Tripura

West Tripura

CC/24/2016

Sri Goutam Chakraborty. - Complainant(s)

Versus

The Manager of HDFC Life & 1 another. - Opp.Party(s)

Smt. P.Roy.

05 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
WEST TRIPURA :  AGARTALA

CASE   NO:   CC-   24 of 2016 

Sri Goutam Chakraborty 
S/O- Sri Ramapada Chakraborty,
143, Hospital Extension Road,
Near Gandhighat, West Agartala,
Tripura West.                ...…..…...Complainant.

           VERSUS

1. The Manager,
of HDFC Life Ramon House,
H.P. Parek Mark,
169, Backbay Reclamation,
Mumbai-400020.

2. Branch Manager,
HDFC SL, Agartala Branch,
1st Floor, 9, Mantri Bari Road, 
West Agartala, Tripura West.         .............Opposite parties.

      __________PRESENT__________

 SRI A. PAL,
PRESIDENT,
  DISTRICT CONSUMER  
DISPUTES REDRESSAL FORUM,
      WEST TRIPURA, AGARTALA. 

SMT. Dr. G. DEBNATH
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.

C O U N S E L

    For the Complainant        : Mrs. Sujata Deb(Gupta),
                          Smt. Paramita Roy,
                          Advocate.
                          
    For the O.P.                 : Smt. Rajashree Purakayastha,
                          Mr. Satyakam Chakraborty,
                          Mr. Sudipta Sarkar,
                          Advocates.

        JUDGMENT  DELIVERED  ON:  05.12.2016
J U D G M E N T
        This case arises on the petition filed by one Goutam Chakraborty U/S 12 of the Consumer Protection. Case filed against the Manager HDFC Life & Branch Manager, Branch office at Mantribari Road, Agartala. Petitioner's case in short is that in the year 2013 he purchased one HDFC life Health Assurance plan policy in favour of him and his wife and daughter. The cover period was 3 years. Within the coverage period petitioner suffered abdominal pain on 17.08.15. He was admitted in the ILS hospital. Thereafter he was treated in the Columbia Asia Hospital at Kolkata. Claim the treatment cost but O.P. HDFC life refused to pay the amount. So, he claimed the medical expenses  Rs.46,686/- and also compensation Rs. 1 lakh. 

        O.P. No.1 and 2 Columbia Asia Hospital filed W.S denying the claim. It is stated that cashless facility was denied as Dr. Amitabha Roy in the ILS hospital observed that petitioner suffered from alcoholic liver disease. Such refusal was as per terms and condition of the policy. There was no deficiency of  service. Petitioner therefore, is not entitled to get any compensation. 

         On the basis of contention raised by the parties following points cropped up for determination
        (I) Whether the refusal of the Mediclaim placed by the petitioner was right or wrong?
        (II) Whether the petitioner is entitled to get compensation for deficiency of service by O.P.?
    
        Petitioner produced the Health Assure Proposal Form, medical certificate, discharge summary, bill vouchers of ILS hospital and Columbia Asia Hospital, policy certificate.
         Petitioner also produced the statement of affidavit of the petitioner.
        O.P. on the other hand produced the statement on affidavit of one Sanjay Malakar, Senior Associate Custom Relates HDFC Bank Agartala. Also produced some photocopies of documents.
         On the basis of all the evidence we shall no deterine the above points.

Findings and decision:
        We have gone through the policy certificate. Proposal date was on 13th June 2013 and risk commencement date was 22nd June 2013. Policy terms was for 3 years. It is to expire  in the year 2016. petitioner fell ill in the year 2015. Within the policy period  Rs.14,838/- as premium was paid. O.P. did not deny all these facts. Claim was repudiated on the ground that as per report of Dr. Amitabha Roy petitioner was alcoholic and developed liver disease due to  alcohol consumption. 

        In the policy certificate under Clause- 9 premium exclusions from the coverage is given in case the treatment received outside India, none allopathic treatment, injury due to breach of law, military services, aviation, hazardous activity, self inflicted injuries or attempted suicide, substance misuse and de-addiction. Most probably O.P. Insurance company had used this clause 9.9 to repudiate the claim. In this clause it is written that due to abuse or consequences of the abuse of intoxicants or  drugs and alcohol if the disease arise. Petitioner was finally treated by Dr. Sujoy Maitra, Consultant- Gastroenterology at Columbia Asia  Hospital Kolkata. The concerned doctor certified that the patient was admitted for abdominal pain. He has got no evidence of any form of liver disease on imaging or liver function test. Therefore, the question of alcoholic liver disease which might have been  mentioned in the prescription done outside does not arise. Firstly petitioner was treated in the ILS hospital, Agartala. There Dr. Amitabha Roy attended him. Patient was discharged in a stable condition. Nothing written in the discharge summary to support that he was alcoholic. However, in the prescription Dr. Amitabha Roy made some uncalled for irresponsible remarks without proper examination of the patient. It was written that petitioner was alcoholic and developed liver disease. This doctor finally certified  that they suspected that he consumed alcohol but on detailed evaluation it was found that alcohol intake was insignificant and occasional. Illness was not related to alcohol intake. He was diagnosed of gastritis & colitis found infective which is not related to alcohol intake. From the discharge summary it is also found that patient did not suffer any disease of alcohol. It is unfortunate that O.P. HDFC life relied on the baseless remark of Dr. Amitabha Roy and repudiated the claim on the ground that petitioner was drug addicted. This is improper. Without any investigation and final report of the disease HDFC life Insurance company repudiated the claim within the policy coverage period. Petitioner is entitled to get compensation therefore. Both the points are decided accordingly. 
    
        In view of our above findings over the two points this petition is allowed.
        O.P. HDFC life Insurance is directed to pay the treatment cost within the limit of the sum assured spent in the ILS Hospital and Columbia Asia Hospital, Kolkata total amount is to be paid immediately. We also direct the  HDFC Life Insurance Company to pay compensation Rs.20,000/- for their deficiency of service in realizing the amount in time. We also direct Insurance company to pay Rs.5,000/- as litigation cost. In total HDFC life Insurance is directed to pay Rs.71,686/-. Amount is to be paid within 2 months if not paid it will carry interest @ 9% P.A. Supply copy.                
                          Announced.

SRI A. PAL
PRESIDENT,
DISTRICT CONSUMER  DISPUTES 
REDRESSAL FORUM,
WEST TRIPURA,  AGARTALA.

 

SMT. DR. G. DEBNATH,
MEMBER,
 DISTRICT CONSUMER DISPUTES 
REDRESSAL FORUM, 
WEST TRIPURA, AGARTALA    SRI U. DAS
MEMBER,
  DISTRICT CONSUMER 
DISPUTES REDRESSAL FORUM, 
  WEST TRIPURA,  AGARTALA.