New India Assurance has been directed by a consumer forum here to pay Rs 1.05 lakh to a policy holder for rejecting his claim for medical expenses incurred on treatment of his injuries suffered in an accident.
The Central District Consumer Disputes Redressal Forum held that denial of the claim by the insurance firm by relying on the medical report,which mentioned smell of alcohol from claimant’s breath,was “not justified” as no examination was
conducted to see if he was under the influence of alcohol at the time of accident.
“In the present case the doctor merely recorded in the MLC (medical report) that there was smell of alcohol. No further examination was conducted. There is no evidence on the file nor was collected by the insurance firm to find out that cause
of accident due to which the complainant received injury was due to the fact that he was under the influence of liquor.
“The insurance firm did not find out any connection of accident of the complainant with taking of liquor or smell of alcohol. Hence,it is held that repudiation of the claim was not justified.
“We allow the complaint with directions to the insurance firm to pay to the complainant a sum of Rs 90,000 (the claim amount) along with Rs 10,000 for causing harassment,pain and mental agony and Rs 5,000 towards litigation charges,” the bench presided by B B Chaudhary said.
The forum’s order came on a complaint filed by north-west Delhi resident Sahil Kwatra,who had said that he was insured under a medi-claim policy bought for the period from January 8,2009 to January 7,2010.
Kwatra had met with an accident and was admitted in Jaipur Golden Hospital on February 22,2009 and was discharged four days later,he had said,adding that he had spent Rs 90,000 on his treatment.
He had said his claim was rejected by the insurance firm on the ground that as per the report of his medical examination after the accident,he smelt of alcohol.
The insurance firm was proceeded against ex-parte as no one appeared on its behalf.