Haryana

Ambala

CC/361/2010

MANSIH AHUJA - Complainant(s)

Versus

UII CO. - Opp.Party(s)

P. S. SHARMA

27 Apr 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

Complaint Case No.361of 2010

Date of Institution:   05.08.2010

Date of Decision  :  27.04.2016

 

Manish Ahuja S/o Sh. Banarsi Dass Ahuja R/o H.No.1261, Sector-1, Phase-II, HUDA Shahbad, District Kurukshetra.

                                                                                                                                                                                   ……Complainant.

                                                                                                    Versus

1.         United India Insurance Company Ltd., Ambala Cantt (Haryana) through its  Branch Manager.

2.         Andhra Bank, Branch Ambala Cantt (Haryana) through its Branch Manager.

…..Opposite Parties.

Complaint Under Section 12 of the Consumer Protection Act

CORAM:        SH. A.K. SARDANA, PRESIDENT.

                        SH. PUSHPENDER KUMAR, MEMBER.

Present:          Sh. P.S. Sharma, Adv. counsel for complainant.

                        Sh. R.K. Vig, Adv. counsel for OP No.1.

                        Sh. P.K. Bansal, Adv. counsel for OP No.2.

ORDER:

                        Present complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter in short called as the ‘Act’) has been filed by the complainant alleging therein that he purchased a family medi-claim policy of Rs.3.00 lac bearing No.050400/48/07-41/00000075 w.e.f. 09.01.2008 to 08.01.2009 from the OP No.1 through OP No.2 being agent of OP No.1 and the OPs assured that all the health problems of whole of the family is covered under the policy. It was also assured that  in case of any treatment of any disease, OP No.1 will provide the cashless facility. It has been submitted that father of complainant Banarsi Dass Ahuja got some health problems in October 2008 and admitted in Fortis Health Care, Mohali on 14.10.2008 and was discharged  on 27.10.2008 but the hospital refused to entertain the complainant without payment and  the complainant had to make a payment of Rs.5,50,000/-. On 21.10.2008, complainant submitted claim papers with the OP and when no response received, the complainant wrote letter dated 24.03.2009 but that was also not responded, then the complainant got served a legal notice dated 28.04.2009 but of no avail. Claim of the complainant was referred to Insurance Ombudsman, Chandigarh by the Op No.1 which was dismissed by the said authority having no merits and logic in it. The complainant has alleged that there is no opinion of any doctor that the ailment for which father of complainant got treated was due to alchololic use. Thus the complainant has contended that the act of the Ops amounts to grave deficiency in service and unfair trade practice  and prayed for issuing a direction to Ops to provide reliefs as mentioned in prayer para of the complaint.

2.                     Notices were served upon the Ops. OP No.1 tendered reply raising preliminary objections qua non-maintainability of complaint and this Forum has no jurisdiction. On merits, it has been admitted that a group medi-claim policy was obtained by the complainant alongwith other four members of the family for the period from 09.01.2008 to 08.01.2009 through Op No.2-Andrhra Bank. It has been urged that  Shri B.B. Ahuja remained admitted in the hospital at Mohali whereas Sh. Manish Ahuja has filed the complaint who has no locus standi to file the present complaint. It has been further urged by Ops that after going through the discharge summary of Fortis Hospital  relating to Banarsi Dass coupled with report dated 05.08.2009 of Dr. I. Srivenu, M.D. (AIIMS), he was diagnosed for Alcholic Liver Disease (ALD). Alcholic Cirrobosis requires 5-15 years of regular alcohol intake for the patient to develop it and thus the insured  has violated the terms & conditions of medi-claim policy and therefore the insured Sh. B.D. Ahuja is not entitled to any claim and the answering OP has rightly repudiated the claim of insured. The complainant submitted claim papers on 21.10.2008 in the office OP whereas Sh. B.D. Ahuja was discharged from the hospital on 27.10.2008. It has been further submitted that answering OP has not received any letter dated 24.03.2009 as alleged rather the complaint filed by complainant before Insurance Ombudsman was dismissed on 10.08.2009. Hence, the TPA/Insurance company has legally repudiated the claim of complainant. As such, the answering OP has contended that there is no deficiency or negligence on their part and prayed for dismissal of the complaint with costs.

                        Op No.2 filed separate written statement raising preliminary objections qua  non-maintainability of complaint, no cause of action, suppression of material facts  and mis-joinder & non-joinder of necessary parties etc. On merits, it has been submitted that there is no privity of contract between the complainant & answering OP whereas  the answering OP is doing the business only to get  petty commission. It has been denied that complainant obtained the alleged family medi-claim policy through the answering OP on the alleged assurance that the OP No.1 is providing cashless facility. It has been submitted that complainant might have been earlier suffering from the alleged ailment and to claim the amount of treatment, complainant purchased the present medi claim policy, hence, the claim of the complainant was repudiated.   Rest of the contents of complaint have been denied and prayed for dismissal of complaint with costs.  

3.                     To prove his contention, counsel for complainant tendered affidavit of complainant as Annexure CX alongwith documents as Annexures C-1 to C-22 and closed the evidence whereas on the other hand, counsel for Ops No.1 tendered affidavits of Sh. Ajay Sareen, Assistant Divisional Manager of OP insurance company as Annexures RX & RY alongwith documents as Annexures R-1 to R-9 and closed the evidence on behalf of Ops No.1. Counsel for OP No.2 also tendered in evidence affidavit of  Sh. K.Allah Baksh as Annexure RZ alongwith documents as Annexure R10 & R-11  and closed  the evidence.

4.                     We have heard learned counsel for the parties and perused the records. Learned counsel for the complainant argued that the Ops have wrongly repudiated the claim of the complainant whereas he was duly covered under the policy terms & conditions of mediclaim Group Insurance Policy taken by Op No.2 Bank for its  customers.  Counsel for complainant has placed reliance on case laws titled as National Insurance Co. Ltd. & Anr. Vs. Girin R. Shah 2012(3) CPJ-322: 2012(4)CLT-624 (NC), Bajaj Allianz General Insurance Co. Ltd. Vs. Kamal Kumar Rateria 2012(3) CPJ 599:2013(1)CLT-150(NC), United India Insurance Co. Ltd. Vs. Anumolu Rama Krishan  2012(3) CPJ-44:2012(4) CLT-221(NC) & Star Health and Allied Insurance Co. Ltd. Vs. Asha and others 2015(1) CLT 590 :2015(2)CPJ -78 (State Commission, Haryana)  and prayed for acceptance of complaint

                         On the other hand, counsel for OP argued that  father of complainant was having alchoholic disease prior to taking  of the policy as such he violated the terms & conditions of the insurance policy and as such his claim was repudiated.   In support of his case counsel for OP has placed reliance on case laws titled as United India Insurance Co. Ltd. Vs. M.K.J. Corporation, Appeal (Civil) 6075-6076 of 1995 (S.C.) decided on 21.08.1996, Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. Civil Appeal No.2776 of 2002 (SC) decided on  10.07.2009, K. Malleswari & 2 Ors. Vs. LIC of India & Anr.  Revision Petition No.1180 of 2013 (NC) decided on 03.03.2014, Smt. A. Sujata Vs.LIC of India Revision Petition No.776 of 2011 (NC) decided on 04.03.2014 and Jai Kishan Vs. LIC (NC) Revision Petition No.1883 of 2015 decided on 12.08.2015 and thus prayed for dismissal of the complaint with costs.

5.                     We have gone through the document Annexures R-2 i.e. Group Mediclaim Insurance Policy having terms & conditions  wherein the insured is OP No.2 Andhra Bank and complainant & his family members are beneficiaries under the Andhra Bank Arogyadan  Mediclaim Insurance Policy. From the said document, it is clear that the complainant’s father was insured at the time of his admission in the hospital through OP No.2 Bank and  this fact has also been admitted by OP No.1 but as per Exclusions of the insurance policy terms & conditions, complainant is not entitled for any claim . Relevant clauses are as under:-                                  

4.         EXCLUSIONS:

The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:

4.1       All diseases/injuries which are pre-existing when the cover incepts  for the first time. For the purpose of applying this condition, the date of inception of the initial Medicalim policy taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break. However, this exclusion will be deleted after 3 consecutive continuous claim free policy years provided, there was no hospitalization for the pre-existing ailment during these  three years of insurance.

4.8       Convalescence, general debility: run down condition or rest cure, Congenital external disease or defects or anomalies, sterility, venereal disease, intermonal self injury and use of intoxication drugs/alcohol.

                        During the course of arguments, counsel for Ops has drawn our attention towards documents Annexure R-5/C-20 whereby opinion has been given on the treatment of complainant by Dr. I.Srivenu of Krishna Institute of Medical Sciences Ltd.  that “ As per the request from the United India Insurance Company Limited, I have reviewed the records of Mr. Manish Ahuja who seems to have admitted with  Massive UGI Bleed caused by ALD which denotes alcoholic liver disease.  The cause of Massive UGI bleed was due to Esophageal and Gastric varices which are a consequence of alcoholic liver disease (Alcholic Cirrhosis).  Normally Alcholic Cirrhosis requires 5-15 yrs of regular alcohol intake for the patient to develop it.  I hereby give my report for the reason of his admission is related long standing alcohol intake resulting in alcolohic liver disease. Further the case laws referred by counsel for Ops are fully applicable to the facts of the present case whereas case laws referred by complainant are not applicable to the facts & circumstances of the said case.

                        In view of the above discussed facts, we have come to the conclusion that complainant’s father was having pre-existing Alcoholic Liver Disease (ALD) and  thus is not covered under the benefit of the policy in question rather falls under the terms & conditions (exclusion clause) of the policy. As such, complaint is devoid of merits and dismissed accordingly. Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room after due compliance. 

 

Announced:27.04.2016

                                                                                                                 Sd/-

                                                                                                      (A.K. SARDANA)

                                                                                                          PRESIDENT

                                                                                                                

                                                                                                Sd/-

                                                                                 (PUSHPENDER KUMAR)                                                                                                                                                                                      MEMBER