State Consumer Disputes Redressal Commission
New India Assurance Co. Ltd. vs Ashok Soni on 13 October, 2014
IN THE STATE COMMISSION : DELHI (Constituted under Section 9 of the Consumer Protection Act, 1986) Date of Decision : 13.10.2014 First Appeal No.958/2008 (Arising out of the order dated11.08.2008 passed by District Consumer Disputes Redressal Forum, Barracks, Kasturba Gandhi Marg, New Delhi in complaint case No. 261/2006) M/s New India Assurance Co. Ltd. Level-5, Tower-II, Jeewan Bharti Building Connaught Place, New Delhi Appellant VERSUS Sh. Ashok Soni S/o Late Sh. M.G.Soni R/o A-46, New Delhi Sought Extension Part (NDSE)-II, New Delhi-110049 ..Respondent CORAM S.A.Siddiqui, Member (Judicial) S.C.Jain, Member
1. Whether reporters of local newspaper be allowed to see the judgment?
2. To be referred to the reporter or not?
S.A.Siddiqui, Member (Judicial) Judgment
1) This is an appeal under Section 15 r.w.
Section 17 of the Consumer Protection Act 1986 (in short the Act) against the order dt. 11.08.2008 passed by Ld. District Forum Barracks, Kasturba Gandhi Marg, New Delhi in Complaint Case No. 261/06.
2) Through aforesaid impugned order, the Ld. District Forum directed the New India Assurance Company Ltd-OP to pay Rs. 01,01,150/- towards insurance claim and Rs. 1,00,000/- towards compensation and Rs. 20,000/- towards costs of litigation. Feeling aggrieved OP-New India Assurance Company Ltd preferred this appeal against complainant/respondent.
3) Relevant facts relating to this appeal are discussed below:-
Complainant/respondent Sh. Ashok Soni subscribed to one of the policies/special scheme namely good health plan medisave through city bank in the year 1996.
Thereafter the policy was regularly renewed till date i.e. for the period of 01.02.2000 to 31.01.2001. It has been alleged that complainant was fully healthy till 18.10.2000, he was not suffering from disease like diabetes, hypertension, loss of appetite, jaundice, indigestion cough and loss of weight etc. However, the complainant was in the habit of occasionally taking alcohol (1/4 to pint) since last 20 years, whenever he was in the company of his friends. Suddenly, on 19.10.2000 he felt weakness with giddiness and thereafter passed a black colour stool along with blood in vomiting. Therefore, he was immediately rushed to hospital M/s Jain Medical Centre where he was examined. He was referred to Dr. Ranbir Sudh, Gastro Enterologist of Sir Ganga Ram Hospital. Dr. Ranbir Sudh examined the complainant after taking entire history including taking of liquor etc. He was further investigated through Lab, Pack, X-ray and UGI Endoscopy and it was found that complainant was suffering from hiatus hernia and there were some open and dilated vessels in complainant esophagus and for the same EVL was done simultaneously. Blood was also given. He was found ok on 30.10.2000.
However, suddenly on 31.10.2000 complainant again passed blood in vomiting. Again blood was given to the complainant, UGI Endoscopy was done on 01.11.2000. He was finally discharged on 06.11.2000 complainant was suffering from unknown type of acute liver disease (ALD, Portal Hypertension (PHT-reason behind which not known) Hiatus Hernia and bleeding in vomitious was prone esophagus. The complainant paid hospital bill of Rs. 01,01,150/-.
Thereafter he lodged a claim and provided all necessary informations and documents to the OP, but, it took undue delay in settling the matter and the claim was ultimately rejected, complainant was therefore compelled to file consumer complaint.
4) Notice was issued to the OP, who contested the case by filing written statement.
5) OP took plea that complainant suffered from liver disease due to prolonged consumption/intake of alcohol for the last 20 years which comes under the exclusion clause 2 of the terms and condition of the insurance policy, the claim was rightly rejected. There was no deficiency in service of any sort from the side of the OP.
6) Parties led evidence in support of their cases. However, the Ld. District Forum came to the conclusion that OP was beyond deficient in providing service and decreed the complaint.
7) OP/appellant-M/s New India Insurance Company Ltd. preferred appeal against impugned order dt. 11.08.2008 mainly on the ground that the Ld. District Forum committed grave error by decreeing the complaint. It failed to examine the discharge summary issued by the Sir Ganga Ram Hospital. In the said discharge summary, it was clearly pointed out that complainant/respondent was a chronic alcoholic for the past 20 years and was regularly taking alcohol (1/4 to daily), the Ld. District Forum wrongly assumed that complainant/respondent was only taking liquor occasionally (1/4 to pint) whenever he was in the company of his friends. Due to regular consumption of liquor complainant suffered from acute liver disease which falls under the exclusion clause 2 of the policy and therefore the claim of the complainant was not payable there was no deficiency of service on the part of the appellant-insurance company.
8) It was further alleged that appellant/OP before repudiation of the claim obtained the opinion of the Doctor who concluded that complainant was a chronic alcoholic and suffered with acute liver disease as a consequence of intake of alcohol continuously by the last 20 years. The Ld. District Forum did not consider this important aspect of the matter and failed to appreciate the contention of the OP/appellant.
9) It was also alleged that the impugned order was mechanical without proper appreciation of the evidence on record and also without application of the judicial mind. The amount of the compensation and the costs awarded was also without any rational basis.
10) Complainant/respondent filed reply.
Complainant/respondent in his reply maintained that the appeal was devoid any merit. The appellant also did not come with clean hands and no legal point was involved in the appeal. The compensation and the costs awarded by the Ld. District Forum was totally inconsonance with the facts and circumstances of the case. It was wrong to allege that complainant was suffering from cirrhosis of liver, which was a direct result of continuation intake of alcohol for years together. The appellant has tried to twist the facts. The hospital or the doctor has nowhere mentioned that complainant was suffering from cirrhosis of liver. The complainant/respondent was found suffering from hiatus hernia.
11) We have heard Ld. Counsel for the appellant. Since none was present on behalf of the OP/respondent no arguments could be advanced. However, during the course of trial, the complainant/respondent/counsel participated in the proceedings and filed reply. Complainant/respondent also filed written arguments. We have carefully gone through the record including impugned order dt. 11.08.2008.
12) Dispatch summary of Sir Ganga Ram Hospital is available on record. According to this document, complainant/respondent Sh. Ashok Soni was admitted in the hospital on 26.10.2000 and was discharged on 06.11.2000, he was aged about 52 years.
History and course of the illness during the hospital stay has been recorded as 52 years old male, non diabetic, normotensive chronic alcoholic for past 20 years (1/4-1/2 daily) presented with complaints of malena for one day Haematemesis in evening generalised weakness and giddiness since evening etc. Diagnosis Column described ALD, PHT, Decompensated, Upper GI Bleed cause Eso. varices EVL Done with Hiatus Hernia. Thus describing the history of the patient, it has been noted that complainant/respondent was chronic alcoholic for past 20 years (1/4-1/2 daily). He was diagnosed suffering from ALD (which is unknown type of liver disease) Portal Hypertension PHT Upper GT Bleed cause ESO. varices EVL done with Hiatus hernia. There is no doubt about the fact that the complainant/respondent was chronic alcoholic for the past 20 years but his daily intake of liquor was limited to (1/4-1/2 pint daily) but the discharge summary nowhere mentioned that he was suffering from acute cirrhosis, a kind of liver diseases resulting from very prolonged intake of alcohol. Apart from an unknown liver diseases, the complainant/respondent was also suffering from other diseases as well. There is no evidence on record that complainant/respondent was taking excessive liquor which continued for a very long time about 20 years, therefore, we are broadly in agreement with the conclusion reached by Ld. District Forum in its impugned order dt. 11.08.2008. However, we have also noted the fact that no rational basis has been shown while awarding compensation and the costs. This needs modification. Consequently, appeal is partly allowed and the following modified order is passed:-
i.
OP/appellant will pay Rs. 01,01,150/- for reimbursement of the insurance claim.
ii.
OP/appellant will also pay Rs. 50,000/-
towards compensation to the complainant for mental pain, agony and harassment.
iii.
OP/appellant will further pay Rs. 10,000/- towards costs of litigation.
13) Compliance of the order will be made within 30 days from the date of knowledge or receipt of the copy of the judgment.
14) The complaint stands decided accordingly.
15) The amount deposited through FDR will be released to the appellant by the registry as per rule.
16) Let copies of the judgment be provided to the parties free of cost as per rule.
17) A copy of the judgment shall also be placed on the complaint file maintained by the Ld. District Forum. Thereafter, file be consigned to record room.
(S.A.SIDDIQUI) MEMBER(JUDICIAL) (S.C.JAIN) MEMBER FATIMA