Haryana

StateCommission

A/530/2016

MANISH AHUJA - Complainant(s)

Versus

UNITED INDIA INSURANCE CO. - Opp.Party(s)

BRIJENDER KAUSHIK

15 Dec 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :    530 of 2016

Date of Institution:    09.06.2016

Date of Decision :     15.12.2016

 

Manish Ahuja s/o Sh. Banarsi Dass Ahuja, Resident of House No.1261, Sector-1, Phase-II, HUDA, Shahabad, District Kurukshetra.

                                      Appellant-Complainant

Versus

1.      United India Insurance Company Limited, Ambala Cantt, through its Branch Manager.

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

                                      Respondents-Opposite Parties

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

                             Shri Diwan Singh Chauhan, Member   

 

Argued by:          Shri Brijender Kaushik, Advocate for appellant.

                             Shri B.R. Madan, Advocate for respondent No.1.

                             None for respondent No.2. 

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          This complainant’s appeal is directed against the order dated April 27^th, 2016 passed by District Consumer Disputes Redressal Forum, Ambala (for short ‘the District Forum’) whereby the complaint was dismissed.

2.                Manish Ahuja-complainant (appellant herein) purchased a Mediclaim Policy from United India Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1 covering risk of family members for the period January 9^th, 2008 to January 8^th, 2009 vide Proposal Form (Annexure C-1). The sum insured was Rs.3.00 lacs. Banarsi Dass Ahuja-complainant’s father fell ill. He was admitted in Fortis Hospital, Mohali on 14^th October, 2008 and was discharged on 27^th October, 2008, vide Case Summary Annexure C-3. The complainant alleged to have spent Rs.5,50,000/- on the treatment of his father. He filed claim with the Insurance Company (Annexure C-7) but it did not pay the benefits of insurance despite having issued Legal Notice (Annexure C-11). Claim was referred to Insurance Ombudsman, Chandigarh but the same was rejected vide order dated 31^st July, 2009 (Annexure C-21). Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed before the District Forum.

3.                The Insurance Company-Opposite Party No.1 in its reply stated that Banarsi Dass Ahuja-insured, was suffering from pre-existing disease. The insured was diagnosed vide report dated 05.08.2008 (Annexure C-20) to be suffering from “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 (Alcoholic Cirrhosis).” Thus, complainant’s claim was not covered as per the terms and conditions of the policy. It was prayed that the complaint be dismissed.

4.                The Opposite Party No.2 – Andhra Bank in its reply stated that the policy was purchased by the complainant from the Insurnace Company through it. Supporting the case of the opposite party No.1, it was prayed that the complaint be dismissed.

5.                After evaluating the pleadings and evidence of the parties, the District Forum dismissed the complaint.

6.                Indisputably, the insurance policy was purchased by the complainant for the period January 9^th, 2008 to January 8^th, 2009. It is also not in dispute that the parties were bound by the terms and conditions of the policy.  It is also admitted that the insured- Banarsi Dass Ahuja, remained admitted in Fortis Hospital, Mohali from 14^th October, 2008 to 27^th October, 2008. As per treatment record, the patient suffered from “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 (Alcoholic Cirrhosis)”. District Summary (Annexure C-6) shows that the patient had past history “K/C/O DM 2 x 3-4 yrs”.  

7.                Annexure R-5 is the report of Krishna Institute of Medical Sciences Limited, the relevant part of which is reproduced as under:-

“As per the request from the United India Insurnace 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 (Alcoholic Cirrhosis).

Normally Alcoholic 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 alcoholic liver disease.”

 

8.                The Exclusion Clause of the policy reads 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 3 years of Insurance.

4.2    Any disease other than those stated in clause 4.3, contracted by the Insured person during the first 30 days from the commencement date of the policy. this condition 4.2 shall not however, apply in case of the insured person having been covered under this scheme or Group Insurance Scheme with any of the Indian Insurance Companies for a continuous period of preceding 12 months without any break.”

9.                In view of the evidence available on the record, the insured-patient was suffering for the last 3-4 years and therefore complainant’s case fall exclusion clause. So, nothing was payable by the Insurance Company to the complainant.  The District Forum has rightly dismissed the complaint. The impugned order does not require any interference.

10.              Hence, the appeal is dismissed being devoid of merits.

 

Announced 15.12.2016

(Diwan Singh Chauhan) Member

(B.M. Bedi) Judicial Member

(Nawab Singh) President

CL