The judgment establishes the principle that mere mention of chronic alcoholic abuse in medical records is not sufficient to justify the repudiation of an insurance claim, and the burden of proof lies with the insurance company to establish the violation of terms and conditions of the policy.

ORDER :

Balbir Singh, Judicial Member

This appeal has been preferred against the order dated July 24th, 2017 passed by District Consumer Disputes Redressal Forum, Faridabad (for short ‘the District Forum’).

2. Balbir Saini (since deceased)-husband of Smt. Bimla Saini-complainant (respondent No. 1 herein), the complainant-Bimla Saini, their daughters Kajal and Dolly and son Vishal were provided a ‘Family Medicare Policy’ bearing No. 222800/48/13/6/00004066 (Exhibit P-5) regarding the period from September 25th, 2013 to September 24th , 2014 mentioning the total sum insured as Rs. 2,00,000. During the insured period, all of a sudden the insured Balbir Saini fell ill. He was suffering from jaundice and was admitted in Metro Heart Institute, Sector 16-A, Faridabad – opposite party No. 3 on December 29th, 2013. The opposite party Nos. 1 and 2 were immediately informed regarding ailment of the insured and officers of the opposite party No. 1 - United India Insurance Company Limited (for short ‘the Insurance Company’) came to the above mentioned hospital and advised the complainant to get treatment of the insured Balbir Saini and also assured to release payment of the claim amount. The insured Balbir Saini died on January 11th, 2014 during his treatment in the hospital. The complainant spent an amount approximately Rs. 4,00,000 for treatment of her husband. The complainant submitted insurance claim which was not accepted by the Insurance Company. The complainant had to suffer unnecessary harassment, mental agony and hardship due to faults of the Insurance Company.

3. The complainant filed complaint under Section 12 of the Consumer Protection Act, 1986 (for short ‘the Act, 1986’) before the District Forum with a prayer to direct the opposite party Nos. 1 and 2 to pay an amount of Rs. 2,00,000 being the sum insured with interest at the rate of 18% per annum; to pay an amount of Rs. 1,00,000 on account of unnecessary harassment, mental agony and an amount of Rs. 11,000 as litigation expenses.

4. The opposite party No. 1-Insurance Company has taken plea in its written version that the complainant has no locus standi to file the present complaint and that the complaint is not maintainable in the present form. It is pleaded that the complainant has suppressed and concealed the true and material facts from the District Forum. It is further pleaded that in fact the insured Balbir Saini was a known case of alcoholic liver disease since long time and he used to take alcohol on daily basis. Due to daily taking of alcohol, liver of the insured Balbir Saini was damaged and became non-functional. This fact was very well in the knowledge of the complainant that the deceased was not suffering from simple jaundice. Previous ailment of the disease comes under the ambit of Clause 4.8 of the insurance policy. The complainant is not entitled for insurance claim due to the above mentioned reasons.

5. It is admitted fact that Balbir Saini was provided ‘Family Medicare Policy’ regarding the period from September 25th, 2013 up to September 24th , 2014 mentioning the total sum assured as Rs. 2,00,000. It is denied that the complainant along with baby Kajal and Dolly and Master Vishal are the legal heirs of the deceased. It is denied that the complainant and the minors were dependent upon the income of the deceased. The insurance claim cannot be accepted as the insured concealed material facts and violated the terms and conditions of the insurance policy. The case of the complainant falls under Exclusion Clause No. 4.8 of the policy. The complainant was well aware that the deceased was not suffering from simple jaundice. The illness of the insured was outcome of regular intake of liquor. This factum is established from the documents furnished by the treating doctor of Metro Heart Institute, Faridabad. As the insured has concealed material facts, the complainant is not entitled for any amount as claimed in the complaint. It is prayed that the complaint filed by the c