JUDGEMENT

          Complainant by filing this complaint has submitted that complainant is a holder of Mediclaim Policy being No.510900/34/10/11/00001389 dated 04.03.2011 which covers the hospitalization benefit covering the Policy period from 17.06.2010 to 16.06.2011 under the op and complainant paid Rs.11,952/- as premium for the said Mediclaim Policy.

          Fact remains that complainant being suffered from acute Pancreatitis with hypertension and having pain in the abdomen was admitted in the Health Point Hospital on 04.03.2011 at 11 PM and was discharged on 06.03.2011 at 12 Noon and the discharge certificate shows that acute abdominal pain diagnosed as acute pancreatitis and there is no indication in the discharge certificate that the patient was alcoholic and or having any effects of drugs.

          Thereafter the complainant was also admitted at Belle Vue Clinic having released from Health Point on 06.03.2011 and discharge summary and certificate manifestly clears that he was suffering from acute Pancreatitis with hypertension and no indication of alcoholism is found in the Discharge Certificate.  So, complainant subsequently lodged claim with the op no.1 insurance company within time.  But op no.2’s manufactured a concocted story of alcoholism to deprive the complainant of his legitimate claim of the Mediclaim amount, which he is entitled to receive under the policy.

          Though there is no iota of evidence that patient was addicted to any other drugs which has been raised by the op no.2 to deprive the complainant of his legitimate due of Mediclaim op no.2 Heritage Health TPA Pvt. Repudiated the claim for a sum of Rs.2,51,799/- who is appointed as agent of op no.1 i.e. the New India Assurance Co. Ltd. and in fact the repudiation of the claim was made on filmsy ground and asked the complainant to appeal before op no.1, the New India Assurance Co. Ltd. for his final decision.  But due to outright rejection of the genuine claim, which was lodged with the New India Assurance Co. Ltd. complainant thought that it would be the waste of time because it was the repudiation by the ops.

          Fact remains that complainant never enjoyed any Mediclaim benefit though he has been paying premium per year with effect from 17.06.2011 and till now.  But anyhow in the repudiation letter it is specifically mentioned that complainant’s claim was rejected as complainant is known alcoholic person and practically acute Pancreatitis with hypertension was caused due to continuous period of taking alcohol.  But anyhow the op did not consider the Discharge Certificate properly and wrongly repudiated the same for which the present complaint is filed against the op for proper redressal and also for their deficiency and negligent manner of service etc.

          On the other hand op by filing written statement submitted that there was/is  no deficiency of service on the part of the op because parties are guided  by the terms and conditions of the policy and in fact repudiation was made as per policy condition in view of the fact that it was clearly stated in the admission sheets that patient is a known alcoholic for last 35 years and took alcohol six to seven times in a day.  But his habit of smoking was not considered by the op and practically in view of the above fact, as per Clause-4.4.6 of the Terms and Conditions of the Policy, the present complainant’s alcoholism is a direct risk factor of pancreatitis and for which the claim was repudiated. 

          In fact complainant lodged this complaint suppressing that admission documents at the time of filing claim with other documents.  So, the present complaint should be dismissed.

                                                         Decision with reasons

          After thorough study of the complaint and the written version as made by the complainant and the op and also considering the first day of treatment sheet of Belle Vue Clinic dated 06.03.2011, it is clear that doctor noted against past history of present illness to the effect that “he is a known alcoholic and hypertensive – treatment” and about past illness, it is noted by doctor a known hypertensive on Tab Asomex AT, a known alcoholic occasional and smoker 6 to 7 in a day for the last 35 years and this treatment sheet was not produced by the complainant and it was suppressed and from that treatment sheet of Belle Vue Clinic, it is clear that complainant has a good history of taking alcohol for last 35 years and on the date of said admission on 06.03.2011 he was 57 years, that means since the age of 22 years this patient is habituated with taking alcohol daily and for the last 35 years he enjoyed alcohol and ultimately the present disease Pancreatitis was detected.

          Moreover complainant has a past history of hypertension for last 35 years and he was under medicine all along.  Fact remains as per medical science, alcoholism is direct risk factor of pancreatitis and anyhow complainant in the complaint has also mentioned that the decision of the op on the basis of the discharge certificate of Health Point Nursing Home is completely bad in law because op has come to a conclusion that complainant is habituated with taking alcohol for last 35 years that means since his age of 22 years because on the date of his admission to Health Point Nursing Home he was aged about 57 years.  But such a decision is completely baseless. 

          It is equally true that complainant intentionally did not submit the final document that is first day of his admission to Belle Vue Clinic and on that date he was diagnosed by the doctor in his present and past history was noted by the doctor and that paper was collected by the op and that has been produced and now complainant’s Ld. Lawyer at the time of argument failed to deny that matter.  When that is the fact, then it is clear that no doubt complainant suffered from Pancreatitis.  But it was no doubt caused for taking alcohol for last 35 years and also for his hypertension for last 35 years that is the past history of the complainant as noted by the doctor and after diagnosis and it was detected that it was acute Pancreatitis.

          So, considering the medical science book about acute Pancreatitis we have gathered that taking of alcohol for long period is direct risk factor of Pancreatitis.  So, the documents which are produced by the op in respect of the complainant’s treatment at Belle Vue Clinic clearly show that the complainant is not entitled to any claim as per Policy Clause-4.4.6.  But it is peculiar that the complainant appeared before this Forum suppressing this particular treatment sheet on the date of his admission at the Belle Vue Clinic on 06.03.2011 and if op would not be able to collect this document from Belle Vue Clinic in that case, complainant’s case ought to have been proved.

          But in the particular case, after considering that treatment sheet of the complainant which was not produced by the complainant but as produced by the op we are astonished how this complainant appeared before this Forum with uncleaned hand without producing this treatment sheet and not even it was produced before the op.  But op collected it and thereafter decided the claim of the complainant and considering the medical literature on acute Pancreatitis, it is found that due to long period of taking alcohol is a vital cause for acute Pancreatitis and in this case it is proved that the complainant is a renowned alcohol taker for last 35 years and started to take alcohol from the age of 22 years.

          So, practically due to consumption of alcohol for last 35 years, Pancrea has been damaged and function of Pancreatitis has been decreased for which he has been feeling abdominal pain and it is the habit of such a person who takes alcohol daily to take alcohol as and when he feels pain in his abdomen and it is also fact that due to taking of alcohol for long 35 years or 30 year or 20 to 25 years another diseases i.e. Cyrosis of Liver is also caused.  But in the particular case, alcoholism of the complainant is direct risk factor of Pancreatitis.  When that is the truth, them invariably for justified ground as per terms and conditions of the policy 4.4.6, the claim was repudiated by the op rightly and practically they did it considering all the medical point perfectly and there was no laches on the part of the op for repudiating the claim and for which we are convinced that there was no deficiency or negligence on the part of the op.

          On the contrary it is proved that suppressing the truth of his treatment and case of his acute Pancreatitis i.e. alcoholism were not ventilated before this Forum, not even the treatment sheet of Belle Vue Clinic is produced by the complainant, that was not also produced before the op at the time of submitting the claim.  But TPA after receiving the claim form along with other papers and discharge certificate enquired about the treatment sheet and ultimately collected the sheet which has been submitted by the op before this Forum and when complainant was found dumb and the Ld. Lawyer for the complainant very silently closed his argument when Ld. Lawyer of the complainant found that complainant is a very renowned alcoholic person for the last 35 years and started consuming of alcohol at the age of 22 years and now he is about 57 years.

          So, it is clear that complainant suppressing the truth has not appeared before this Forum with clean hand.  So, laches was there on the part of the complainant who was suffering from acute Pancreatitis only for his heavy taking of liquor starting from the age of 22 years that means in our society it is called that a person who starts his career of taking alcohol at the age of 22 years, he must be a renowned alcoholic person at the age of sixty years what happens in this case and long time of taking alcohol is the direct risk factor of different type of diseases such as Pancreatitis, Syrosis of Liver, Alzimer, Perkinson disease and all other diseases related to liver, Pancrea, Kidney and other Intestinal part and in the particular case acute Pancreatitis was caused due to complainant’s 35 years of alcohol taking experience and so invariably op rightly dismissed the claim and practically in view of the present position and also there is no denial of taking alcohol for 35 years by the complainant we are of the view that in the particular case there was no laches or deficiency or negligence on the part of the op.

          But fact remains that since 2001 complainant has been paying premium for Mediclaim Policy and he never enjoyed any claim prior to this present claim and considering the present situation and the future of the present complainant, we are directing the op to release a sum of Rs.1,25,000/- on humanitarian ground and by finally deciding this claim application and this order is being passed considering the socio economic aspect and also to show humanity to such a person whose future is only bubling.

          Accordingly this complaint is disposed of finally.

          Hence, it is

                                                              ORDERED

          That the complaint be and the same is allowed in part on contest but without any cost.

          Op the Insurance Company is directed to pay a sum of Rs.1,25,000/- to the complainant against the above claim stating as a final disposal and also treating it on humanitarian ground and it must be paid within 45 days from the date of this order and this Forum hopes that op Insurance Company shall have to show their morality in this particular case and their human approach in view of the socio economic condition of the complainant.

          If it is not paid by op, in that case invariably this Forum shall have to take penal action for which op Insurance Company may be imposed penalty also.