BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.233 of 2015
Date of Instt. 29.05.2015
Date of Decision : 22.01.2016
Sangeeta Mahindru aged about 45 years wife of Manish Mahindru resident of 164 Greater Kailash, Maqsudan, Jalandhar.
..........Complainant....... Versus
United India Insurance Company Limited, 19, G.T. Road,
Jalandhar through its Branch Head.
.........Opposite Party......
Complaint Under Section 12 of the Consumer Protection Act.
Before: Sh. S.S. Panesar (President)
Mrs. Jyotsna Thatai (Member)
Sh.Parminder Sharma (Member)
Present: Sh.Chandandeep Singh Adv., counsel for complainant.
Sh.Bhupinder Pal Singh Adv., counsel for opposite party.
Order
S.S. Panesar (President)
1. Smt. Sangeeta Mahindru, the complainant has filed instant complaint for re-imbursement of Rs.1,51,682/- i.e. expenses incurred for hospitalisation on account of medical expenses of her
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deceased husband Manish Mahindru insured on the allegations that Munish Mahindru along with Complainant Sangeeta Mahindru, daughter Nindya Mahindru, Son Shivam Mahindru purchased family medi-care policy from the opposite party w.e.f. 07.10.2014 to 06.10.2015. The husband of the complainant namely Manish Mahindru co-insured, was admitted to Sacred Heart Hospital on 11.11.2014 with chief complaint of watery loose stools and thereafter Manish Mahindru was referred to Dayanand Medical College and Hospital, Ludhiana on 12.11.2014, where he remained admitted up-till 16.11.2014, To the ill-luck and misfortune of the complainant, Manish Mahindru, husband of complainant, died on 16.11.2014 due to natural death at prime of his age leaving behind his wife and two dependent children. After discharge from the hospital, the complainant made a claim for re-imbursement for Rs.1,51,682/- i.e. expenses incurred for hospitalisation and on account of medicine etc. of assured Manish Mahindru. The complainant submitted the claim form, bills, receipts and discharge certificate along with clinical test reports to opposite party. All the formalities and requirements which were asked for were completed and complied with for settlement and re-imbursement of medi-claim. To the utter surprise and dismay of the complainant, the opposite party vide letter dated
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13.4.2015 unilaterally, arbitrarily on whims and fancies repudiated medi-claim of Rs.1,51,682/- on the purported ground that the claim is not payable as per exclusion Clause 4.8 of Insurance Policy as the disease is caused by misuse/abuse of alcohol. The claim of the complainant has been repudiated without any reasonable cause or excuse. There is no remotest indication of intake of alcohol and record of treatment prior to insured dated 7.10.2014. The repudiation of claim by opposite party is illegal as use of alcohol is not the only cause which leads to death. Hence this complaint.
2 Upon notice opposite party appeared through counsel who filed written reply contesting the claim of the complainant and took preliminary objections there; interalia: that the present complaint is not maintainable; there is no deficiency in service or unfair trade practice on the part of the opposite party. The present complaint has been filed on the basis of wrong and incorrect facts only to harass the opposite party. The complainant has not come to this Forum with clean hands and has concealed the material and true facts from this Forum; that no cause of action has ever accrued to the complainant to file the present complaint. This Forum has got no jurisdiction to entertain, try and decide the present complaint and same is liable to be dismissed. On merits facts narrated in the complaint have been
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specifically denied. It is stated that there is no deficiency in service on the part of opposite party and the opposite party has repudiated the claim of the complainant after considering all the legal aspects and prayer for dismissal of the complaint with costs has been made.
3 Both the parties led evidence to prove their respective case.
4 We have heard learned counsels for both the parties and have carefully gone through the record on file.
5 Learned counsel for the complainant has vehemently denied that it is admitted fact that the complainant and her deceased husband Manish Mahindru, Nindya Mahindru daughter and Shivam Mahindru son jointly purchased a family medi-care policy in dispute bearing No.2005002814P105121480 for the period from 07.10.2015 to 06.10.2015 (at midnight). Copy of the Insurance Policy is Ex.R-2 on record. It is also not disputed that Manish Mahindru, one of the insured person, expired on 16.11.2014. After the death of insured Manish Mahindru, the complainant approached opposite party for re-imbursement of the medical expenses incurred on insured Manish Mahindru (now deceased). However the claim of the complainant was repudiated vide Lettter Ex.R-3 by the opposite party on the ground that insured Manish Mahindru died due to Cardiac
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Arrest for consuming excessive alcohol and due that case of complainant was covered under clause 4.8. i.e. exclusion clause of the insurance policy. The opposite party has placed reliance on TPA Report Ex.R-5, but however the opposite party has failed to prove that insured Manish Mahindru died due to excessive use of alcohol. Medical record of the Sacred Heart Hospital as well as Dayanand Medical College and Hospital Ludhiana, no where state that the treatment of the complainant pertained to use of excessive alcohol. Moreover; the TPA report vide Ex.R-5 do not disclose the name of Doctor who gave such opinion nor any such doctor has been examined before this Forum to prove the cause of death of the insured namely Manish Mahindru.
6 Learned counsel for the complainant has further contended that the opposite party has failed to prove that the use of alcohol by the insured Manish Mahindru was sole cause which led to the death of the deceased. In such situation, the repudiation made under clause exclusion 4.8 of the Insurance Policy is totally illegal, null and void. It is contended that the complainant has been able to prove on record that a sum of Rs.151,682/- was incurred on the treatment of the insured Manish Mahindru which the complainant is entitled to be re-imbursed from the opposite party under insurance cover in dispute. It
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is further contended that instant complaint is liable to be allowed and complainant may be awarded Rs.1,51,682/- i.e. sum incurred on treatment of insured Manish Mahindru, as well as compensation on account of mental agony & physical pain.
7 On the other hand, Learned Counsel for the opposite party has vehemently contended that repudiation has rightly been made under exclusion clause 4.8 of the insurance policy Ex.R-2 which is reproduced as under :
“Convalescence, general debility; run-down condition or rest cure, obesity treatment, Cogenital external disease or defects or anomalies, Sterility, Venereal disease, intentional self injury and use of intoxication drugs/alcohol.”
Not only that matter was referred to TPA by the opposite party for settlement of the claim. The TPA referred the case for medical opinion to their medical expert. Copy of the medical report is Ex.R-5 on record. Medical report clearly states that the death of the insured was caused due to excessive use of alcohol. There is no deficiency in service on the part of the opposite party, nor there is any unfair trade practice on the part of he opposite party and therefore, it is requested that the complaint may be dismissed with costs.
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8 We have thoroughly considered rival contentions.
9 There is no dispute that insured Manish Mahindru along with his wife, daughter and son jointly purchased family medi-care policy bearing No. 2005002814P105121480, copy of whereof is Ex.R-2 which was operative with effect 07.10.2014 to 06.10.2015. It is also not disputed that Manish Mahindru suffered from watery loose stools and he has to be admitted to Sacred Heart Hospital on 11.11.2014 and from where he was referred to Dayanand Medical College and Hospital Ludhiana on 12.11.2014 where he remained admitted uptil 16.11.2014. It is also not disputed that insured Manish Mahindru died on 16.11.2014 at Dayanand Medical College and Hospital Ludhiana. The complainant has produced copy of Medical History Ex.C-1 (Pages 1-107) in support of expenses as well as medical treatment administered to insured Manish Mahindru. It is also proved on record that a sum of Rs.1,51,682/- was incurred by the complainant on treatment of the patient. It is also not disputed that the complainant applied for re-imbursement of the medical expenses stated above with the opposite party. However, the Opposite Party turned down the claim on basis of the Exclusions clause 4.8. of the insurance policy, but however the opposite party has failed to prove that the death of the insured Manish Mahindru occurred due to excessive use of
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alcohol as stated in repudiation letter. It was incumbent upon that opposite party to prove that the only cause of the death of the insured was the excessive use of alcohol/poisoning. No doctor from the TPA has been produced before this Forum nor the TPA Report Ex.R-5 mentions the name of the alleged doctor, who submitted the medical report, for reasons best known to the opposite party. In this connection reliance can be placed on New India Assurance Company Limited – Petitioner Versus Smt.Usha Yadav & others – Respondents 2008(3) RCR (Civil) Page 111 Punjab & Haryana High Court where in it has been laid down that it is accordingly noticed that alcohol consumption could not be the only cause for all those complicated diseases which led to the death of the deceased. The action of the Insurance Company in repudiating the claim by adopting some mean or the other, as such, has rightly been rejected. The order passed by the Lok Adalat is just, fair and reasonable and as such would not call for any interference.
10 In this case, onus to prove repudiation lay upon the opposite party, but, however, no credible evidence has been adduced by the opposite party. The alleged report Ex.R-5, is based on conjecture & surmises, which can not be made basis for repudiation legally. Repudiation in this case amounts to deficiency in service.
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Reliance in this connection can be placed on “Tarlok Chand Khanna - Petitioner Versus United India Insurance Company Ltd.- Respondent 2012(1) C.P.J. 84 : 2012(2) CLT 617 (NC) wherein it was held down that in absence of in credible formal documentary or other evidence by the respondent on whom was onus to prove the reason for repudiation. We, therefore, allow revision petition by setting aside order of Fora below. The respondent/Insurance company is directed to pay petitioner Rs.1,78,945/- along with interest @ 6% from the date of claim and Rs.10,000/- as litigation charges within six months from the date of this order and Revision Petition was allowed accordingly.
11 From the appreciation of the facts & circumstances as well as legal position stated above, the complainant has been able to prove her case through cogent evidence on record. On the other hand, opposite party has failed to prove the repudiation legally. As such instant complaint succeeds & the complainant is entitled to re-imbursement of the medi-claim to the tune of Rs.1,51,682/- fully detailed and descried in document Ex.C-1 as per terms and conditions of the insurance policy. The opposite party is further directed to pay a sum of Rs.1,51,682/- along with interest @ 6% from the date of filing of the claim until full & final recovery. The opposite party is also
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directed to pay a sum of Rs.2000/- on account of litigation expenses. Complaint is allowed accordingly. Copy of this order be supplied to the parties free of costs under the rules forthwith.
Dated (Parminder Sharma) (Jyotsna Thatai) (S.S.Panesar)
22.01.2016 Member Member President
