Order dictated by:
Sh.Anoop Sharma,Presiding Member
- Sh.Vijay Aggarwal complainant has filed the present complaint under section 11 & 12 of the Consumer Protection Act on the allegations that complainant was obtaining Mediclaim Insurance Policies from the opposite parties since 1998. Complainant has alleged that only cover note or schedule of the insurance were supplied but the opposite parties never supplied any terms and conditions of the impugned insurance. During the validity of mediclaim policy bearing No. 2003012814P112127310 valid for the period from 13.2.2015 to 12.2.2016, complainant was admitted to Parvati Devi Hospital ,Amritsar on 21.4.2015 having problem in breathing (Asthma). The complainant incurred an expenditure of Rs. 57,830/- during hospitalization for the period from 21.4.2015 to 26.4.2015. The complainant lodged his claim to the opposite parties for reimbursement of medical expenses and supplied all the requisite documents and original medical bills to the opposite parties. But the opposite parties instead of paying the genuine claim of the complainant, repudiated the same on flimsy grounds. Earlier the complainant was admitted to Parvati Devi Hospital, Amritsar on 8.1.2014 with the problem of COPD and discharged on 12.1.2014 . Thereafter again the complainant was admitted to ALTECH Hospital on 19.3.2014 and was discharged on 22.3.2014 with the same problem of COPD. Firstly the opposite parties have paid a sum of Rs. 25,292/- on 21.3.2014 and thereafter they paid a sum of Rs. 32,919/- on 15.5.2014. It is pertinent to mention here that on previous two occasions, the opposite parties had reimbursed the amount as claimed by the complainant but now has repudiated the genuine claim of the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
- Opposite parties be directed to pay the amount of Rs. 57,830/- alongwith interest @ 12% p.a. ;
- Compensation to the tune of Rs. 30000/- alongwith adequate litigation may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite parties No.1 & 2 appeared and filed written version taking certain preliminary objections therein inter alia that complainant has violated the basic terms and conditions of the policy in question . That in the light of terms and conditions of the mediclaim policy , it was found that the claim was not payable as per exclusion clause 4.9 of the Insurance policy in question due to history of alcohol/intoxication. That as per clause 4.9 of the policy, diseases or defects or anomalies and their treatment treating to intentional self injury and use of intoxication drugs/alcohol are not payable. Accordingly, the claim was considered as inadmissible by competent authority of opposite party. Therefore opposite parties repudiated the claim on merits in accordance with law; that complainant has not approached this Forum with clean hands and has concealed the material facts. That as per discharge summary, the complainant was diagnosed with COAD with DM-II with Cirrhosis of Liver (Alcohol Liver Disease) and as per treating doctor certificate underlying cause of COAD is smoking. On merits, it was submitted that the Regional office of the opposite parties No.1 & 2 vide letter dated 15.7.2015 had recommended that as the mediclaim policy does not cover treatment of problem arising out of alcoholism/intoxication vide exclusion clause 4.9 of the Insurance policy in question, hence the claim is not admissible. Accordingly, opposite parties No. 1 & 2 repudiated the claim and intimated the same to the complainant accordingly. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite party No.3 did not opt to put in appearance and was ordered to be proceeded against ex-parte.
4. In his bid to prove the case Sh.Amit Bhatia,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-28 and closed the evidence on behalf of the complainant.
5. To rebut the aforesaid evidence Sh.Sandeep Khanna,Adv.counsel for opposite parties No.1 & 2 tendered into evidence duly sworn affidavit of Sh.P.S.Maan,Deputy Manager Ex.OP1,2/1, copy of treatment record Ex.OP1,2/2 copy of Insurance policy schedule cum terms and conditions Ex.OP1,2/3 and closed the evidence on behalf of opposite parties No.1 & 2.
6. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
7. Ld.counsel for the complainant has reiterated the facts narrated in the complaint and submitted that complainant has been obtaining Mediclaim Insurance Policies from the opposite parties since 1998. It was the case of the complainant that only cover note or schedule of the insurance were supplied but the opposite parties never supplied any terms and conditions of the impugned Insurance. During the validity of mediclaim policy bearing No. 2003012814P112127310 valid for the period from 13.2.2015 to 12.2.2016, complainant was admitted to Parvati Devi Hospital ,Amritsar on 21.4.2015 having problem in breathing (Asthma), where the complainant incurred an expenditure of Rs. 57,830/- on his treatment during hospitalization for the period from 21.4.2015 to 26.4.2015. The complainant lodged his claim to the opposite parties for reimbursement of medical expenses and supplied all the requisite documents and original medical bills to the opposite parties. But the opposite parties instead of paying the genuine claim of the complainant, repudiated the same on flimsy grounds. Complainant has alleged that earlier he was admitted to Parvati Devi Hospital, Amritsar on 8.1.2014 with the problem of COPD and discharged on 12.1.2014 . Thereafter again the complainant was admitted to ALTECH Hospital on 19.3.2014 and was discharged on 22.3.2014 with the same problem of COPD. Firstly the opposite parties have paid a sum of Rs. 25,292/- on 21.3.2014 and thereafter they paid a sum of Rs. 32,919/- on 15.5.2014. Complainant has alleged that on previous two occasions, the opposite parties had reimbursed the amount as claimed by the complainant but now has repudiated the genuine claim of the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency in service on the part of the opposite parties.
8. On the other hand opposite parties have repelled the aforesaid contentions of the complainant on the ground that complainant has violated the basic terms and conditions of the policy in question . It was submitted that as per exclusion clause 4.9 of the Insurance policy in question due to history of alcohol/intoxication, the claim was not payable It was further submitted that as per discharge summary, the complainant was diagnosed with COAD with DM-II with Cirrhosis of Liver (Alcohol Liver Disease) and as per treating doctor certificate underlying cause of COAD is smoking. Accordingly, the claim was considered as inadmissible by competent authority of opposite party and the opposite parties repudiated the claim . Ld.counsel for the opposite parties has prayed for dismissal of the complaint.
9. But, however, from the facts and circumstances of the case, it becomes evident that the complainant has obtained the mediclaim Insurance policy bearing No. 2003012814P112127310 for the period from 13.2.2015 to 12.2.2016. The complainant was admitted to Parvati Devi Hospital on 13.2.2015 and was discharged on 12.2.2016 and the complainant incurred an expenditure of Rs. 57,830/- on his treatment. The complainant lodged claim with the opposite parties by submitting all the requisite documents as well as medical bills . But the opposite parties have repudiated the genuine claim of the complainant under exclusion clause 4.9 of the Insurance policy due to history of alcohol/intoxication. But the opposite parties have not produced any evidence to show that the complainant had any history of intoxication. However, the opposite parties itself had produced on record Discharge card Ex.OP1,2/2 which proves that the complainant was admitted to hospital with chief complaint of difficulty in breathing, cough and chest congestion. It further shows that complainant had history of present illness DM-II with Cirrhosis of Liver/COPD. However, the opposite parties itself examined Dr. Bipan Chander Sareen, MBBS, MD, Parvati Devi Hospital . The said doctor in his examination in chief stated that the patient was a known case of diabetes mellitus, chronic obstructive pulmonary disease, benign hypertrophic prostate, liver cirrhosis, hypertension, Osteoprisis. But , however, the said Dr. in his cross examination has stated that patient is non alcoholic and non smoker . He has further stated in his cross examination that it is not definite that cirrhosis of liver is caused due to alcohol. The said doctor further stated that he has not treated the patient for Cirrhosis of liver. Rather he has treated the patient for acute breathlessness and chest infection. He has stated that the reason behind the COPD can be old age, untreated bronchial, asthma or occupational. So the ground of the opposite parties in repudiating the claim of the complainant is not genuine as the doctor produced by the opposite party clearly stated that patient is non alcoholic and non smoker and it is not definite that cirrhosis of liver is caused due to alcohol. The said doctor stated that he has treated the patient for acute breathlessness and chest infection and not for Cirrhosis of liver. The other plea of the opposite party that the patient had history of DM-II with Cirrhosis of Liver/COPD. In this regard Dr. Bipan Chander Sareen has stated that the reason behind the COPD can be old age, untreated bronchial, asthma or occupational . Even otherwise Hypertension and Diabetes Mellitus are no longer the material diseases as millions of people in this country are afflicted with these ailments. We draw support from II(2008) CPJ 213 wherein Hon'ble Mr. Justice S.N. Aggarwal and Mrs. Jasbir Kapoor member have held in an appeal titled as Life Insurance Corporation of India Vs. Sushma Sharma in para 18 of the judgement as follows:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from II(2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi in an appeal titled as Life Insurance Corporation of India Vs. Sudha Jain have held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease. The opposite parties have not produced any other doctor to rebut the aforesaid version as stated by Dr. Bipan Chander Sareen. So the opposite parties have wrongly repudiated the claim of the complainant.
10. It is also seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
11. Consequently, we allow the instant complaint and opposite parties are directed to pay Rs. 57,830/- alongwith interest @ 6% p.a.from the date of filing of the complaint until full and final recovery . Cost of litigation are assessed at Rs. 2000/-.Compliance of this order be made within a period of 30 days from the date of receipt of copy of order ; failing which, complainant shall be entitled to get the order executed through the indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated: 2.6.2016.
