Punjab

Bhatinda

CC/12/244

Neelam Ahuja - Complainant(s)

Versus

The New India Assurance co. ltd - Opp.Party(s)

Naresh Garg

14 Jan 2013

ORDER

DISTT.CONSUMER DISPUTES REDRESSAL FORUM,Govt.House No.16-D,Civil Station, Near SSP Residence,BATHINDA-151001(PUNJAB)
 
Complaint Case No. CC/12/244
 
1. Neelam Ahuja
wife of Satish Ahuja son of Kundan Lal,R/o 602,Phase-I,Urban Estate, Bathinda
...........Complainant(s)
Versus
1. The New India Assurance co. ltd
ll,Bathinda through its Divisional Manager
2. Raksha TPA Pvt ltd
Second floor SCO 181 Sector 7-C,Chandigarh
............Opp.Party(s)
 
BEFORE: 
 HONABLE MRS. Vikramjit Kaur Soni PRESIDENT
 HONABLE MR. Amarjeet Paul MEMBER
 HONABLE MRS. Sukhwinder Kaur MEMBER
 
PRESENT:Naresh Garg, Advocate for the Complainant 1
 
ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA


 

C.C. No. 244 of 24-05-2012

Decided on 14-01-2013


 

  1. Neelam Ahuja aged about 65 years Wife of Satish Ahuja

  2. Satish Ahuja aged about 71 years S/o Sh. Kundan Lal, R/o 602, Phase -I, Urban Estate, Bathinda.

........Complainants Versus


 

  1. The New India Assurance Co. Ltd., Divisional Office, The Mall, Bathinda, through its Divisional Manager

  2. Raksha TPA Pvt. Ltd., Second Floor, SCO 181, Sector 7-C, Chandigarh.

     

    .......Opposite parties


 

Complaint under Section 12 of the Consumer Protection Act, 1986.


 

QUORUM

Smt. Vikramjit Kaur Soni, President.

Sh.Amarjeet Paul, Member.

Smt. Sukhwinder Kaur, Member.

 

For the Complainant : Sh. Naresh Garg, counsel for complainant.

For Opposite parties : Sh. Sunder Gupta, counsel for the opposite parties.


 

O R D E R


 

VIKRAMJIT KAUR SONI, PRESIDENT:-


 

  1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act'). Briefly stated, the case of the complainants is that they purchased the insurance policy firstly on 18-05-2004 after filling the proposal form and thereafter the same was renewed in 2005, 2006, 2007 and 2008 issued till 2012. There is no break in this period from 2004 to 2012. The complainants were lastly issued insurance certificate w.e.f 19-05-2011 to 18-05-2012 vide certificate No. 36060034110100000004, but no policy or its terms and conditions were ever supplied to the complainants. Vide the said insurance certificate dated 19-5-2011, both the complainants are covered for Rs. 2.50 Lacs each under medi-claim insurance policy. The opposite parties took the signatures of the complainants on the proposal forms in each and every year wherein the complainants disclosed all the material facts before purchasing the insurance cover. The complainant No. 2 had some problem of ulcer on 20-7-2011 and was admitted with Jindal Heart Hospital, Power House, Road, Bathinda, from where he was discharged on 26-7-2011. The ultra sound was done by Pioneer Imaging and Diagnostics Centre on 21-7-2011 and thorough examination of complainant No. 1 by Dr. Gursewak Singh, D.M. Gastro on 21-7-2011, he has done the Endoscopy of complainant Satish Kumar. The complainant No. 2 was ultimately referred to Higher Institution on 26-7-2011 by Dr. Atin Gupta of Jindal Heart Institute, Bathinda. He also issued the certificate to the effect that the bleeding is due to medication as the patient was on nemuslide for the last one year. The complainant No.2 was immediately shifted to Medanta The Medicity at Gurgaon on the same day i.e. 26-07-2011 and remained admitted there w.e.f. 26-07-2011 to 29-07-2011. The complainants alleged that complainant No. 2 spent Rs. 1,30,033/- as hospital charges, diagnostic test charges, consultation and Anesthesia charges, medicine purchased from chemist and other expenses including blood etc., The complete detail alongwith original bills alongwith duly filled form were submitted with opposite party No. 1. The complainants received letter dated 15-10-2011 from the office of opposite party No. 2 vide which the claim of complainant No. 1 has been repudiated with the remarks that the patient is chronic alcoholic, hence claim is not payable as per clause 4.4.6 of the policy. The complainants alleged that the disease of the complainant No. 1 i.e. ulcer is due to medication and this fact is duly certified by Dr. Atin Gupta of Jindal Heart Institute, Bathinda, but the opposite parties rejected his claim on flimsy and illegal ground. The opposite parties have not even sent the aforesaid clause alongwith no claim letter dated 15-10-2011. The complainants made several requests to the opposite parties, but nothing has been replied by them till date. Hence, the complainants have filed the present complaint seeking directions to the opposite parties to pay the claim amount of Rs. 1,30,033/- with interest alongwith compensation and cost.

  2. The opposite parties filed their joint written statement and admitted that the complainant obtained medi claim Insurance policy 36060034110100000004 effective from 19-05-2011 to 18-05-2012 with capital sum insured of Rs. 2,50,000/-, but denied that terms and conditions alongwith policy were not sent to the complainants. The opposite parties have pleaded that the proposal form is not required in case of renewal policy. The proposal form obtained from Satish Ahuja in the year 2005 was blank, unsigned and proposal form thereafter received from the complainant are not traceable. The complainant No. 2 has suffered disease of duodenal ulcer due to chronic alcoholic nature and alcohol is a risk and contributing factor of Gastro intestinal tract illness, including ulcers. The opposite parties have denied that terms and conditions of medi claim policy were not sent to the complainant and duodenal ulcers are due to medication. Dr. Attin Gupta has issued false certificate to favour the complainant. The opposite parties have further pleaded that the claim of the complainant has been repudiated by the opposite party No. 2 vide letter dated 15-10-2011 as the patient is chronic alcoholic and as per exclusion clause 4.4.6 the claim is not payable.

  3. The parties have led their evidence in support of their respective pleadings.

  4. Arguments heard. The record alongwith written submissions submitted by the parties perused.

  5. These are undisputed facts between the parties that the complainants obtained medi claim Insurance policy bearing No. 36060034110100000004 with the opposite parties effective from 19-05-2011 to 18-05-2012 with capital sum insured of Rs. 2,50,000/-. The complainant No. 1 suffered Duodenal ulcers and remained admitted in the hospitals. The complainants filed claim with the opposite parties and they rejected the claim on the ground that claim is not payable as per clause 4.4.6 of the policy as the complainant is chronic alcoholic.

  6. The submission of the learned counsel for the complainant is that the complainants obtained first medi-claim policy in the year 2004 and getting the same renewed till date. The complainants filled up the proposal form on 18-05-2004 and thereafter on 17-5-2005 for renewal of the policy. Thereafter the policy was again renewed in 2006 and continuously issued till 2012. The complainant No. 2 suffered from Duodenal ulcer and remained admitted in the hospitals at Bathinda and Gurgaon and spent Rs. 1,30,033/- . The complainants filed claim with the opposite parties which was rejected by them on the ground that complainant No. 2 was a chronic alcoholic and alcohol is a risk factor and contributing factor of Gastro Intestinal Tract Illness including Ulcers whereas the treating physician i.e. Dr. Atin Gupta has clearly mentioned in his certificate Ex. C-7 that complainant No. 2 was under his care from 20-7-2011 to 26-7-2011 with diagnosis of bleeding Duodenal ulcers due to medications. Hence, the rejection of claim is illegal and the complainant is entitled to the claim amount alongwith compensation and cost.

  7. On the other hand, the submission of the opposite parties is that the claim of the complainants has rightly been repudiated as per clause 4.4.6 of the policy. The complainant No. 2 suffered from Duodenal ulcer. As per record produced by him, he was a chronic alcoholic and alcohol is a risk factor and contributing factor of Gastro Intestinal Tract Illness including Ulcers.

  8. The opposite party No. 2 has declared the claim of the complainant No. 2 as Non payable vide Ex. C-6. The relevant portion of the said letter reads as under :-

    Patient suffered from Duodenal ulcer. On going through the records, it was found that patient is chronic alcoholic. Alcohol is risk factor and contributing factor of Gastro Intestinal Tract illness including ulcers. Therefore, claim falls out of the scope of the policy and hence claim is not payable as per clause 4.4.6 of the policy. Duodenal Ulcer NA.”

    In response to this letter, the complainant No. 1 wrote letter dated 21-10-2011 Ex. C-8 to the opposite party No. 2 intimating that after receiving the aforesaid letter, she contacted the treating doctor i.e. Dr. Atin Gupta of Jindal Heart Institute & Infertility Centre, Bathinda. The relevant portion of the said letter is reproduced hereunder :-

    ...I have contacted Dr. Atin Gupta of Jindal Heart Institute & Infertility Centre, Bathinda, who treated my husband before referring the case to Dr. Randhir Sud of Medanta Medicity Gurgaon for further management. He clarified that it is routine of any doctor to note down the history & habits of patients, which helps him to diagnose, but he certified that the illness is due to medication. (Original certificate enclosed)”

    The certificate Ex. C-7 issued by Dr. Atin Gupta of Jindal Heart Institute & Infertility Centre, Bathinda, reads as under :-

    To whom soever it may concern

    This is to certify that Mr. Satish Ahuja was under my care from 20th July, 2011 to 26th July, 2011 with diagnosis of bleeding Duodenal ulcers due to medications. Patient was treated conservatively and was referred to Medanta Medicity, Gurgaon, for further management.”

  9. The claim of the complainants was not paid and after filing the complaint by the complainants before this Forum, opposite party No. 2 wrote a letter Ex. R-14 to opposite party No. 1, enclosing therewith complete claim file of complainant No. 2 mentioning therein that :-

    ....5. Later in response to the repudiation, we received a representation from the insured with enclosed Treating Doctor certificate stating that the illness is due to medications. In this regard, we would like to apprise you that as per the detail available, nothing supportive of NSAID (Non Sterodial Anti Inflammatory Drugs – Pain Killers) in take was found.

    This is to bring to your kind notice that the aetiology of illness in presence of chronic alcoholic history of the patient cannot be considered to be of NSAID induced.

    Therefore the claim still stands non payable as per Clause 4.4.6 of the policy.”

  10. The opposite parties have been relying upon the prescription slip Ex. R-4 of Jindal Heart Institute & Infertility Centre, Bathinda, for the rejection of the claim of the complainant wherein a word “Ch. Alocholic/Smoker” is mentioned. The complainant has produced on record the aforesaid certificate of the said treating doctor wherein he has clearly mentioned that “diagnosis of bleeding Duodenal ulcers due to medications”. The opposite parties have pleaded that nothing supportive of NSAID (Non Sterodial Anti Inflammatory Drugs – Pain Killers) in take was found whereas a perusal of UGI Endoscopy Report of Gursewak Gasto Care, Pragma Hospital, Bhatti Road, Bathinda, reveals that at the end of this report under the heading “Impression” it has been mentioned “D.U. ?NSAID related”. A perusal of whole record of Medanta Medicity Gurgaon, produced on file reveals that nothing has been mentioned by any of the doctor and it is nowhere came in any test that the disease of the complainant No. 2 was due to consumption of alcohol. The Ch. Alocholic/smoker mentioned by the doctor on Ex. R-4 is due to the reason that in routine any doctor note down the history & habits of patients, which helps him to diagnose the disease and consumption of the alcohol may be one of the reason, but when the various tests of the complainant No. 2 were conducted it was nowhere proved that he was suffering from disease Duodenal ulcer due to consumption of alcohol.

  11. A perusal of file reveals that complainants have been purchasing the medi-claim insurance policies since 2004. There is no record on the file that during these 8-9 years, they ever filed any claim with the opposite parties. Now, when complainant No. 2 suffered from some disease and he filed claim with the opposite parties, they rejected his claim without any sufficient cause and on flimsy ground whereas the opposite parties have utterly failed to prove on file that Duodenal ulcer from which disease the complainant had suffered was due to consumption of alcohol and not due to medication whereas the complainant has placed on record complete medical record wherein nothing was mentioned regarding consumption of alcohol. Hence, repudiation of claim of the complainants amounts to deficiency in service on their part.

  12. The Insurance Regulatory and Development Authority vide its Circular Ref. No. IRDA/HLTH/MISC/CIR/216/09/2011 dated 20-09-2011 issued special guidelines to the Insurance Companies in this context. The relevant portion of the said circular is reproduced here under :-

    ...To All Life Insurers and non-life Insurers

    Re : Delay in claim intimation/documents submission with respect to

    i) All life insurance contracts and

    ii) All Non-life individual and group insurance contracts

    ....The Insurer's decision to reject a claim shall be based on sound logic and valid grounds. It may be noted that such limitation clause does not work in isolation and is not absolute. One needs to see the merits and good spirit of the clause, without compromising on bad claims. Rejection of claims on purely technical grounds in a mechanical fashion will result in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.”

  1. In view of what has been discussed above, this complaint is accepted against the opposite parties with Rs. 10,000/- as compensation and cost. The opposite parties are directed to pay Rs. 1,30,033/- being the claim amount, as detailed in Ex. R-7, to the complainants.

  2. The compliance of this order be made by the opposite parties jointly and severally, within 45 days from the date of receipt of copy of this order and incase of non-compliance within the stipulated period, the claim amount of Rs. 1,30,033/- will yield interest @ 9% P.A. from the date of institution of this complaint i.e. 24-05-2012 till realization.


 


 


 


 

  1. A copy of this order be sent to the parties concerned free of cost and the file be consigned to record room.

Pronounced :

14-01-2013

(Vikramjit Kaur Soni)

President

 

 

(Amarjeet Paul)

Member


 

 

(Sukhwinder Kaur)

    Member

     

     

 
 
[HONABLE MRS. Vikramjit Kaur Soni]
PRESIDENT
 
[HONABLE MR. Amarjeet Paul]
MEMBER
 
[HONABLE MRS. Sukhwinder Kaur]
MEMBER

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