( Passed on dated 29^th  September, 2015 )

Per Shri Atul D. Alsi – Hon’ble President.

              The deceased namely Shri Jasbir Mohanlal Arora had taken family medicare policy having policy No. 230903/48/13/00000056, valid from 30/04/2013 to 29/04/2014, having sum insured Rs.3,00,000/- from Opposite Party.   The above policy is in continuation of earlier two family Medicare policy having policy No. 230903/48/11/06/00000039, valid from 29/04/2011 to 28/04/2012 and policy No. 230903/48/12/06/00000034, valid from 29/04/2012 to 28/04/2013.  Thus, the above family Medicare policy is in force since 2011 issued by Opposite Party.       

2.            Shri Jasbir Arora had suffering from liver disease since October 2013 and had firstly hospitalized from dt. 07/10/2013 to 09/10/2013 at Aditya Hospital, Nagpur.  At that time as per claim form submitted on dated 12/10/2013, the opposite party had settled the claim by depositing Rs. 20,126/-  in account of Shri. Jasbir Arora.

3.            Subsequently, Shri. Jasbir Arora had undergone liver transplantation surgery at Medanta, Global Health Pvt. Ltd., Gurgaon, on dated 12/12/2013 and incurred expenditure of more than Rs.17,50,000/- towards medical treatment and medical bills.  There was sad demise of husband of complainant namely Shri. Jasbir Arora on dated 20/05/2014.  The complainant had duly submit claim form mentioning period of treatment, expenditure etc. on dated 27/12/2013 with opposite party.  

4.            The opposite party had repudiated legal claim of complainant on the ground “that the insured was admitted for alcohol liver disease and treatment related to chronic alcohol consumption is excluded from the scope of policy”.  

5.            The complainant had issued legal notice dated 13/06/2014 to opposite party.  The opposite party in spite of due receipt of notice had failed to comply or reply the same till today.  Hence the complaint is filed.  

6.            The complainant praying for to direct the opposite party to pay sum insured Rs. 3,00,000/- to complainant with 12% interest from date of death of insured i.e. dated 20/05/2014 and also the opposite party be pay compensation of Rs.20,000/- towards mental harassment and Rs. 10,000/- towards litigation charges.

7.            After receiving the notice issued by the Forum, the O.P. appeared through their counsel and filed their written statement before the forum. 

8.            In their reply, the O. P. submits that, the complaint as framed and filed is not tenable.  The O. P. after the perusal of entire medical paper rejected the claim.  The deceased was patient of liver disease from 2011.  This fact was revealed after the death during the verification of documents.  Thus it is a case of suppression of true and material fact.  The contract of insurance based on utmost good faith and there is no scope for person to suppress the true fact.  The proper platform for the complainant is only before the civil court and not before forum. 

9.            By bare reading the MMR report of Dr. A. S. Soni of Medanta Global Health Pvt. Ltd. dated 27/12/2013 and discharge summary of Medanta Global Health Pvt. Ltd. dated  11/12/2013 clearly revealed that deceased was suffering from Jaundice from last four years it is very comma feature that jaundice is a diseases related to liver and deceased was habitual alcohol addict.  Hence the complaint is liable to be dismissed with cost in the interest of justice.    

10.                   The complainant has filed repudiation letter at page no. 12, Copy of insurance policy dated 29/04/2011 to 28/04/2012 at page no. 13, Copy of insurance policy dated 29/04/2012 to 28/04/2013 at page no. 15, Copy of insurance policy dated 29/04/2013 to 28/04/2014 at page no. 17, Copy of letter of insurance company at page no. 19, Copy of claim form at page no. 20, Copy of discharge summary at page no. 24, Copy of hospital bill at page no. 30, Copy of legal notice  at page no. 43, Copy of statement of account at page no. 47 on record.

11.                   The learned counsel for complainant Mr. S. B. Rajankar argued that the opposite party has not proved by independent evidence of doctor that the deceased has liver disease from long back and therefore there could not be suppression of material fact.  There is no evidence that the death occurred due to heavy liquor intoxication and therefore the repudiation of claim under exclusion clause of policy is bad in law.   

12.                   The learned counsel for opposite party Mr. M. K. Gupta argued that M. D. India healthcare who investigate the claim is necessary party hence non-joinder results in dismissal of complaint.  The investigation report and medical report of Dr. Soni which is filed on page 8 & 9 clearly disclose that the deceased had chronic liver problem and it is proved from the documents itself filed on record and it is not necessary to examine the doctor on oath.  Hence repudiation of claim is rightful.    

13.                   Considering pleading and rival contention of the party & submission made before us the following points arise for consideration & finding there on along with reasons.

REASONING & FINDINGS

14.                    The opposite party has accepted the Medicare policy bearing no. 230903/48/13/00000056 valid from 30/04/2013 to 29/04/2014  for sum assured Rs.3,00,000/-.  Hence it is proved that the complainant has taken Medicare policy from opposite party. 

15.                   It is also admitted by opposite party that the opposite party has paid the claim of Rs.20,126/- to deceased on 12/10/2013 by depositing amount in his saving account of bank for the first hospitalization from 07/10/2013 to 09/10/2013 at Aditya Hospital, Nagpur for suffering from liver disease since October 2013.

16.                   Subsequently the deceased had undergone the liver transplantation surgery at Medanta Global Health Pvt. Ltd., Gurgaon on dated 12/12/2013 and incurred expenses of Rs. 17,50,000/- but he was died on 20/05/2014.

17.                   The insurance company has come specific defence in repudiation letter that the deceased was died due to heavy intoxication of alcohol/drug but did not produce any documentary evidence that the liver was damaged due to excessive consumption of alcohol.  The medical report does not support the contention of opposite party that the liver was damaged due to heavy alcohol hence the contention of defence of opposite party can’t be proved for want of direct and proper report filed on record.  Therefore, it can’t be suppression of material fact on the other hand the opposite party after proper medical examination issued policy and disburse the first claim in October 2013 for the hospitalization from 07/10/2013 to 09/10/2013 at Aditya Hospital, Nagpur for liver disease.  Therefore, the contention of chronic liver disease can’t be accepted and proved.  Therefore repudiation of claim amounts to negligency of service hence the complaint is partly allowed with following order:-                           

-: ORDER :-

1.            The complaint is partly allowed.

2.            The O.P. is directed to pay the sum assured  Rs.3,00,000/- (in wards Rupees Three lacs only) for the Medicare policy to complainant with interest @ 9% p.a. from the date of  filing of complaint till its realization.

3.            The O.P. is directed to pay complainant Rs.15,000/- towards mental torture and mental agony along with cost of litigation of Rs. 10,000/-.

4.            The above amount shall be paid within 30 days from the date of receipt of this order.