Order No. -36 Dt.- 18/02/2016
Shri Asoke Kumar Das,President
F I N A L O R D E R
Complainant’s case in short is that he took one “Reliance Life Care for you Plan” Insurance Policy bearing no.-50209090 from the OP Reliance Life Insurance Com. Ltd. in June-2012 and that was valid from 29/06/12 to 29/06/2015 and the sumassured was Rs.2,00,000/-. The complainant renewed that policy in time. Some times in January-2014 the complainant fail in ill and he got himself admitted at Touch Nursing Home Pvt. Ltd. at Jalpaiguri and he was treated there from 12/01/’14 to 18/01/’14. Thereafter he got himself admitted at Pasupati Singhania Research Institute at New Delhi for better treatment,and he was discharged therefrom on 28/01/2014. On 07/04/’14 he submitted bills with supporting documents to OP Realiance Life Insurance Com. Ltd. for settlement of his claim amounting to Rs.1,75,354/- which he incurred for his aforesaid treatment. But OP no.4 TPA has repudiated such claim of the complainant vide it’s letter dt.02/05/’14 stating therein, that “the member concerned is a habitual consumer of alcohol. As complication of alcohol consumption are not covered under the scope of the policy. Hence, the claim is not payable”. The complainant denied that he was ever habitual consumer of alcohol.
Hence, the case.
The OPs i.e. Reliance Life Insurance Com. Ltd. and the TPA have contested the case by filing W/vs wherein the OPs have denied and disputed the claim and contention of the complainant with prayer for dismissal of this case. Their specific stand is that the complainant was habitual drinker of alcohol as it is evident from the discharge summery and the medical certificates and the complainant have suppressed this fact at the time of procurement of the policy. So, the policy was void abinnitio and he is not entitled to get the claim as per terms&conditions of the policy.
POINTS FOR CONSIDERATION
- Is the case maintainable?
- Is the complainant is a consumer?
- Are the O.Ps. guilty for deficiency in service and/or unfair trade practice as alleged?
- Is the complainant entitled to get the reliefs as prayed for?
DECISION WITH REASONS
All points are taken up together for consideration and decision.
After due consideration of the materials of record i.e. the petition of complaint, the W/Vs (supported by affidavits) documents and the W/A, filed both the parties and after due consideration of oral argument advanced by the Ld. lawyers of the both sides we find that admittedly the complainant purchased “Realiance Life Care For You Plan” Insurance Policy no.50209090 from the OP Realiance Life Insurance Com. Ltd. in Jun2012 and that was valid from 29/06/’12 to 29/06/’15 and that the complainant had renewed that policy in time. Admittedly this Forum has territorial as well as pecuniary jurisdiction to hear and to disposed off this case, and that the petition of complainant has been filed well within the period of 2 years from the date of repudiation of complainant’s claim by OP no.4. The OPs have claimed that the complainant is a habitual consumer of alcohol and as his complications arises for consumption of alcohol which are not covered under the scope of the policy, the claim of the complainant was rightly repudiated by TPA i.e. OP-4 on 02/05/’14. The OPs couldn’t produce any evidence or document to establish their claim that the complainant is a habitual alcohol consumer and his complications had arisen due to consumption of alcohol. Now after going through copy of discharge summery and other papers filed by the complainant, we find nothing where from we can come to the conclusion that the complainant is habitual alcohol consumer. So we fail to understand as to how OP4 has come to the conclusion that the complainant is a habitual alcohol consumer? It will not out of place to mention here that the complainant took the policy in question in June-2012 and he renewed that policy in time. It was the legal obligation as well as duty on the part of OP Realiance Life Insurance Com. Ltd. to medically test the complainant and to verify his statements in the Proposal From before acceptance of the proposal and issue of Policy Deed in favour of the complainant. It is presumed that before acceptance of the proposal and issue of Policy Deed to complainant the OPs have medically tested him and verified his statements in the Proposal Form. Therefore we find sufficient reason to hold that the OPs have hopelessly failed to establish that the complainant was a habitual consumer of alcohol and his complications had arisen due to consumption of alcohol by any evidence, so the repudiation of the claim of the complainant as maid by OP4(TPA) vide its letter dt.02/05/’14, was not proper and valid. So, we can safely come to the conclusion that such act of repudiation of OP4 certainly comes within the purview of deficiency in service and/or unfair trade practice as alleged. In this view of the matter we find and hold that the case is well maintainable and that the complainant is a consumer of OPs, and that the OPs are guilty for deficiency in service and/or unfair trade practice, and that the complainant is entitled to the reliefs as specified below.
All points are disposed off.
In the result the case/application succeeds.
Hence, it is
- ORDERED
That the case/application stands allowed on contest against all OPs with litigation cost of Rs.1,000/-(Rupees One Thousand)only.
The complainant do get an award of Rs.1,75,354/-(Rupees One Lakh Seventy Five Thousand Three Hundred and Fifty Four)only against the OPs.
The complainant do get further award of Rs.5,000/-(Rupees Five Thousand)only against the OPs in the head of compensation for mental pain and agony suffered by the complainant and for said deficiency in service and/or unfair trade practice of the OPs.
The OPs 1 to 4 are jointly and severally liable to pay the aforesaid litigation cost and awarded sum of money stated above to the complainant.
The OPs are hereby directed to pay to the complainant the aforesaid litigation cost and awarded sum of money Rupees One Lakh Eighty One Thousand Three Hundred and Fifty Four)only in total(Rs.1,000/-+Rs.1,75,354/-+Rs.5,000/-=Rs.1,81,354/-) within 30 days from the date here of, failing which it will carry interest@8% P.A. till realisation and the complainant shall be at liberty to put this order into execution in accordance with law.
Let plain copy of this final order be supplied free of cost forthwith to the parties/ their Ld. Advocates/agents on record by hand under proper acknowledgment/sent by ordinary post, in terms of Rule 5(10) of West Bengal Consumer Protection Rules 1987.
