BEFORE THE IV ADDL DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BENGALURU

1^ST FLOOR, BMTC, B-BLOCK, TTMC BUILDING, K.H ROAD, SHANTHINAGAR, BENGALURU – 560 027.

27^th DAY OF NOVEMBER 2020

ORDER

SMT.PRATHIBHA. R.K., PRESIDENT

The complainant has filed this complaint U/s.12 of the Consumer Protection Act, 1986 against Opposite Parties (hereinafter referred as OPs) with a prayer to direct the OPs to reimburse the actual insurance claim amount of Rs.1,19,053-43, to pay additional medical treatment costs of Rs.8,683/-, to pay Rs.5,000/- towards cost of the complaint and to pay Rs.32,000/- towards compensation.

2. The brief allegations made in the complaint are as under:

Complainant availed Mediclassic health insurance policy bearing No.P/141111/01/2018/010784 from OPs about 7 years back.  Even since then it has been renewed from time to time.  The said insurance policy covers himself and his mother.  The sum assured was Rs.2,00,000/-.  Due to non-claim bonus for 7 years, the insured sum has been raised to Rs.2,50,000/- each.

Complainant further submitted that on 22.10.2018 after completion of his work on the night, he visited the friend house Mr.Suresh at his residence No.16^th Cross, Malleshwaram, Bangalore.  Since the main gate was closed complainant jumped the compound wall attached to complainant’s friend house.  While doing so the complainant sustained knee fracture.  There was acute and unbearable pain and complainant rushed to M.S Ramaiah Memorial Hospital, Bangalore on the next day i.e., on 23.10.2018.  At the time of admission the complainant given details about the insurance policy to the hospital to avail the cashless benefits.  The complainant was admitted to the hospital on 23.10.2018 and was discharged on 26.10.2018.  During that period the complainant underwent surgery.  On 26.10.2018 the OPs have repudiated the claim of the complainant due to presence of alcohol before admission to the hospital.  The hospital authority forced the complainant to settle the hospital bill immediately.  Complainant has no other option paid an amount of Rs.1,19,053-43 on 27.10.2018 and discharged from the hospital.

The complainant further submitted that he has not taken alcohol on the night of 22.10.2018.  Even the policemen taken a statement at the time of visiting the complainant in the hospital and recorded the statement that there is no record of intake of alcohol.  Complainant further submitted that the hospital authority were preparing the bill.  Complainant confessed to hospital authorities that rarely takes alcohol during parties and special occasions on Sundays and holidays but on the day of incident complainant had not consumed alcohol and it was a normal working day.  The hospital authority has also not conducted the alcohol test.  In this regard the complainant sent 2 letters dated 23.10.2018 and 26.10.2018 stating that the said statement is false and baseless allegations.  The notice has been served on the OPs but the OPs have not consider the letters sent by the complainant.  Hence complainant approached this Commission.   

3. In response to the notice issued, OPs appeared through their advocate and filed their version contending in brief, as under:

OPs submitted that the complaint is totally misconceived and based on erroneous assumptions of facts and in law while making the complaint.  The policy issued subject to various terms, conditions, exceptions, limitation thereof.  The complaint is not maintainable.  OPs have issued a policy in the year 2011.  The same was renewed by the complainant regularly upto 23.02.2019.  The details of the renewed policy periods as under:

OPs further submitted that the claim is rejected in the 8^th year of the medical insurance policy from inception.  On 23.10.2018 complainant admitted to M.S Ramaiah Memorial Hospital, Bangalore for treatment.  The doctor diagnosed as Fracture RT TIBIA.  The complainant raised a pre-authorization request to avail cashless facility.  As per submitted Pre-Anesthetic check-up records from the treating hospital, it clearly mentioned that patient was under influence of alcohol at the time of injury and last intake was on 22.10.2018.  From the above finding it is noted that present admission and treatment of the insured patient is for alcohol related ailments which is not payable as per exclusion clause 9 of the policy.  Clause 9 of the policy which reads as under:

9. Convalescence, general debility, run-down condition or rest cure, nutritional deficiency states, psychiatric, mental and behavioral disorders, congenital external disease or defects or anomalies, venereal disease, intentional self injury and use of intoxicating drugs/alcohol, smoking and tobacco chewing.

Hence cashless authorization was rejected and the same was communicated to the treating hospital as well as the complainant on 26.10.2018.  There is no deficiency in service on the part of OPs.  Rest of the allegations made by the complainant is denied by OPs.  Hence OPs prayed for dismissal of the complaint.

4. In the course of enquiry into the complaint, the complainant and the OPs have filed their affidavit reproducing what they have stated in their respective complaint and objections.  Complainant and OPs have produced certain documents.  Both parties have produced their written arguments.  We have heard the arguments of complainant and OPs and we have gone through the oral and documentary evidence of both parties scrupulously and posted the case for order.

5. Based on the above materials, the following points arise for our consideration;

1. Whether the complainant has proved that there is deficiency in service on the part of the OPs, if so, whether complainant is entitled for the relief sought for?

2.  What order?

6. Our findings on the above points are as under:

Point No.1:  Affirmative in part

Point No.2:  As per the order below

REASONS

7. Point No.1:- On perusal of the pleadings, evidence and documents produced by both the parties, it is an admitted fact that the complainant availed Mediclassic health insurance policy bearing No.P/141111/01/2018/010784 from OPs.  The first inception of the policy was on 24.02.2011.  It is also admitted fact that at the time of incident the policy was in force.  The OPs have repudiated the claim of the complainant that the complainant was under influence of alcohol at the time of injury.  As per exclusion clause 9 of the policy, the complainant is not entitled for the claim amount. 

8. The repudiation letter dated 26.10.2018/Ex-A8 which reads here as under:

Documents reviewed.  As per submitted PAC records, it is clearly mentioned that patient was under influence of alcohol at the time of injury and last intake was on 22/10/2018.  Expenses for such treatment are not admissible in accordance with exclusion no.9 of the issued policy.  Hence rejection stands.

Further on perusal of the terms and conditions exclusion clause-3 sub clause-9 which reads here as under:

9. Convalescence, general debility, run-down condition or rest cure, nutritional deficiency states, psychiatric, mental and behavioral disorders, congenital external disease or defects or anomalies, venereal disease, intentional self injury and use of intoxicating drugs/alcohol, smoking and tobacco chewing.

9. Now the question before us is whether the complainant was under the influence of alcohol at the time of injury.  Admittedly the complainant fall from the compound wall on 22.10.2018 near Malleshwaram and he has sustained injury over his right knee.  The complainant was admitted to M.S Ramaiah Memorial Hospital from 23.10.2018 to 26.10.2018.  For the treatment the complainant has spend an amount of Rs.1,19,053-43.  The OPs have repudiated the claim of the complainant only on the ground that at the time of injury the complainant was under the influence of alcohol.  Hence it is against the policy terms and conditions.  On perusal of the discharge summary nowhere it is mentioned that the complainant was under the influence of alcohol at the time of injury.  Further on perusal of the entire records OPs have not produced any medical report nor the police report to prove that the complainant was intoxicated the alcohol at the time of injury.  Therefore, when there is no piece of evidence or proof to show that the complainant was under the influence of alcohol, the claim of the complainant repudiated by the OPs amounts to deficiency in service on the part of OPs.  Therefore, we feel it appropriate to direct the OPs to pay a sum of Rs.1,19,053/- to the complainant towards medical expenses incurred as per Ex-A5 together with interest @ 9% p.a from the date of repudiation till the date of realization.  Further we feel it appropriate to direct the OPs to pay compensation of Rs.20,000/- for deficiency of service resulting in hardship, inconvenience and mental agony, together with litigation cost of Rs.10,000/- to the complainant.  Accordingly, we answer the point no.1 affirmative in part.

10. Point No.2: In the result, for the foregoing reasons, we proceed to pass the following order:    

  O R D E R

1) The complaint filed by the complainant is allowed in part.

2) OP-1 & 2 are directed pay a sum of Rs.1,19,053/- (One Lakh Nineteen Thousand Fifty Three Rupees Only) to the complainant towards medical expenses incurred as per Ex-A5 together with interest @ 9% p.a from the date of repudiation till the date of realization. 

3) Further OP-1 & 2 are directed to pay compensation of Rs.20,000/- to the complainant for deficiency of service resulting in hardship, inconvenience and mental agony, together with litigation cost of Rs.10,000/-.

4) This order is to be complied by the OP-1 & 2 within 45 days from the date of receipt of this order.

5) Supply free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed and corrected, pronounced in the Forum on this 27^th day of November 2020)

(SURESH D)                                               (PRATHIBHA R.K)

  MEMBER                                                     PRESIDENT

Witnesses examined on behalf of the complainant by way of affidavit:

Sri.Jagan Venkatesh.

Copies of documents produced on behalf of complainant:

Witnesses examined on behalf of the OPs.1 & 2 by way of affidavit:

Sri.Mahadevan.

Copies of documents produced on behalf of Opposite Parties:

(SURESH D)                                               (PRATHIBHA R.K)

  MEMBER                                                     PRESIDENT

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