National Consumer Disputes Redressal
Pradeep Kriplani vs New India Assurance Co. Ltd. & 2 Ors. on 7 September, 2017
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 2617 OF 2016 (Against the Order dated 31/05/2016 in Appeal No. 205/2015 of the State Commission Rajasthan) 1. PRADEEP KRIPLANI R/O A-232, MADHAV NAGAR CHOURSIYAVAS ROAD VAISHALI NAGAR AJMER RAJASTHAN ...........Petitioner(s) Versus 1. NEW INDIA ASSURANCE CO. LTD. & 2 ORS. HAVING ITS REGISTERED AND HEAD OFFICE AT: 87, MAHATMA GANDHI ROAD FORT MUMBAI - 40001 2. THE NEW INDIA ASSURANCE COMPANY LTD. HAVING REGINAL OFFICE AT SECON FLOOR SOUTH BLOCK NEARU PLACE THONK ROAD THORUHG ITS CONSTITUENT ATTORNERY JAIPUR 3. LIFE INSURANC E CORPORATION OF INDAI RANADE MAGR, ALWAR GATE THOURHG BRAHCH MANAGER AJMER RAJASTHAN ...........Respondent(s)
BEFORE: HON'BLE MRS. REKHA GUPTA,PRESIDING MEMBER
For the Petitioner : MR. PAWAN KUMAR RAY For the Respondent :
Dated : 07 Sep 2017 ORDER
REKHA GUPTA, PRESIDING MEMBER
The present revision petition has been filed against the judgment dated 31.05.2016 of the Rajasthan State Consumer Disputes Redressal Commission, Jaipur Bench no. 1, Jaipur ('the State Commission') in First Appeal no. 205 of 2015.
2. The facts of the case as per the petitioner/ complainant are that the petitioner took a medi-claim policy through his department, i.e., Life Insurance Corporation of India. The said policy was valid from 01.04.2012 to 31.03.2013 and on his illness, the payment of the amount was to be made by respondent nos. 1 and 2, i.e., New India Assurance Company Ltd. During the first week of July 2012, the petitioner fell ill. The petitioner consulted Doctor M P Sharma but got no relief. The petitioner thereafter went to S R Kalla Hospital at Jaipur, where he was admitted on 28.07.2012 and after number of tests, the petitioner was diagnosed as suffering from ALD, CLD and Ascites K/c HTN. The petitioner took treatment at S K Kalla Hospital from 28th July to 8th August 2012. Thereafter, the petitioner went to ILBS Delhi for consultation and check-up. The petitioner filed his claim with respondent no. 2 for an amount of Rs.1,26,359/- and Rs.45,380/- for the expenditure incurred on 17.08.2012 and 18.10.2012 respectively. The respondents rejected both these claims unlawfully on the ground that on investigation in connection with the both the claims and as per the opinion of the Panel Doctor, the disease developed due to consumption of alcohol, therefore, no claim was payable under clause no. 4.8 of the Group Medi-claim Policy. The petitioner has stated that he has never been a habitual drinker.
3. The insurance company in their reply had stated that the claim of the petitioner was got examined by the panel doctors and according to the panel doctors, the petitioner suffered the disease due to consumption of alcohol hence, the claim was appropriately disallowed.
4. The respondent no. 3 - LIC of India in their reply had stated that the petitioner got the group Medi-claim policy of the employees working in their office from the New India Assurance Company, in which the policy of the petitioner was also included. Hence, there was no deficiency on their part.
5. The District Consumer Disputes Redressal Forum, Ajmer ("the District Forum') vide its order dated 12.01.2015 while allowing the complaint gave the following order:
< > Applicant shall be entitled to get the amount of Rs.3,000/- against cost of the case and mental agony from the non-applicant no. 1 and 2 insurance company;
The non-applicant no. 1 and 2, the insurance company are directed to pay the amount mentioned in the serial no. (1) and (2) to the applicant within a period of two months from the date of this order or to send the ordered amount by Demand draft at the address of the applicant by registered post;
In the event, the ordered amount is not paid within a period of two months, the applicant shall be entitled to get interest also at the rate of 9% per annum from the date of judgment until payment of the same on the above-mentioned amounts from the non-applicant nos. 1 and 2 - the insurance company;
Complaint against the non-applicant no. 2, the LIC of India is dismissed."
6. Aggrieved by the order of the District Forum, the respondent nos. 1 and 2 / OP nos. 1 and 2 filed an appeal before the State Commission. The State Commission vide its order dated 31.05.2016 while allowing the appeal observed as under:
"The complainant has relied upon 2014 (4) CPR 114 (NC) United India Insurance Co. vs Krishna Prakash Dubey where no other evidence has been submitted except the opinion of penal doctor to prove the health problem of the insured which is not the case here. The discharge summary clearly narrates that the insured was suffering from ALD. He was a chronic alcoholic and as per exclusion clause 4.6 the insurance company was justified to repudiate the claim. Hence, the order of the Forum below deserves to be set aside. The appeal is allowed and the order of the Forum below dated 12.01.2015 is set aside".
7. Hence, the present revision petition.
8. I have heard the learned counsel for the petitioner Mr Pawan Kumar Ray. Learned counsel for the petitioner has contended that while it is true that S R Kalla Hospital had diagnosed the petitioner as suffering from ALD the Institute of Liver and Biliary Sciences had diagnosed the petitioner as suffering from Chronic Liver Disease. He further argued that the petitioner had admitted that he consumes alcohol but it was only occasionally and it cannot be said to be that he was an alcoholic. The State Commission had erroneously concluded that his liver disease, hepatitis was caused due to consumption of alcohol and had upheld the repudiation of his claim by the insurance company.
9. I have carefully gone through the record. As per the discharge summary of S R Kalla Hospital at Jaipur, Shri Pradeep Kriplani - petitioner was suffering from ALD, CLD with Ascites K/c HTN disease. He was also known case of Hypertension. As per the personal history, which could have been given only by the petitioner, he was an alcoholic. This discharge summary dated 08.08.2012 is supported by medical certificate of S R Kalla Hospital dated 06.10.2012, which reads as under:
"TO WHOMSOEVER IT MAY CONCERN (Medical Certificate) This is to certify that Mr Pradeep Kripalani son of Shri D M Kripalani, 47 years old male, vide registration no. 47918 was admitted on 28.07.2012, ALD, CLD with ascites, K/c HTN and discharged on 08.08.2012. He was advised rest for 45 days and was fit to join his duties from 22.09.2012."
10. Placed on the file is also a day care discharge summary certificate issued by the Institute of Liver and Biliary Sciences by which also the petitioner has been diagnosed as suffering from CLD. On-going through the complaint of the petitioner, it is seen that he has admitted that the petitioner was admitted to S K Kalla Hospital, Jaipur on 28.07.2012 and after conducting a number of tests, it was concluded that the petitioner was diagnosed as ALD, CLD with Ascties and known case of HTN Disease. He further admitted in his complaint that the though petitioner did not consume liquor habitually he did consume liquor occasionally.
11. Alcoholic liver disease is a term that encompasses the liver manifestations of alcohol over consumption including fatty liver, alcoholic hepatitis and chronic hepatitis with liver fibrosis or cirrhosis. Chronic liver disease in the clinical context is a disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Chronic liver disease, refers to disease of the liver which lasts over a period of six months. While the list of conditions associated with chronic liver disease is extensive one of many categorisations is alcoholic liver disease.
12. Counsel for the petitioner could not give any evidence to controvert the findings of the State Commission that the petitioner was not suffering from CLD with ALD due to heavy consumption of alcohol. Further, the extensive tests carried out in both the hospitals did not give any other cause for his chronic liver disease.
13. In view of the discussion above, I find no jurisdictional error or material irregularity in the impugned order which may call for interference in exercise of powers under section 21 (b) of the Consumer Protection Act, 1986. Revision petition is, therefore, dismissed with no order as to costs.
Sd/-
...................... REKHA GUPTA PRESIDING MEMBER