CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM
Present
Sri. Bose Augustine, President
Sri. K.N. Radhakrishnan, Member
CC No. 180/2011
Wednesday, the 17th day of July, 2013
Petitioners : 1) C.L. Thomas (Died)
Chirayil House,
Kanakkary P.O.
Kottayam.
2) Girly Thomas,
W/o Thomas,
Chirayil House,
Kanakkary P.O.
Kottayam.
3) Heidi T.Chirayil
(D/o. Thomas)
-do-
4) Hilda T. Chirayil
(D/o Thomas)
-do-
5) Harry T. Chirayil,
(S/o. Thomas)
-do-
(Adv. Joseph C.L)
Vs.
Opposite parties : 1) The New India Assurance Company Ltd.
(A Govt. of India Undertaking)
New India Assurance Building
87 M.G. Road, Fort Mumbai – 400001
2) New India Assurance Company Ltd.
Poozhikkala Building,
M.C. Road, Ettumanoor
Rep. by the Branch Manager
(Adv. Girija P.G.)
O R D E R
Sri. Bose Augustine, President.
The case of the petitioners filed on 18-07-2011 is as follows:
Petitioners 2 to 5 are the legal heirs of the 1st petitioner, who died on 05-01-2012. 1st petitioner had taken a Mediclaim Insurance Policy from the opposite party Insurance Company. The policy covers the entire family members. Total premium paid for policy is Rs.9,420/-. As per the policy conditions opposite party assured an amount of Rs.1,00,000/- for medical expenses incurred by the petitioner and his family members. The 1st petitioner had to undergo treatment for various illness at different hospitals from 29-10-2010, at Vimala Hospital- Ettumannoor, Karithas Hospital- Thellakom and finally at Christian Medical College, Velloor from 04-11-2010 to 14-11-2010. The deceased 1st petitioner had to spent Rs.1,01,635/- for treatment and medicines with various hospital. The 1st deceased petitioner forwarded the claim for reimbursement of the amounts spent at various hospital to the opposite party in the prescribed form with all required documents. But the opposite party repudiate the claim of the petitioner by a reply dated 09-03-2011 stating that clause 4,4,6 of the conditions of the policy exempted them from any liability. According to the petitioners opposite party have no legal right to deny the claim and is liable to pay the petitioner for the amount of insurance coverage with 12% interest till realization. According to the petitioners they are the beneficiary of the service rendered by opposite party and the act of opposite party in rejecting the claim is deficiency in service from the part of opposite party. Hence this petition.
Opposite party filed version contenting that the opposite party repudiated the claim as per clause 4.4.6 of the mediclaim policy which excludes insurer’s liability with regard to any medical expenses incurred or arising out of the “use of intoxicating drugs / alcohol”. According to opposite party as per the discharge summary of the deceased petitioner from CMC, Velloore, the deceased petitioner had a history of “ethanol intake”. Therefore the claim of the deceased petitioner was repudiated. Hence the opposite party is not liable to pay any amount to the petitioners and the opposite party pray for dismissal of the petition with cost.
Points for determination
1) Whether there is any deficiency in service or unfair trade practice on the part of opposite party?
2) Relief and Cost?
Evidence in this case consists of affidavits filed by both parties and Ext. A1 to A7 documents on the side of the petitioner.
Point No.1
The case of the petitioners are that the claim of the deceased 1st petitioner was repudiated by the opposite party on flimsy ground. From Ext. A3 it can be seen that the deceased 1st petitioner had spent Rs.1,01,635/- for his treatment expenses. Ext. A2 is the copy of policy certificate issued by the opposite party. The opposite party had no dispute with regard to Ext. A2 and A3. The only contention of opposite party is that clause 4.4.6 of the mediclaim policy, excludes the liability with regard to any medical expenses incurred or arising out of the “use of intoxicating drugs / alcohol”. Petitioners are produced the discharge summery of the deceased petitioner and the same is marked as Ext.A6. According to opposite party, from Ext. A6 discharge summary of the deceased petitioner from CMC, Velloor, it can be seen that the deceased petitioner had a history of “ethanol intake”. So the opposite party repudiate the claim. Even though opposite party repudiated the claim of the deceased petitioner on the ground that that the illness of the deceased petitioner is due to consumption of alcohol. But opposite party has not adduced any evidence to prove that the illness of the deceased petitioner was due to alcohol consumption. Mere stating of the history of ‘ethanol intake’ in Ext. A6 does not help the opposite party to say that the illness was sustained due to alcohol consumption. In our view act of opposite party is repudiating the claim of the deceased petitioner amounts to deficiency in service. So Point No.1 is find accordingly.
Point No.2
In view of the finding in Point No.1 petition is allowed.
In the result
1) Opposite party is ordered to pay the insured amount of Rs.1,00,000/- as treatment
expenses with 10% interest from the date of petition till realisation to the petitioners.
2) Since interest is allowed no separate compensation is allowed.
3) Opposite party is ordered to pay an amount of Rs.2000/- as litigation cost to
the petitioners.
Order shall be complied within one month of receipt of the copy of the order.
Sri. Bose Augustine, President Sd/-
Sri. K.N Radhakrishnan, Member Sd/-
APPENDIX
Documents of the Petitioner:
Ext.A1 : Copy of terms and conditions of Mediclaim policy.
Ext.A2 : Copy of Insurance Policy No.760109/34/10/11/00000108.
Ext.A3 : Copy of consolidated receipt from Christian Medical College dtd. 15-11-2010.
Ext.A4 : Copy of reference card from Vimala Hospital.
Ext.A5 : Copy of discharge summery from Caritas Hospital dtd.30-11-2010.
Ext.A6 : Copy of discharge summary from Christian Medical College, Velloore
dtd. 14-11-2010
Ext.A7 : Letter from Medi Assist dtd.09-03-2011.
Documents of the Opposite party
Nil
By Order
Senior Superintendent
