NEW INDIA ASSURANCE COMPANY LIMITED Vs. USHA YADAV

JUDGEMENT

(1.) PERMANENT Lok Adalat (Public Utility Services), Gurgaon has decided the application filed by the respondents, who are widow and off- springs of late Ramesh Chand Yadav for directing the petitioner-Insurance Company to honour their medi-claim at a pre-litigating stage. It would sound unfortunate to notice that the hapless respondents had to fight for getting claim of insurance on account of death of their husband/father. The children though are minor, but respondent-wife would certainly remember the day when the insurance agent would have come to her late husband to persuade him or to goad him to take a medi-claim so that he is able to look after himself without worrying for finances if he ever happened to fall sick. How these assurances advanced by Insurance Company would sound hollow, must have now been realised by the respondents. The Insurance Company is even not felt satisfied with the detailed order passed by the Lok Adalat in considering their objections and directing payment of the amount claimed, but has chosen to file the present revision petition before this court to impugn the said order. All the usual pleas are pressed as are generally advanced by the Insurance Companies.

(2.) THIS medi-claim insurance policy was obtained by late Ramesh Chand Yadav from 1.2.2002 to 31.3.2023. On 13.7.2006, Ramesh Chand Yadav fell sick and was admitted in Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi. He was found to be suffering from liver disease with portal hypertension with decompansation jaundice, ascites and non-bleeder. He had informed the Insurance Company about this development on 14.7.2006. He was discharged from the hospital on 20.8.2006. He had earlier been also admitted in the hospital on 8.8.2006 on account of the same ailment besides mild renal failure and bronchial asthma. This time he had again fallen sick and taken to the same hospital on 20.8.2006. Unfortunately he expired on 28.8.2006 in the hospital itself. The claim is made on the Insurance Company for a sum of Rs. 2,75,000/-, which was spent on treatment and purchase of medicines. The Insurance Company, against all the tall promises it had made, repudiated the claim vide their letter dated 8.1.2007 on the ground that disease was caused due to use of alcohol and drugs and as such, is not payable in terms of the policy. The respondent-wife and her two minor siblings, thus, filed this application alleging that repudiation of the claim is illegal as use of alcohol was not the only cause which led to the disease, as was being construed by the Insurance Company.

(3.) WHILE rejecting the plea raised by the Insurance Company, the Lok Adalat has found that late Ramesh Chand Yadav was found suffering from several diseases and all those diseases could not be as a result of alcohol consumption alone. It has also been noticed that there is no specific finding by any medical expert that any disease with which the deceased was found suffering had developed on account of alcohol consumption. It is a case of death of a young man aged 41 years. He has left behind his young wife and two minor daughters. A reference has been made to the findings recorded by the panel of doctors as seen from the summary made at Sir Ganga Ram Hospital, New Delhi. It is noticed that the investigation had revealed increased TLC and deranged liver and renal functions. Despite treatment, the ascetic fluid cell count was not decreasing while urine progressively decreased. The deceased had also developed respiratory distress. He was shifted to ICU, but suffered a massive upper GI bleeding and went into shock. He expired on 28.8.2006. It is accordingly noticed that alcohol consumption could not be the only cause for all those complicated diseases which led to the death of the deceased. The action of the Insurance Company in repudiating the claim by adopting some mean or the other, as such, has rightly been rejected. The order passed by the Lok Adalat is just, fair and reasonable and as such would not call for any interference.