OFFICE OF THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAMRUP,GUWAHATI
C.C.113/2016
Present:-
1)Md.Sahadat Hussain, A.J.S. - President
2)Smti Archana Deka Lahkar - Member
3)Md. Jamatul Islam - Member
Maibam Basanta Singh - Complainant
R/O- Madhuban Apartment
Panjabari Road,Guwahati,
Assam- 781037
-VS-
1. Star Health and Allied Insurance Co.Ltd. - Opp.parties
Head office at KRM Centre,
VI Floor , No.2, Harringrton Road,
Chetpet, Chennai -600031,
Through its Chairman /Managing Director.
2. Star Health and Allied Insurance Co.Ltd.
City Branch Office at 4th floor, 1,Guwahati Shillong Road,
Ganapati Enclave, Above Kotak Mahindra Bank,
Opp.Bora Service, Ulubari,Guwahati, Assam-781007,
Through its Divisional Manager.
Appearance-
The complainant himself conducted his case.
Date of exparte argument- 6-9-2018
Date of exparte judgment- 21-09-2016
EXPARTE JUDGMENT
This is a complaint u/s 12 of the Consumer Protection Act, 1986.
1) The complaint filed by Sri Maibam Basanta Singh against the opp.parties was admitted on 22.2.2017 and notices were served on the opp.parties and they also appeared in this proceedings, but defaulted to file written statement and also defaulted to appear in this forum from 30.1.18 and accordingly this forum vide order dtd. 22.5.18 directed that the complaint against the opp.parties will proceed on exparte. The complainant filed exparte evidence affidavit and he also filed exparte written argument; and finally on 6.9.18, forwarded his exparte oral argument; and today we deliver the exparte judgment which is as below-
2) The case of the complainant is that he had taken a policy with the opp.parties under Senior Citizen Red Carpet Policy vide Policy No P/700002 /01/ 2015/ 005868 for an insured amount of Rs. 1,00,000/- for the period from 13.6.2015 to 12.6.2016 and during effectiveness of the said policy he was admitted in Advance Speciality Hospital & Research Institute, Imphal with complaint of altered sensorium (inability of think clearly or concentrate) and the said hospital diagnosed him as Oesophageal Candidiasis Oesophageal Varices Gr.I-III) and he informed the op.party on the same day about his treatment of the said hospital and opp.party also acknowledged receiving the request No. CR2000196994; and inspite of that, the opp.party had neither appointed any TPA nor given a cash-less facility to him, although he spent Rs.72,170/- in his treatment in the said hospital. He was discharged from the said hospital on 12.2.16 and paid entire amount from his purse and after discharged from that hospital he sent claim for re-imbursement of the said expenditure to the opp.party, but the opp.party did not response and after passing of three months the opp.party sent a letter dtd. 25.3.16 to him to furnish certain document and in response to that letter he sent letter dtd. 1.4.16 and submitted the requisite documents and on further query from the opp.party , he furnished all the requisite documents to them. The opp.party repudiated his claim vide letter dtd. 7.6.16 on the ground that he was an old alcoholic and he was admitted in hospital for Oesophageal Varices which is a complication due to use of alcohol and the cause is covered under Exclusion No. 12 of the policy and he receiving the said letter sent a letter dtd.9.8.16 and a certificate issued by said hospital where it is written the patient had history of alcohol intact before 15 years since then he had total abstrance from alcohol. As per opinion of the treating doctor the alleged disease cannot be linked his past history (i.e. 15 years of alcohol intact and that opinion was not considered by the opp.party and repudiated the claim as per Exclusion No. 12. He was not supplied with the terms and condition of the policy by the opp.party and as such the opp.party cannot take the ground taken the repudiation letter. He was never made aware of terms and condition of the policy . As the doctor opined that he has left intake of alcohol of last 15 years. It cannot be linked that past history of alcohol intake. He was admitted in International Hospital, Guwahati on 8.2.2016 and discharged on 24.2.2016 and the DHS has provided cash-less facility for the said treatment. He had again undergone treatment on 26.2.16 and discharged on 1.3.16 and the DHS has approved the same for re-imbursement, which shows that the opp.party does not want to pay the claim made by him on flimsy ground. The opp.party had never at any point of time made the complainant aware to the complainant that he had taken alcohol prior to 15 years from taking of policy, this will come under Exclusion Clause of the terms and condition of the policy. The opp.party is liable to re-imburse the treatment cost which he had done at Imphal (Rs.72,170/-) and also to pay Rs.1,00,00,000/- as compensation for causing harassment to him and Rs.50,000/- towards the litigation cost.
3) We have perused the evidence of complainant. From his evidence it is crystal clear that he insured with the opp.party under Senior Citizen Red Carpet Policy bearing No. P/700002 /01/ 2015/ 005868 for an insured amount of Rs. 1,00,000/- for the period from 13.6.2015 to 12.6.2016 and during effectiveness of the said policy he was admitted in Advance Speciality Hospital & Research Institute, Imphal and on 7.1.2006 and was disgnosed as Oesophageal Varices and was treated their and he immediately informed the opp.party about said treatment, which the opp.party received and acknowledged vide request No. CR 200196990 and he paid an amount of Rs. 72,171/- to the said hospital from his pocket and then he filed the claim with the opp.party requesting them to re-imburse the said amount, but the opp.party repudiated his claim vide their lette dtd. 7.6.16 stating that his disease is a complication due to use of alcohol and said type of disease attract Exclusion 12 of the policy which makes a company not liable to pay the expenditure made in the said treatment.
4) Now, the question is that whether the complainant was alcoholic at the time of taking the said treatment. From the record of the doctor of the said hospital of Imphal, it is found that the doctors of the said hospital opines that he suffered from UGIB disease; but the history of the patient shows that he had taken liquor before 15 years and thereafter he had total abstrance from the alcohol. The doctor also opined that the disease suffered by the complainant cannot be linked for his past history of alcohol intact 15 years prior to taking the policy. From the opinion of treating doctor given in Ex.7 report, it is crystal clear that intaking of liquor by the complainant before 15 years of taking treatment in Imphal cannot be linked with the disease he suffered, for which he took treatment at the Advance Speciality Hospital & Research Institute, Imphal. From evidence of the complainant, it is also seen that he was again admitted International Hospital, Guwahati on 8.2.16 and he was treated their up to 24.2.16 mainly for Oesophageal Varices with their sufferings like arthities vertiblal lesions. Thus , it is seen that the complainant was treated at International Hospital for suffering mainly from Oesophageal Varices, which is similar to UGIB disease, for which he had been treated at Advance Speciality Hospital & Research Institute, Imphal. The complainant states that he also filed claim with the opp.parties for re-imburse of the expenditure he incurred for his treatment taken in International Hospital, Guwahati and that was also already settled . Thus, it is seen that for same disease the opp.parties settled the claim of the complainant for re-imbursment the expenditure made in International Hospital, Guwahati, which shows that the opp.parties are inclined to hold that the disease for which the complainant treated at International Hospital, Guwahati has no linked with intact of alcohol by the complainant prior to 15 years. It is also found that doctor of Imphal hospital clearly states that intaking of alcohol 15 years ago by the complainant is not linked with disease of UGIB for which he was treated in their hospital meaning thereby that the said diseases is not caused due to taking liquor by the complainant 15 years ago. We have perused the policy Exclusion No. 12 of the concerned policy and found that it provides if any disease caused for taking alcohol by the insured, the insurance company is not liable to reimburse the expenditure made by the insured in-taking treatment for such disease. In our present case, it clearly established that the disease for which the complainant had taken treatment in the said hospital at Imphal was not caused as a result of intaking of liquor (alcohol) by the complainant before 15 years of taking treatment. Therefore, the case of the complainant does not attrack the provision of Exclusion 12 of the policy taken by the complainant . Therefore, the order of repudiation of claim of the complainant which the opp.party intimated the complainant, vide letter dtd. 7.6.2006 (Ex.5), is an illegal order. In consequence , we hold that the opp.parties are liable to reimburse the expenditure made by him for his treatment in Imphal Hospital. The complainant states that he spent Rs.72,170/- in his treatment for the hospital at Imphal and the opp.party is also found isnot disputing this figure. Therefore, we hold that the opp.parties are liable to reimburse the said amount to the complainant.
5) The opp.parties are found to have caused harassment to the complainant by illegally repudiating the said claim of the complainant. So, we hold that the opp.parties are liable to pay at least Rs.10,000/- to him as compensation for causing harassment to him. At last, we also hold that the opp.parties are liable to pay another amount of Rs.10,000/- as cost of the proceeding as for their fault; the complainant became compelled to prosecute them before this forum.
6) Summing up our discussion as above, we hold that the complainant has a prima facie case against the opp.parties, which he has succeeded to prove. Accordingly, the complaint is allowed on exparte and the opp.parties are directed to pay Rs.72,170/- to the complainant as re-imbursement of the expenditure he made for the treatment, which he had taken in the Advance Speciality Hospital & Research Institute, Imphal, and also to pay Rs.10,000/- as compensation for causing harassment to him by illegally repudiating his claim as well as Rs.10,000/- as cost of the proceeding, to which both the opp.parties are jointly and severally liable. They are directed to pay the awarded amount within 45 days , in default , the amounts shall carry interest @ 12% per annum from the date of filing of the complaint (1.12.16).
Given under our hands and seals on this day of 21st September ,2018.
(Smt Archana Deka Lahkar) (Md.Jamatul Islam) (Md.Sahadat Hussain)
Member Member President
