BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.455 of 2016

Date of Instt. 07.11.2016

Date of Decision: 25.10.2017

Shri Pershant Sareen aged 45 years son of Shri V.K. Sareen, resident of 7, New Rajinder Nagar, Jalandhar.

..........Complainant

Versus

1. The New India Assurance Company Limited Registered Head Office, 87,Mahatma Gandhi Road, Mumbai through its Chairman/Managing Director.

2. Branch Manager, The New India Assurance Company Limited Patel Chowk Branch, Jalandhar-2.

….….… Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Sh. Parminder Sharma (Member)

Present: Sh. VK Sareen, Adv Counsel for the complainant.

Sh. RK Sharma, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. This complaint is presented by the complainant with the prayer that the complainant is a practicing Lawyer at Jalandhar and is aged about 45 years. He has taken medical insurance policy from New India Assurance Company Limited, Jalandhar for a number of years for himself as well as for his family consisting of his wife and two children, including the policy bearing No.36100234152800000023 valid from 31.05.2015 to 30.05.2016. On 11.05.2016, while the complainant was going to Indian Overseas Bank, situated in Guru Nanak Mission Chowk, Jalandhar, he started feeling uncomfortable and instead of going to the bank, he straightway went to the clinic of Dr. Sudhir Sethi, who on examining him, opined that he has a heart problem and consequently, without any loss of time, the complainant was taken to Global Hospital, situated on Link Road, Jalandhar and on examination in the said hospital, it was discovered by the doctors attending upon him that he had a block in the main artery carrying the blood to the heart. Immediately, surgery was performed and the blockage was removed and at the place of blockage, stents had been implanted. He remained as an indoor patient in Global Hospital from 11.05.2016 to 14.05.2016 and when he was discharged from the said hospital, he was directed to take the medicines prescribed to him by the surgeon and to revert to the hospital aforesaid periodically for check up. Since the day of discharge, the complainant is regularly taking the medicines prescribed by the doctors.

2. That for the treatment in the said hospital, a sum of Rs.2,50,000/- had been paid to Global Hospital by way of a package for the surgery performed on him. Besides paying the said amount to the hospital, the complainant had also incurred expenses on buying medicines, while he was an indoor patient in the said hospital. That some time, after the discharge of the complainant from Global Hospital, he had submitted a claim to the insurance company for reimbursement of the expenses incurred by him on his treatment but the claim of the complainant was repudiated by the insurance company, vide letter dated 23.07.2016, on the ground that the complainant had suffered from CAD (Coronary Artery Disease) acute MI (Myocardial Infaction) as per discharge summary and indoor case papers, patient is chronic alcoholic, alcohol consumption is cause of heart disease (including CAD and MI) illness due to alcohol is excluded from the scope of the policy, therefore, claim is non payable as per clause 4.4.6 of the policy.cad. ac.mi.chr alcoholic, meaning thereby that the OP has repudiated the claim lodged by the complainant. The said repudiation on the part of the OPs is absolutely wrong and illegal because it is not understandable as to where from it had been concluded by the OP that the complainant was a chronic alcoholic or that the illness suffered by the complainant was the result of alcohol consumption. It appears that the authority, which had issued the said letter, did not comprehend the word “chronic alcoholic”. It may be pointed out that whenever a patient is admitted in any hospital, the doctor attending upon him usually put two questions to the patient while examining him as to whether he is a smoker and as to whether takes hard drinks and when the answer given by the patient is that he does not indulge in smoking or that he takes hard drinks also, the doctor in his record always write the word “chronic smoker”/chronic alcoholic”. Even, if the patient may be a casual smoker or takes alcohol casually. Otherwise, the word “alcoholic” by dictionary meaning, means a person, who is addicted to the intake of alcohol. The complainant is a leading Legal Practitioner at Jalandhar and had never been addicted to alcohol. Had it been so, he would not have been a front runner in his profession. His early income from his profession is more than Rs.20,00,000/- per year and a professional at the District level earning such an amount every year has too mentally and physically fit. Therefore, the observation in the letter dated 23.07.2016 was absolutely wrong and amounted to unfair trade practice on the part of the OPs and then a legal notice dated 16.08.2016 was served upon the OP to reimburse the said amount of the medical expenditure, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs may be directed to pay to the complainant the amount of Rs.2,85,582/- on account of the claim lodged by the complainant in connection with the expenditure incurred by him for his treatment in Global Hospital and purchase of the medicines and to pay to him a sum of Rs.5,00,000/- by way of damages for illegally repudiating the claim and thereby causing him physical and mental torture and also directed to pay litigation expenses to the tune of Rs.50,000/-.

3. Notice of the complaint was given to the OPs and accordingly both the OPs appeared through their counsel and filed their joint written reply, whereby contested the complaint by taking preliminary objections that the complaint is not maintainable against the OP, as such, the same is liable to be dismissed. It is further averred that the claim of the complainant stands repudiated as per terms and conditions of the insurance policy. The claim papers submitted by the complainant were referred to Raksha TPA Pvt. Ltd., the third party administrator as per insurance policy for processing the claim as per terms and conditions of the insurance policy. The claim of the complainant was processed by the Raksha TPA Pvt. Ltd., as per the terms and conditions of the insurance policy and on scrutiny of the documents submitted by the complainant for the reimbursement of medical expenses, the Raksha TPA Pvt. Ltd. found that complainant received treatment for CAD and Acute MI. As per discharge summary and indoor case paper of Global Hospital, patient/complainant is Chronic Alcoholic. Alcohol consumption is cause of heart disease and as per terms and conditions of the insurance policy, illness due to alcohol is excluded from the scope of the policy, as such, the claim was not payable as per Exclusion Clause 4.4.6 of the policy and as such, the claim of the complainant was repudiated by the Raksha TPA Pvt. Ltd. as per terms and conditions of the insurance policy and the complainant was intimated vide letter dated 23.07.2016. On merits, it is admitted that the complainant has purchased an insurance policy, after making a payment of the premium and the said policy was valid from 31.05.2015 to 30.05.2016 and it is also admitted that the complainant submitted a medi claim but the same was scrutinized and thereafter, the same was repudiated according to the Exclusion Clause 4.4.6 of the terms and conditions of the policy and the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and the same may be dismissed.

4. In order to prove the case of the complainant, the counsel for the complainant Sh. VK Sareen, Adv tendered into evidence affidavit of the complainant Ex.CA and affidavit of the Dr. Sudhir Sethi, Cardiologist, Jalandhar as Ex.CB and further tendered some documents Ex.C1 to Ex.C31 and closed the evidence.

5. Similarly, the counsel for the OP No.1 and 2 tendered into evidence affidavit of Jaibir Shanker as Ex.OA alongwith some documents Ex.O1 to Ex.O7 and closed the evidence.

6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.

7. There is no dispute in this complaint that the complainant Pershant Sareen got an insurance policy, valid for the period 31.05.2015 to 30.05.2016 and it is also not denied by the OP that the complainant remained admitted in Global Hospital, where from he got treatment for his heart problem and thereafter submitted a medi insurance claim, but the same was repudiated by the OP, vide letter Ex.C28 and same repudiation letter brought on the file by the OP is Ex.O5 and the reason for repudiating the medical claim of the complainant as elaborated in the said repudiation letter is that the complainant has suffered from CAD (coronary artery disease) acute MI (myocardial infaction) as per discharge summary and indoor case papers, patient is chronic alcoholic, alcohol consumption is cause of heart disease (including cad and mi) illness due to alcohol is excluded from the scope of the policy, therefore, claim is non payable as per Clause 4.4.6 of the term and condition of the policy and accordingly, the insurance claim of the complainant was rightly repudiated by the OP. Due to the above reason, the claim of the complainant has been repudiated and further, the learned counsel for the OP referred some documents i.e. discharge summary Ex.O3 and indoor patient's file Ex.O4 and in both the documents, it is categorically mentioned that the complainant is chronic alcoholic and learned counsel for the OP gave much stress upon these documents and further submitted that these documents co-related with the term and condition of the insurance policy and the said term and condition of the policy is available on the file Ex.O2, where from he again referred column 4.4.6 and further submitted that the claim of the complainant has been rightly and legally repudiated according to the term and condition of the policy.

8. On the other hand, in order to meet out the plea taken by the OP that the complainant is chronic alcoholic, the complainant himself stepped into the witness box and tendered his affidavit Ex.CA, whereby reiterated the entire facts as detailed in the complaint and categorically deposed that there is no past history of heart problem to him nor he is in habit to take alcohol daily rather he is taking a liquor on some occasions and these factum have been narrated to the doctor attending to him but who has written the word 'chronic alcoholic' in the discharge summary as well as history of the patient, which is absolutely wrong because the complainant is a leading legal practitioner at Jalandhar and had never been addicted to alcohol and these factum have been got proved by the complainant by examining Dr. Sudhir Sethi, Heart Specialist, whose affidavit is available on the file Ex.CB and evidence of the said doctor is very important in this case to find out whether the complainant is virtually having the heart problem due to consumption of alcohol or not, for that purpose, the said doctor Sudhir Sethi deposed in his affidavit Ex.CB that the complainant Pershant Sareen came to his clinic on 11.05.2016 and he was complaining of uneasiness and on his examination, he found that there is a some heart problem to the complainant and he was immediately shifted to Global Hospital, Jalandhar, where blockage in the artery was removed by implanting stent and further deposed that the complainant Pershant Sareen did not have any previous history of any heart problem, the blockage in his artery had occurred all of sudden, in the normal course of life in every human being there are cholesterol deposits in the lining of the arterial walls, which start to deposit as earlier as the age of 10 years of life. This deposit rate varies from person to person depending upon the genetic tree history, smoking, uncontrolled hypertension, diabetes and a very sedentary life style are known factors to excelrate earlier heart attacks and further deposed that the data and medical experience suggests that social alcoholic intake in moderation is most protective against heart attacks than just tea totallers and further deposed that the blockage in the artery of the complainant, had occurred because of the rapture of the cholesterol deposit inside the lining of the artery which in no way is related to social drinking and further deposed that if the complainant is chronic alcoholic, then he would have been a patient of Liver Cirrhosis or pancreatitis but at the time of admission of the complainant in the hospital, he was not the patient of above Liver Cirrhosis or pancreatitis.

9. If, we analyze the evidence of Dr. Sudhir Sethi, then reach to conclusion that the complainant has established on the file that even casual taking of liquor does not make a cause for a heart attack or blockage of artery and this medical evidence of the complainant is not rebutted by the OP by examining any counter doctor. So, the evidence of the doctor, examined by the complainant remains un-rebutted and un-challenged and moreover, it is the duty of the OP, who took a plea that the blockage in the artery was caused due to consumption of alcohol, but the OP has not brought on the file any expert witness to establish these factum, simply narrating in the discharge summary Ex.O3 and indoor patient file Ex.O4 that the complainant is chronic alcoholic is not sufficient until there is not any other co-related evidence is available on the file. So, with these observations, we are of the opinion that the heart problem occurred to the complainant does not relate to consumption of alcohol in any manner, if so then, the insurance claim of the complainant is illegally repudiated by the OP without any reason and rhyme or on any solid ground.

10. Further more, the complainant has claimed an amount of Rs.2,85,582/- on account of expenditure incurred by him for his treatment in the Global Hospital, Jalandhar and for purchase of medicines and to support his version, the complainant has brought on the file a bill Ex.C9, paid to the Global Hospital and also brought on the file some medicine bills Ex.C12 to Ex.C25 and if the amount of these bills are included in the bill Ex.C9, then obviously the amount comes to as claimed by the complainant. So, accordingly, we reach to the conclusion that the complainant is entitled for the relief.

11. In view of the above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay the amount of Rs.2,85,582/- as an insurance claim with regard to expenditure incurred by him for his treatment as well as for purchase of medicines and OPs are also directed to pay interest on the aforesaid amount @ 9% per annum from the date of repudiation of insurance claim i.e. from 23.07.2016 till realization and further OPs are directed to pay a compensation for mentally and physically harassment to the complainant to the tune of Rs.25,000/- and also directed to pay litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. The complaint could not be decided within stipulated time frame due to rush of work.

12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Parminder Sharma Karnail Singh

25.10.2017 Member President