Order by:
Sh.Mohinder Singh Brar, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed spouse health policy no.2012002821P113211598 from the Opposite Parties on 20.03.2013 and the said policy got renewed from time to time. Unfortunately the complainant suffered Paralysis attack on 02.01.2023 and he was admitted for treatment in Christian Medical College, Ludhiana and after treatment got discharged from the hospital on 24.01.2023. The complainant is still under regular treatment. The complainant spent Rs.6,42,831/- on his treatment. On 27.02.2023, the complainant filed a claim with the opposite parties but the claim of the complainant was rejected by the opposite parties on the ground that “Case of acute stroke, substance use alcohol dependence, clause of stroke is alcohol dependent". Alleged that the opposite parties withheld the claim amount on this lame excuse. Alleged further that complainant somehow arranged the amount of Rs. 642831/- and got deposited the same with the said hospital. Opposite Parties were asked many times to pay the claim amount, but they flatly refused to do so. On 14.08.2023, the complainant issued a registered AD notice through his attorney Shiv Kumar to the Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay a sum of Rs.6,42,831/- being hospital charges spent by the complainant on his treatment.
b) To pay an amount of Rs.1,00,000/- as compensation on account of unfair trade practice, deficiency in service as well as harassment.
c) To pay an amount of Rs.50,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint is not maintainable; the complainant has got no locus-standi; no deficiency in service has been attributed to the opposite parties and from the allegations in the complaint no deficiency in service is made out; the complaint is false and frivolous; complicated questions of law and facts are involved in the present complaint. Moreover, lengthy examination-in-chief and cross examination of the parties/witnesses are required in the complaint. So, the complaint is required to be decided by the civil court and as such this Commission has got no jurisdiction to entertain, try and dispose off the complaint. Averred further that complainant was insured with Opposite Parties, vide Family Medical policy no.2012002821P113211598 for the period from 28.03.2022 to 27.03.2023, but it is submitted that each and every claim is subject to the terms and conditions to the insurance policy. The complainant has not approached this Commission with clean hands rather he has willfully concealed the material and patent facts from this Commission while filing the present complaint which ipso-facto disentitles the complainant to seek any relief against the opposite parties. Averred further that the claim intimation was received by the answering opposite party No.1 through Claim Form dated 06.02.2023 received on 27.02.2023 along with documents for an amount of Rs.6,52,831/- regarding Paralysis attack suffered by him on 02.01.2023 and regarding the admission in CMC Hospital, Ludhiana. Averred further that as per case summary, the complainant was Diagnosis as:-
i. Acute Stroke- infarct involving left fronto-parieto- occipital, brain parenchyma, head of left caudate nuclues and left thalamus.
ii. Left ICA Stenosis (CA Vernous Part).
iii. Diabetes Mellitus (HBA lc 9.7)
iv. Dyslipidemia (Mixed)
v. Substance use, alcohol dependence
vi. Obesity.
vii. TO RO BPH
As per letter dated: 10.03.2023, Ref. No. 54572223839483 sent to the answering opposite party by the Raksha Health Insurance TPA Pvt. Ltd, the claim of the complainant is "Non-Payable under Clause 4.8 of the policy" for the following reasons:
"Patient's case of Acute Stroke. Substance use alcohol dependence. Cause of stroke is alcohol dependence. Hence claim recommend for repudiation. Clause 4.8. Hence, claim is recommended for repudiation & claim file is being sent for required action. 4.8: Convalescence, general debility; run-down condition or rest cure, congenital external disease or defects or anomalies. Sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.
The claim of complainant was considered by the answering opposite parties and vide letter no.1543 dated 22.03.2023, the Mediclaim under Policy No.2012002821P113211598 was repudiated as per clause 4.8, which is reproduced as under:-
4.8: Convalescence. general debility: run-down condition or rest cure, Congenital external disease or defects or anomalies, Sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.
Averred further that the complaint filed by the complainant is absolutely false, frivolous and has been filed only to harass and blackmail the Opposite Parties. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove the case, the attorney of the complainant Shiv Kumar has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C25.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Inderjit Ghosh, Divisional Manager, United India Insurance Co. Ltd. as Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP6.
5. It is not disputed that complainant availed “Family Medicare Policy” no.2012002821P113211598 for the period from 28.03.2022 to 27.03.2023 and complainant has been purchasing the policy from the Opposite Parties since the year, 2013. It is also not disputed that during the policy period, complainant suffered “Paralysis attack” and got admitted in CMC Hospital, Ludhiana on 02.01.2023 and after treatment got discharged from the hospital on 24.01.2023. After discharge from the hospital, the complainant lodged the claim with Opposite Parties for the reimbursement of the expenses incurred by him on the treatment, but the claim of the complainant was repudiated by the Opposite Parties vide letter dated 22.05.2023.
6. The Opposite Parties repudiated the claim of the complainant vide repudiation letter dated 22.05.2023 (Ex.OP6). The contents of which are reproduced as under:-
“We thank you for choosing “United India” as your insurer for the above Health Policy. Against this policy you have lodged a claim and submitted the supporting documents. While going through the papers, it is observed that:-
Observation and opinion (As per submitted documents)
Case of Acute Stroke, Substance use Alcohol Dependence. Cause of Stroke is alcohol dependence. Hence Claim repudiated as per Clause 4.8.
4.8: Convalescence, general debility; run-down condition or rest cure, congenital external disease or defects of anormalies. Sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.”
7. The repudiation of the claim of the complainant on the aforesaid ground is not genuine, as first of all in the discharge summary of the CMC and Hospital, Ludhiana nowhere it is mentioned that main cause of Stroke of the complainant is Acohol use. Further it is proved on record vide Ex.C3 that complainant was availing the policy in question from the Opposite Parties, since 2013 without any break and earlier the complainant purchased the policy for the period 28.03.2022 to 27.03.2023, meaning thereby that policy is in its 10th year of continuation, so at this stage repudiation of genuine claim of the complainant is not justified.
8. Perusal of the record reveals that as per policy document (Ex.C3) the date of birth of the complainant is 01.01.1961 and as per Aadhar Card (Ex.C2) date of birth of the complainant is 18.07.1960 and in the policy document date of inception of first policy is mentioned as 20.03.2013, meaning thereby that at the time availing the first policy, the age of the complainant was 52 years i.e. more than 45 years, so it was the bounden duty of the Opposite Party-Insurance Company to get the life assured medically examined before issuing the policy in his/her name who was above the 45 years of age. As per the I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the Opposite Party-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured.
9. Further the repudiation of the claim of the complainant by Opposite Parties cannot be considered as genuine, as the Opposite Parties repudiated the claim of the complainant as per clause 4.8, but the Opposite Parties have not placed on record terms and conditions of the policy showing the alleged 4.8 clause on the basis of which, they repudiated the claim of the complainant. In view of the above discussion we are of the considered view that Opposite Parties illegally and wrongly repudiated the claim of the complainant.
10. Vide instant complaint, the complainant claimed the amount of Rs.6,42,831/-, however, complainant has placed on record copies of bills Ex.C11 to Ex.C20 and the total amount of the said bills comes to Rs.6,02,831/-. Hence we allow the said amount.
11. From the discussion above, we allow the complaint of the complainant in part and direct the Opposite Parties to pay a sum of Rs.6,02,831/- (Rupees Six Lakh Two Thousand Eight Hundred Thirty One only) to the complainant. Opposite Parties are further directed to pay compository cost of Rs.20,000/- (Rupees Twenty Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost Rs.20,000/- (Rupees Twenty Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
