue of Exclusion Clause No.4, 9 of the terms and conditions of the Policy, the claim deserved to be rejected. The Exclusion Clause is reproduced as under:

“The 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 Convalescence, general debility, run down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, Sterility Venereal disease, intentional self injury and use of intoxication drugs/alcohol”

5.                We have heard the learned counsel for the appellant and have also gone through the record. The complainant was admitted for the treatment of Acute Gastroenteritis in the specialty of Gastroenterology. He was discharged after two days for which he spent Rs.27,940.54. He was neither complaining about any alcoholic disease or was he treated for de-addition. The mere consumption of some alcohol by any person does not disentitle him for claiming reimbursement of the expenses incurred by him on his treatment of any other illness. Therefore, whether in the first or second discharge summary there was mentioned of any alcohol are not are wholly irrelevant for the purpose of allowing the reimbursement. Consequently, we uphold the order passed by the learned District Forum and there being clear deficiency in service on the part of the OP. We dismiss the appeal.

6.                The statutory amount of Rs.13970/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules.

 

July,1st 2016

Mrs.Urvashi Agnihotri, Member, Addl.Bench

R.K.Bishnoi, Judicial Member Addl.Bench

 

S.K.