Date of Filing: 24.02.2020
Date of Order: 05.02.2021
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION – I, HYDERABAD
P r e s e n t
HON’BLE Shri P.VIJENDER, B.Sc. L.L.B., PRESIDENT
HON’BLE Shri K.RAM MOHAN, B.Sc. M.A L.L.B., MEMBER
On this the Friday the 5th day, of February, 2021
C.C.No. 135 /2020
Between
V. Vijay Gopal Rao,
S/o V. Ramchander Rao,
Age 52 years, Occ: Legal Practitioner,
H.No. 1-10-99/3/3, Bhagyanagar Colony,
Saroornagar, Hyderabad , T.S-500035
….Complainant
And
New India Assurance Co Ltd, (Hyd)
Hyderabad Regional Office,
5th Floor, Surya towers,
S.P.Road, Secunderabad - 500003
….Opposite Party
Counsel for the Complainant : Mr.G.Venu Gopal Rao
Counsel for the Opposite party : Absent
O R D E R
(By Shri K.RAM MOHAN, B.Sc. M.A L.L.B., MEMBER on behalf of the bench)
1. The complainant has filed the above Consumer complaint U/s 12 of the Consumer Protection Act 1986 making allegations against the opposite party as to its failure to settle the claim No 1404012708788 for Rs. 8,00,000/- under the policy No 61190034172800001533 towards medical expenses incurred during his hospitalization i.e, from 31.01.2018 to 21.02.2018 in Global Hospital, Lakidikapool, Hyderabad praying the Hon’ble District Forum to direct the opposite party to pay to the complainant for Rs. 8,00,000/- covered under the said policy along with interest @ 24% p.a from 31.01.2018 till realization , Rs. 5,00,000/- as compensation towards mental agony and sufferings , Rs. 50,000/- towards costs of the litigation; and such other relief/s as it deems fit and proper in the interest of justice.
2. Briefly stated, the facts of the case relevant for disposal of the complaint, are that the complainant has obtained two policies from the opposite party viz., Policy no 61190034182800001418 ( “hereinafter referred to as policy No.1 “ ) and policy no. 61190034172800001533 ( “ herein after referred to as policy No.2” ). The complainant states that the above policies were taken 20 years ago i.e. in the year 2000. Initially, the OP obtained proposal form but subsequently since 2001, it went on renewing the same till the date of his admission in the said hospital without obtaining any further proposal form.
The complainant states that owing to his continuous abdominal pain he got admitted in the Global Hospital, Lakidikapool, Hyderabad for the period from 16.01.2018 to 22.01.2018 for which he spent an amount of Rs. 2,76,000/- for the treatment of his problem. When a claim under policy No.1 was made for reimbursement of the above amount, he states that the opposite party rejected it initially on the ground of exclusionary clause of the policy concerned. The disease was diagnosed as “CLD – EToH” which is stated to have fallen under the exclusionary clause of the policy as per the OP but later the opposite party settled it for Rs. 1,00,000/-.
The complainant further states that on the advice of the Doctor, he again got admitted in the same Global Hospital, Lakidikapool, Hyderabad for his treatment for the period from 31.01.2018 to 21.02.2018 where the Doctors meted out t treatment and conducted Liver Surgery for which he incurred an expenditure of Rs. 25,29,689/- and the same was stated to have been paid by him. The complainant states that he stopped consumption of alcohol 5 years ago except occasionally. In the discharge summery for this period, stoppage of his alcohol consumption has also been mentioned by the doctor concerned. When he submitted his claim for Rs. 8,00,000/- covered under the policy no.2, to the opposite party along with required relevant documents, it rejected the claim on the ground that the disease falls under exclusionary clause of the policy concerned. In this regard, when the notice was sent through mail to the opposite party for settlement of his claim for Rs. 8,00,000/-, under the policy No.2, the opposite party in turn replied stating that reimbursement of the said claim of the complainant was a rejected on the ground of falling of the above disease under exclusionary clause of the policy The complainant states that the rejection of his claim by the opposite party is incorrect and amounts to deficiency in service. The complainant further states that when his claim for reimbursement of Rs. 2,76,000/- was settled for Rs. 1,00,000/- for the disease “CLD-EToH” , rejection of his subsequent claim for Rs.8,00,000/- under policy No.2, for the same disease in the same hospital by the same opposite party is stated as commission of deficiency in service on their part. Even before the insurance Ombusman, on 15.07.2019, when the opposite party and himself were present for settlement of his claim under policy no.2 , the opposite party stated orally that as the disease suffered by the complainant falls under exclusionary clause of the stated policy for which expenditure met for the treatment given by the Global Hospital, Lakidikapul, Hyderabad, cannot be reimbursed as such his claim cannot be settled. Having vexed with the attitude of the opposite party and having no other alternative remedy, the complainant states that he filed the present complaint before the District Forum-1, Hyderabad praying it to grant reliefs as stated supra.
3. In the enquiry, the opposite party , when called on 28.05.2020 before the District Forum-I, remained absent though served with the notice. The complainant has got filed his evidence affidavit and to substantiate his claim got filed Exs.A1 to Ex.A18. The opposite party continuously remained absent, though served with notice, at every state of the proceedings before the District Forum/Commission and neither evidence affidavit nor any document has been filed by it. A memo has been filed by the complainant stating that the proposal form as ordered to be produced before the District Forum cannot be produced as the opposite party obtained the proposal form only at the very first year i.e, 20 years ago i.e. in the year 2000 and copy of the same was not provided to him at every subsequent renewals of the policy till his admission in the above hospital. It is stated that the opposite party later never obtained any proposal form from him. As such he cannot produce any proposal forum for any year before this District Forum. The above memo filed by the opposite party has been taken on record by this Commission.
4. Heard the learned counsel for the complainant and perused the material brought on record. For the purpose of arriving at a just and proper conclusion, the following points have emerged for consideration.
a) Whether the complainant could prove any deficiency in service on the part of the opposite party.?
b) Whether the complainant is entitled to any reliefs as claimed for .?
c) To what extent.?
4.a. Ex.A 10 proves the issuance of policy No.1 by the opposite party. Ex.A9 (Discharge summary) proves that the complainant undergone treatment for “CLD-EToH”, during the period 16.01.2018 to 21.01.2018. Ex.A13 proves settlement of his claim for Rs. 1,00,000/- by the opposite party against claim for Rs. 2,76,000/- of the complainant. Ex.A3 proves the issuance of health policy by the opposite party to the complainant. Ex.A2 (Discharge summary) proves the hospitalization of the complainant for the period from 31.1.2018 till 21.2.2018 in the Global Hospital, Lakidikpool, Hyderabad for treatment and operation of his problem. Ex.A1 proves the payment by the complainant to the above hospital authorities for the above treatment. Ex.A5 evidences the rejection of the claim for reimbursement of Rs.8,00,000/- under policy no.2 by the opposite party on the ground of falling the disease under exclusionary clause of the policy. The opposite party states, in its reply mail, that the disease suffered by the complainant relates to alcoholic based liver problem, which is stated to have been mentioned in the discharge summary. It is pertinent to mention here that, to base the contention of the opposite party, the said disease is only on account of consumption of the alcohol, it did not file any evidence affidavit of the doctor concerned nor did produce him before he District Forum-I; and did not provide any opportunity to the complainant to cross examine the doctor in order to contradict the contention of the opposite party. It is known fact that the liver disease suffered by the complainant for which he undergone treatment and surgery in the above hospital, is not the only consumption of alcohol but may be by reason of other factors also such as obesity etc., The opposite party has not taken any steps to prove its ground taken for repudiating his claim under policy no.2 nor has it even appeared before the District Commission, though served with notice, which shows its sheer negligence, leaving the complainant to his fate.
The NCDRC, in the case of Birla Sunlife Insurance Company & Anr V/s Arvind Kumar rendered its decision on 13th July, 2017 where the concerned paras read as follows:
“ 2. Being aggrieved from the rejection of the claim, the complainant approached the concerned District Forum by way of a Consumer Complaint. Vide order date 03.05.2010, the District Forum allowed the complaint and directed the insurer to pay an amount of Rs.. 15,10,250/- alongwith interest @ 9% per annum and cost of litigation quantified at Rs. 11,000/-. Being aggrieved from the order passed by the District Forum, the insurer approached the concerned State Commission by way of an appeal. The said appeal having been dismissed, the insurer is before this Commission by way of this revision petition.
3. The whole case of the petitioner company is that the insured was an alcoholic and was diagnosed with alcohol lever disease and its complications. The aforesaid plea of the insurer is based upon certain photocopies of the record purporting to be a Government Medical College & Hospital, Chandigarh in respect of the deceased. It is an admitted position that no doctor who may have treated or examined the insured in Government Medical College & Hospital, Chandigarh was produced before the District Forum to prove that the deceased was an alcoholic and was diagnosed with alcohol lever disease and its complications. Admittedly, no official from the aforesaid hospital was produced to prove that the photocopies filed by the insurer were supplied by the said hospital and were true and correct copies of the record of treatment of the deceased insured. In fact, as noticed by the State Commission, the photocopies produced by the petitioner company were not even authenticated or certified by any official of the hospital. It was also noticed by the State Commission in this regard that even the affidavit of the person who allegedly collected these photocopies from the hospital was not filed. In my view, since the complainant had denied the alleged alcoholism and aliment of the insured, it was obligatory for the insurer to either produce the doctor who had allegedly treated him in the hospital or to file his affidavit. Alternatively, it could have examined an official of the hospital to prove the authenticity of the photocopies which the petitioner company filed before the District Forum in support of its case. In the absence of any such evidence, mere production of some unattested, unverified and unauthenticated photocopies, could not have been the basis of holding that the deceased was an alcoholic and was diagnosed with alcohol lever disease and its complications. No application for producing additional evidence was filed by the petitioner before the State Commission, despite losing before the District Forum. No such application is filed with this Revision Petition. The concurrent findings of the fora below, therefore, do not call for any interference by this Commission in exercise of its revisional jurisdiction.”
Relying on the above decision, our findings, in the instant case, are that when the complainant has specifically pleaded that he stopped the consumption of alcohol 5 years ago, attributing the reason of liver disease suffered by the complainant to the consumption of alcohol and repudiating his claim for Rs.8,00,000/-, under the policy no.2, without proving that the liver disease suffered by the complaint is only due to consumption of alcohol is unsustainable The opposite party neither produced the Doctor nor his evidence affidavit before the District Forum-I, thereby failed to prove the ground taken by it for repudiation of Complainant’s said claim. In view of our above findings, the opposite party cannot escape from its liability in repudiating the Complainant’s said claim under policy no.2. As such, we fasten liability to the opposite party, in this regard. Thus, the answer to this point is given against the opposite party and in favour of the complainant.
5.b. In view of our above discussion, finding and for the reasons stated herein above, we have come to the conclusion that the complainant is entitled to the reliefs as stated under point no.5.c., here below.
5.c. In the result, the complaint is allowed in part directing the opposite party to pay to the complainant :
i) Rs.8,00,000/- along with interest @9% p.a. from the date of the complaint to the date of payment,
ii) Rs.5,00,000/- as compensation towards mental agony and harassment, and
ii) Rs.20,000/- towards costs of the litigation.
Time for compliance : 45 days from the date of service of this order; and in the event of failure, the above ordered amount, except costs, shall carry interest @12% p.a.
Dictated to steno, transcribed and typed by him, pronounced by us on this the 5th day of February, 2021.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED
NIL
Exhibits filed on behalf of the Complainant:
Ex.A1 - Copy of Bills (7 Nos) issued by Global hospital Lakidekapool,
Hyderabad.
Ex.A2 – Copy of Discharge Summary dt. 31.01.2018 to 21.02.2018.
Ex.A3 – Copy of Insurance policy No. 61190034172800001533 dt.
01.10.2017 to 30.09.2018.
Ex.A4 – Copy of Notice of Remainder Dt. 14.09.2018.
Ex.A5 - Copy Letter from the New India Assurance Co Ltd informing
Rejection of Reimbursement claim No. 1404012708788 under
Policy No. 61190034172800001533 dt. 23.08.2018.
Ex.A6 - Copy Grievance letter to New India Assurance Co Ltd dt.
24.05.2019.
Ex.A7 - Copy of Remainder to New India about my Grievance Dt.
16.06.2019.
Ex.A8 - Copy of Reply to my Grievance dt. 26.06.2019.
Ex.A9 - Copy of Discharged summary dt. 16.01.2018 to 22.01.2018.
Ex.A10- Copy of policy bearing No. 620300/34/16/04/00000005 dt.
02.02.2017 to 01.02.2018.
Ex.A11 - Copy of Rejection letter under Policy No.
620300/34/16/04/00000005 Dt. 19.07.2018.
Ex.A12 - Copy of Reimbursement claim approved letter under policy No.
620300/34/16/04/00000005 dt. 08.04.2019.
Ex.A13 - Copy of Claim settlement advice in claim under policy No.
620300/34/16/04/00000005 dt. 12.04.2019.
Ex.A14 - Copy Health policy No. 61190034182800001418.
Ex.A15 – Copy Health policy No. 61190034182800001388
Ex.A16 – Copy of complainant No. HYD-H-049-1920-0118 before
Ombudsman.
Ex.A17 – Copy of Notice of hearing complaint No. HYD-H-049-1920-0118.
Ex.A18 - Copy of Order complaint No. HYD-H-049-1920-0118 dt.
11.11.2019.
Exhibits filed on behalf of the Opposite party :
Nil.
MEMBER PRESIDENT
