Insurance firm directed to pay Rs 1.21L to complainant

Tribune News Service
Amritsar, August 18

The district consumer forum has directed an insurance company to pay Rs 1.21 lakh, which was earlier refused as a medical claim, along with Rs 8,000 as compensation and Rs 5,000 as litigation expenses, to a local resident.

Earlier, Raj Kumar, a resident of Shaheed Udham Singh Colony, had filed a complaint against National Insurance company stating that he had obtained a medical insurance policy of Rs 5 lakh from the opposite party. The complainant said he had been purchasing the policy continuously for around 10 years, but he had never been given a copy of the terms and conditions of the policy.

Raj said in January last year, he fell ill and spent an amount of Rs 1.21 lakh on his treatment. The complainant said he felt that as he had eaten food from outside and drank water from a tap, it could have caused the problem.

The opposite party in its reply stated that “in terms and conditions of the policy, it has specifically been stated that the company shall not liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or respect of a self-inflicted injury of drug abuse”. 

The firm said it was observed that the complainant was admitted to hospital with diagnosis of suspected poisoning and underwent conservative treatment. It added that the patient had overdose of sleeping pills and as such the claim of the complainant has been rejected on the basis of the terms and conditions.

The forum observed that “the claim filed by the complainant has been repudiated on the ground of an intentional self-inflicted injury and drug abuse”. 

The forum said the complainant was never given the terms and conditions of the policy. “The opposite party could not produce any evidence to prove that the terms and conditions of the policy were ever given to the insured,” the forum observed.  

“The insured is not bound by the terms and conditions of the insurance policy unless it is proved that the same was supplied to the insured by the insurance company. The onus to prove that the terms and conditions of the policy are given to the insured lies on the insurance company,” said the forum.

When promise was not kept 

• Raj Kumar, a resident of Shaheed Udham Singh Colony, had filed a complaint against National Insurance company stating that he had obtained a medical insurance policy of Rs 5 lakh from the opposite party. 
• The complainant said he had been purchasing the policy continuously for around 10 years, but he had never been given a copy of the terms and conditions of the policy.
• The opposite party in its reply stated that “in terms and conditions of the policy, it has specifically been stated that the company shall not liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or respect of a self-inflicted injury of drug abuse”.