DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.296/2013
Sh. Ramesh Chand
R/o H.No.22, Near Dispensary, Mahipalpur,
New Delhi-110057 ……Complainant
Versus
United India Insurance Co. Ltd.
Through its Director
60, Janpath, New Delhi-110001 ……Opposite Party
Date of Institution : 14.05.13 Date of Order : 28.11.15
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Briefly stated, the case of the Complainant is that he had obtained a mediclaim policy “Family Medicare Policy” for himself and family members covering risk of hospitalization with the coverage of Rs.3 lakh effective from 02.11.2011 to 01.11.2012. He paid Rs.11,270/- towards premium. On 28.04.2011 (sic), he suffered with acute pain in his stomach and visited his family doctor at Nangloi Clinic but to no relief and he was hospitalized in Prashant Nursing Home, New Delhi-85. He was thoroughly diagnosed in the hospital and was discharged on 06.05.12. He had applied through hospital for cashless medi-claim for his treatment but the OP avoided the same on the one pretext or the other and he was forced to pay Rs.1,15,871/- from his own pocket. When he was discharged from the hospital, he submitted the entire original bills, reports and all supporting documents as per the instruction of OP but OP intentionally repudiated his claim vide letter dated 08.11.2012 on the ground that he takes alcohol occasionally and it was the reason for the hospitalization, whereas in the prescription and in the discharge summary it was nowhere mentioned that the hospitalization was due to alcohol. He visited the office of OP number of times but no reply has been received from the OP till date. The Complainant has prayed as under:-
- Direct the OP to pay to the Complainant the claim amount of Rs.1,15,871/- as per the terms of the Insurance Policy alongwith interest @ 24% per annum from 06.05.2012 till the date of payment.
- Direct the OP to pay a sum of Rs.1 lakh as compensation to the Complainant.
- Direct the OP to pay a cost of Rs.5,000/- to the Complainant.
In the written statement OP has stated that the Complainant was having a mediclaim policy bearing No.040700/48/11/06/ 0002228 issued by them for the period from 02.11.2011 to 01.11.2012. The Third Party Administrator (in short, the TPA) had investigated the claim and on scrutiny of the claim documents, it was found that the patient was admitted in Prashant Nursing Home on 28.04.2012 with the diagnosis as a case of acute pancreatitis with obstructive jaundice with cholelithiasis and medical management was done after investigation. It was found that as per hospital records and ICP’s patient used to take alcohol occasionally. The same is not admissible and, therefore, the claim of the Complainant was repudiated under exclusion clause 4.6 of the Health Insurance Policy The exclusion clause 4.6 of the policy reads as under:-
“Exclusion 4.6 Convalescence, general debility run down condition or rest cure, congenital external disease/defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxication drugs/alcohol.”
OP has stated that there was no deficiency in service. Hence, OP has prayed for dismissal of the complaint with heavy cost.
Complainant did not choose to file rejoinder.
Complainant has filed his affidavit in evidence while affidavit of Sh. Sube Singh, Deputy Manager has been filed in evidence on behalf of OP.
Written arguments have been filed on behalf of the parties. We have gone through the record very carefully.
Admittedly the Complainant had taken a mediclaim policy “Family Medicare Policy” for himself and family members covering risk of hospitalization with the coverage of Rs.3 lakh covering the period 02.11.2011 to 01.11.2012. (copy of the family medicare policy is Annexure A). On 28.04.2012, he had suffered with acute pain in his stomach and visited his family doctor at Nangloi Clinic but to no relief and the Complainant was hospitalized in Prashant Nursing Home, New Delhi. He was thoroughly diagnosed in the hospital and was discharged on 06.05.12 (copy of discharge summary of Prashant Hospital is Annexure-B). The OP vide letter dated 08.11.2012 repudiated the claim of the Complainant on the ground that the Complainant used to take alcohol occasionally and it was the reason for the hospitalization (copy of the repudiation letter is Annexure-D). The Complainant has submitted the prescription slips issued by Prashant Nursing Home, New Delhi alongwith copies of bill/cash memo with the OPs (copy Annexure -C Colly).
In the discharge summary of the hospital it is nowhere mentioned that the Complainant used to take alcohol occasionally and due to which he was hospitalized in the said hospital. Hence, the legitimate claim of the Complainant was rejected by the OP under the garb of exclusion clause No.4.6 of the policy which amounts to deficiency in service and unfair trade practice on the part of OP. Other facts are not in dispute.
We allow the complaint and direct the OP to pay Rs. 1,15,871/- alongwith interest @ 6 % per annum from the date of repudiation of claim i.e. 8.11.2012 till realization, Rs.10,000/- for pain and agony undergone by the Complainant including cost of litigation within a period of 30 days from the date of receipt of copy of this order failing which the OP shall become liable to pay interest @ 12% p.a. from the date of repudiation of claim i.e. 8.11.12 till realization.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 28.11.15.
(NAINA BAKSHI) (N.K. GOEL) v MEMBER PRESIDENT
Case No. 296/13
28.11.15
Present: None
Vide our separate order of even date pronounced, the complaint is allowed and the OP is directed to pay Rs. 1,15,871/- alongwith interest @ 6 % per annum from the date of repudiation of claim i.e. 8.11.2012 till realization, Rs.10,000/- for pain and agony undergone by the Complainant including cost of litigation within a period of 30 days from the date of receipt of copy of this order failing which the OP shall become liable to pay interest @ 12% p.a. from the date of repudiation of claim i.e. 8.11.12 till realization. Let the file be consigned to record room.
(NAINA BAKSHI) (N.K. GOEL)
MEMBER PRESIDENT
