BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Complt. Case No : 1402 of 2009

Date of Institution:    23.10.2009

Date of Decision  :    07.06.2010

Ravi Shankar Sharma, resident of H.No.2586, Sector 40, Chandigarh.

 ……Complainant

V E R S U S

1]       The Oriental Insurance Co. Ltd., Regd. &  Head Office Oriental House, A-25/27, Asafali Road, New Delhi 110 002, through its Chairman/M.D.

2]       The Oriental Insurance Co. Ltd. , Divisional Office, SCO No.99-100 (F/F), Sector 17-B, Chandigarh – 160 017, through its Divisional Manager.

.…..Opposite Parties

CORAM:          SH.LAKSHMAN SHARMA                         PRESIDENT

                    SH.ASHOK RAJ BHANDARI            MEMBER

                    MRS.MADHU MUTNEJA                        MEMBER

PRESENT:     Sh.Raj Karan, Advocate for the complainant.

                   Sh.G.S.Ahluwalia, Advocate for the OPs.

PER MADHU MUTNEJA, MEMBER

                    The instant complaint has been filed by Sh.Ravi Shankar Sharma under Section 12 of the Consumer Protection Act praying for payment/reimbursement of his claim as per mediclaim policy issued to him by the OPs.

1]                 A quick look at the facts of the case shows that the complainant had taken a mediclaim policy from the OPs in 2005 as per Ann.C-1.  The complainant states that he was always a healthy person with a normal life style. He continued with the mediclaim policy for three successive years i.e. till 24.4.2008.  In the month of July, 2007 the complainant suddenly started feeling uneasy.  He had digestive problems, and general weakness and his vomit contained blood.  During this period, he remained under medication intermittently, but his condition kept on deteriorating.  The complainant was admitted to Fortis Hospital Mohali on 5.4.2008 and discharged on 8.4.2008. An amount of Rs.93,749/- was spent by him towards medical bills and hospitalization charges.  The complainant thus approached the OPs for reimbursement/payment of the amount but his claim was repudiated by the OPs saying that his disease has been classified as Alcoholic Liver Disease (ALD) and thus not allowed for reimbursement/payment under the mediclaim policy issued to him.  The complainant then gave legal notice for payment/reimbursement through his Advocate to the OPs.  The OPs in their reply (Ann.C-5) repudiated his claim stating as under:-

“The medical history of your client, maintained by Fortis Hospital, shows that the patient is male of 50 yrs age having past history of chronic alcoholic almost one bottle per day since the age of 25-30.  the claimant was diagnosed of the disease called Alcoholic Liver Disease (ALD) amongst other condition.  Besides, Mr.A.P.Singh was deputed by my client to investigate the claim case, who after comprehensive investigation, submitted the Investigation Report, concluding that your client was in habit of excessive liquor consumption which resulted in liver damage.

Hence, the claim of your client was hit by Clause 4.8. of the Policy condition, which reads as, “…diseases/accident due to and/or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc. are excluded”.  The disease suffered by your client was attributed to his being chronic alcoholic, hence, your client’s claim was rightly and legally repudiated by my client …………………………………………………………..

……….The Record of Fortis Hospital, Mohali, contains the history of ailments suffered by your client, which clearly shows that your client was into drinking one bottle of liquor  daily ever since, the age of 25-30 whereas, at the time of treatment the age of your client was 50 yrs.  Such history by the hospital is reduced into writing by the hospital concerned and is based on the disclosure made by the patient, his relative and the diagnosis by the doctors  besides, the Investigator appointed by my client has comprehensively investigated the claim case, wherein he has verified from the treating hospital, friends/relatives/neighbours, of your client, and all of them confirmed that your client was a chronic alcoholic and that the disease suffered by him is owing to excessive liquor consumption.  Your knowledge about your client seems very limited. Your must at least peruse the Fortis Hospital, Mohali, record pertaining to your client, which shall update your knowledge about the matter in issue.”

The complainant has alleged that the OPs have intentionally attempted to mis-interpret the exclusion clause No.4.8 of the policy condition and have refused to release the claim amount due to him.  Occasional use of alcohol is a part of modern life style and the same is rather advised by medical fraternity as tranquilizer and is not likely to cause any harm to liver etc.  He has alleged that the conduct of OPs in not releasing the claim amount and harassing him constitutes unfair trade practice and deficiency in service.  He has therefore prayed that the OPs be directed to accept his medical bills of Rs.93,749/- and make payment to him, as well as pay compensation for mental and physical harassment.

2]                 The OPs in their reply have laid reliance on the medical history of the complainant maintained by the Fortis Hospital, Mohali from 5^th – 8^th April.  They have also appended this history at Annexure R-2 of the reply.  A brief description of this history has already been reproduced above in the reply to the legal notice of complainant. They have stated that the complainant was diagnosed with Alcoholic Liver Disease (ALD) amongst other conditions, hence the claim of the complainant was hit by Clause 4.8 of the Policy condition, which reads as under:-

“….diseases/accident due to and/or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc. are excluded”

The disease suffered by the complainant was thus not covered by the policy and his claim was legally and rightly repudiated by the OPs.

3]                 We have heard the learned counsels for the parties and perused the evidence led by the parties in support of their contentions. 

4]                 The ld.Counsel for the complainant vehemently argued that since the OPs had been paying premium every year and the complainant was not an alcoholic, they could not repudiate his claim on the ground of Clause 4.8 of the Policy.

5]                 The ld.Counsel for the OPs has at the time of arguments laid reliance on the complete medical record of Fortis Hospital, Mohali of the complainant placed at Ann.R-2. 

                    There are certain statements in the record at Annexure R-2, which clearly show the condition of the patient/complainant.  Some of these are enumerated as under:-

“Date of Admission          :           5.4.2008

Past medical History           :          - Chronic Alcoholic X 25-30 years.

-      ALD – cirrhosis of level and jaundice

Psychosocial History           :          Alcohol – 25-30 years, 1 bottle 1 day

DIAGNOSIS                     :          - ALD, cirrhosis…..

History of Present Illness: 50 yrs male reportedly no significant past history except chronic alcoholic almost 1 bottle per day since age of 25-30 years, was almost consuming daily. ……….In the month of July/August, 2007.. he was found with jaundice and CLD–cirrhosis…..”

6]                 A complete analysis of the evidence and the arguments put forth by the parties, obviously shows that the OPs have rightfully repudiated the claim of the complainant. 

7]                 The complainant has laid reliance on the judgment of Hon’ble National Commission in case of LIC of India vs. Joginder Kaur and Another, 2005(1) CPC 52 where it was held that it was tried to justify that insured was a chronic alcoholic for the last 15 years and was afficted with diabetes mellitus for 13 years and has also history of jaundice, no evidence was  adduced to prove that any doctor had treated the deceased for these diseases and simple allegation not sufficient to prove case of concealment. 

8]                 However, this case is not applicable to the present complaint, as in this case the medical record of the patient/complainant prepared by Fortis Hospital, Mohali, is available.  He was admitted for treatment in Fortis Hospital and he has made his claim of reimbursement on the basis of medical expenses/bills of the hospital.  The record proves that he was a chronic alcoholic and suffered from Alcoholic Liver Disease (ALD) amongst other conditions. 

9]                 In view of the above findings, the complaint can only be dismissed.  The complainant being a chronic alcoholic for about 25-30 years cannot ask the OPs to pay him for his hospitalization expenses especially when the disease is not covered under the  mediclaim policy.

                    Therefore, this complaint is hereby dismissed.  The parties are left to bear their own costs.      

10]               Certified copies of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

07.06.2010                                                                      Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

                                                          Sd/-

                                       (ASHOK RAJ BHANDARI)

MEMBER

                                                          Sd/-

                                                             (MADHU MUTNEJA)

MEMBER

‘Om’