Delhi

North East

CC/68/2021

Mahesh Chand - Complainant(s)

Versus

Tata Aig General Insurance Company Ltd. - Opp.Party(s)

18 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

Complaint Case No. 68/21

 

In the matter of:

	Sh. Mahesh Chand, S/o Sh. Bhagmal, R/o H.No. 191 A, G/F, Khasra No. 60, St No. 5, Main 30 Futa Road, New Sabhapur, Gujran, Karawal Nagar, Delhi 110094	Complainant
	Versus
1.               2.	TATA AIG General Insurance Company Ltd. Through its Relationship Manager, Sh. Pankaj Varshney Unit No. 810-816, Eight Floor, World Trade Tower, Plot No. C 001, Sector 16, Noida 201301   TATA AIG General Insurance Company Ltd. Through its Branch Manager/Authorized Representative Regd. Office at 15th Floor, Tower A, Peninsula Business Park, G.K Marg, Lower Parel, Mumbai-400013	Opposite Parties

 

DATE OF INSTITUTION: JUDGMENT RESERVED ON: DATE OF ORDER:

08.04.21 10.08.23 18.10.23

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

ORDER

Surinder Kumar Sharma, President

The Complainant has filed the present complaint under Section 35 of the Consumer protection Act, 2019.

Case of the Complainant

1. The case of the Complainant is that the on 24.06.20 Complainant purchased TATA AIG Medi Care Policy through TATA AIG Insurances, vide Policy no. 028811819200 w.e.f 24.06.20 to 23.06.21 having insured sum of Rs. 3,00,000/-  and paid premium of Rs. 17,972/- to Opposite Party. The Complainant stated that on 22.11.20 Complainant was admitted to Dr. Ram Manohar Lohia Hospital, Delhi due to corrosive ingestion (approx. 30 ml) accidentally from frooti bottle. The Complainant stated that he filed mediclaim which was rejected on 12.02.20 by Opposite Party stating following reasons:-

1. The submitted claim is for management of an ailment which is consequence of attempted suicide. Hence we regret to inform you that your claim is repudiated under section 3.3 iv

2. The submitted claim is for treatment of which is a consequence/complication of drug intake.  Treatment related to abuse/substance abuse is excluded in the policy. Hence we regret to inform you that your claim has been repudiated under section 3.2ii of the policy.
3. The Complainant got discharged from hospital on 07.12.20. The Complainant stated that he had made various efforts for his claim but all in vain. The Complainant stated that he had also sent legal notice dated 04.03.21 to Opposite Parties but Opposite Parties did not give reply to the notice. Hence, this shows deficiency in service on behalf of Opposite Parties. The Complainant has prayed to pay the medical bills of Rs. 2,23,700/- and Rs. 2,00,000/- towards mental harassment. He has also prayed for Rs. 20,000/- as litigation expenses.

Case of the Opposite Parties

4.  The Opposite Parties contested the case and filed common written statement and stated that the Complainant was admitted to the hospital for consumption of acid and the same was as a result of attempted suicide by the Complainant and the medical records annexed by the Complainant shows that the Complainant was prescribed anti-depressants and was referred to a psychiatrist which clearly shows that the corrosive ingestion was not accidental.  The medical records further show that the case was a medico legal case which suggests the involvement of police. Further, Opposite Party stated that the Complainant claims that he accidentally consumed 30 ml of corrosive substance, the theory is not plausible since if the Complainant had consumed any corrosive substance accidentally, he would have stopped immediately and not consumed the entire 30 ml of the substance. Therefore, the explanation offered by the Complainant for corrosive ingestion is illogical by the Complainant in order to claim under the policy.  It is the case of the Opposite Party that Complainant voluntarily consumed corrosive substance as an attempt to suicide.
5. The Opposite Party rejected the claim of the Complainant as the abuse of intoxicants is expressly excluded in the Medical Exclusions of the policy wordings under section 3 (2) (ii) and attempted suicide by consumption of corrosive element is also excluded in the Non-Medical Exclusions under section 3 (3) (iv) of the policy wordings.  The Opposite Party further states that the preamble of the policy wordings stated that the policy includes only accidental bodily injury or illness. Attempted suicide by consumption of corrosive element does not qualify as accident and is therefore outside the coverage of the policy wordings. Therefore, the claim of the Complainant was rightly rejected by the Opposite Parties.
6. As the Opposite Parties have acted as per the terms and conditions of the policy, there is no deficiency in service and unfair trade practices on the part of Opposite Party. As a result, the present complaint is liable to be dismissed.

Rejoinder to the written statement of Opposite Parties

7. The Complainant filed rejoinder to the written statement of Opposite Parties wherein the Complainant has denied the objection raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

8. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Parties

9. In order to prove its case Opposite Parties have filed affidavit of Sh. Amit Chawla, Associate Vice President-Legal Claims, wherein the averments made in the written statement of Opposite Parties have been supported.

 

 

Arguments and Conclusion

10. We have heard the Ld. Counsels for the parties. We have also perused the file and the written arguments filed by the parties. The case of the Complainant is that on 22.11.20 he has accidentally consumed some corrosive ingestion from frooti bottle. It is his case as revealed from the complaint that from 22.11.20 to 07.12.20 he was admitted in Dr. Ram Manohar Lohia Hospital, Delhi. His case is that his medical claim was wrongly rejected by the Opposite Parties. The perusal of the copy of discharge report of Dr. Ram Manohar Lohia Hospital, Delhi shows that he was admitted in the hospital on 22.11.20 to 26.11.20 and not till 07.12.20 as stated by the Complainant in his complaint. The said discharge report further shows that the psychiatric reference of the Complainant was done and he was advised medicine for the same.
11. The medical record produced by the Complainant shows that he was treated in Dr. Ram Manohar Lohia Hospital, Delhi for corrosive ingestion injury. Similarly, the other hospitals such as AIIMS and Shri Ram Hospital have also diagnosed that the Complainant was suffering from corrosive ingestion injury. The case of the Complainant is that he has accidentally consumed 30 ml of some acid type liquid.  His case is that this was all unintentional. The version of the Complainant cannot be believed because if a person consume some acid type of liquid, in such a case he is not expected to consume 30 ml of the same for the reason that immediately after taking a sip of the said liquid he would feel some bitter taste and would also feel some burning sensation. In such a case, the person would immediately stop consuming the same further and he would spit out the substance which he has already taken.  In the present case, as per the version of the Complainant, he has consumed 30 ml of the acid type liquid accidentally. This version of the Complainant is unbelievable. Therefore, it cannot be said that the Complainant is consumed the said substance accidentally. Therefore, under these circumstances, the Opposite Parties were right in rejecting the claim of Complainant. The complaint is dismissed.   
12. Order announced on 18.10.23.

Copy of this order be given to the parties free of cost.

File be consigned to Record Room.

 

(Anil Kumar Bamba)           Member

(Surinder Kumar Sharma) President