Date of FIling : 25/05/2016
Order No. 14 dt. 21/12/2017
The case of the complainant in brief is that the complainant along with her husband obtained mediclaim policy from the o.p.1 in the year 2005. The complainant and her husband paid the premium regularly and the policy continued. During the subsistence of the said policy i.e. from 31.05.2015 to 30.05.2016 the husband of the complainant became seriously ill and he was removed to Kasturi Medical Research Centre Pvt Ltd. Thakurpukur, Kolkata on 27.10.2015 and for better treatment he was shifted to Woodland Nursing Home on 28.10.2015. But unfortunately the husband of the complainant died on 11.11.2015. For the treatment of the husband of the complainant she had to spend an amount of Rs.7,00,000/-. After the demise of the husband of the complainant the medical claim was made to the insurance company to the tune of Rs.4,00,000/-. But the said claim of the complainant was repudiated on 16.03.2016 on the ground that the said patient was alcoholic. Since the claim of the complainant was repudiated, the complainant had to file this case praying for direction upon the o.ps for refund of the amount of Rs.4,00,000/- and compensation of Rs.1,00,000/- as well as litigation cost of Rs.15,000/-.
O.p.1 contested the case by filing w/v and denied all the material allegations of the complaint. It was stated that the transfer of the patient from Kasturi Medical Centre to Woodland was made because of medical negligence committed by Kasturi Medical Centre. The certificate issued by Kasturi Medical Centre was a tampered one. The o.p.1 repudiated the claim of the complainant as per Clause 4 of the policy which deals with exclusion clause particularly in Clause 4.4.6.1-convalescene, general debility run down condition or rest cure, obesity treatment ……….. intentional self injury and illness or injury caused by use of intoxicating drugs/alcohol. In the medical papers of Woodlands hospital dated 28.10.2015 it is mentioned acute severe pancreatitis (ethanol) and on 31.10.2015 it is written pancreatitis/alcohol withdrawal. Accordingly the o.p. denied that Ganesh Dhara the patient was not having taken liquor and due to intake of liquor which resulted in death of the complainant’s husband and as per the policy terms and conditions the claim of the complainant was not paid and it was rightly repudiated. On the basis of the facts and circumstances of the case the o.p. insurance company prayed for dismissal of the case.
On the basis of the pleadings of parties the following points are to be decided:
- Whether the complainant along with her husband was insured with the o.p. insurance company?
- Whether during the subsistence of the policy the husband of the complainant died?
- Whether there was any justifiable cause on the part of the insurance company for repudiation of the claim?
- Whether there was any deficiency in service on the part of o.p. insurance company?
- Whether the complainant will be entitled to get the relief as prayed for?
Decision with reasons:
All the points are taken up together for the sake of brevity and avoidance of repetition of facts.
Ld. lawyer for the complainant argued that the complainant along with her husband obtained mediclaim policy from the o.p.1 in the year 2005. The complainant and her husband paid the premium regularly and the policy continued. During the subsistence of the said policy i.e. from 31.05.2015 to 30.05.2016 the husband of the complainant became seriously ill and he was taken to Kasturi Medical Research Centre Pvt Ltd., Thakurpukur, Kolkata on 27.10.2015 and for better treatment she was shifted to Woodland Nursing Home on 28.10.2015. But unfortunately the husband of the complainant died on 11.11.2015. For the treatment of the husband of the complainant she had to spend the amount of Rs.7,00,000/-. After the demise of the husband of the complainant the medical claim was made to the insurance company to the tune of Rs.4,00,000/-. But the said claim of the complainant was repudiated on 16.03.2016 on the ground that the said patient was alcoholic. Since the claim of the complainant was repudiated, the complainant had to file this case praying for direction upon the o.ps for refund of the amount of Rs.4,00,000/- and compensation of Rs.1,00,000/- as well as litigation cost of Rs.15,000/-.
Ld. lawyer for the o.ps. argued that that the transfer of the patient from Kasturi Medical Centre to Woodland was made because of medical negligence committed by Kasturi Medical Centre. The certificate issued by Kasturi Medical Centre was a tampered one. The o.p.1 repudiated the claim of the complainant as per Clause 4 of the policy which deals with exclusion clause particularly in Clause 4.4.6.1-convalescene, general debility run down condition or rest cure, obesity treatment ……….. intentional self injury and illness or injury caused by use of intoxicating drugs/alcohol. In the medical papers of Woodlands hospital dated 28.10.2015 it is mentionbed acute severe pancreatitis (ethanol) and on 31.10.2015 it is written pancreatitis/alcohol withdrawal. Accordingly the o.p. denied that Ganesh Dhara the patient was not having taken liquor and due to intake of liquor which resulted in death of the complainant’s husband and as per the policy terms and conditions the claim of the complainant was not paid and it was rightly repudiated. On the basis of the facts and circumstances of the case the o.p.insurance company prayed for dismissal of the case.
Considering the submissions of the respective parties it is an admitted fact that during the subsistence of the policy the husband of the complainant became seriously ill. He was taken to Kasturi Medical Research Centre Pvt Ltd., Thakurpukur, Kolkata on 27.10.2015 and for better treatment he was shifted to Woodland Nursing Home on 28.10.2015. But unfortunately the husband of the complainant died on 11.11.2015. For the treatment of the husband of the complainant, she had to spend the amount of Rs.7,00,000/-. After the demise of the husband of the complainant the medical claim was made to the insurance company to the tune of Rs.4,00,000/-. But the said claim of the complainant was repudiated on 16.03.2016 on the ground that the said patient was alcoholic. The o.p. insurance company during the argument raised the point that at the time of death the policy was valid but the complainant failed to produce any document that the policy continued since the year 2005. On perusal of the record we find that the complainant filed a document wherefrom it appears that the policy continued since the year 2005. The o.p. insurance company relied upon the medical papers of Woodlands Hospital whereby it was mentioned that the patient suffered severe acute pancreatitis (alcohol) it is quite natural that at the time of treatment the patient party on being asked by the treating doctor whether the patient consumed alcohol to which the doctor recorded the same. But it cannot be said that due to consumption of alcohol the patient died at the age 38 years and on the basis of exclusion clause of the policy the claim of the complainant was repudiated. On the basis of the said fact we can rely on decision as reported in ICC 2012 P & H page-98 wherein it was held that exclusion clause would not apply to the consumer because premium for 3 years time already paid and claim cannot be deemed to be made in respect of the period of 3 years – exclusion clause on the basis of which the claim was declined is unfair and unreasonable clause which cannot be acted upon by the insurance company.
Having regard to the facts and circumstances of the case since the policy continued from the year 2005 and sudden detection of acute pancreatitis resulting in the untimely death of policy holder the repudiation of the claim of the complainant undoubtedly a gross deficiency in service on the part of the o.p. insurance company. Accordingly we hold that the complainant will be entitled to get the relief as prayed for.
Hence, ordered.
that the CC No.213/2016 is allowed on contest with cost against the o.p.1 and dismissed ex-parte against the o.p.2. The o.p.1 is directed to pay the sum assured of the policy of Rs.4,00,000/- and compensation of Rs.20,000/- along with litigation cost of Rs.5,000/- within 30 days from the date of communication of this order, i.d. an interest @ 8% p.a. shall accrue over the entire sum due to the credit of the complainant till full realization.
Supply certified copy of this order to the parties free of cost.
