Mumbai

Consumer court sets aside order against insurance firm

Support denied: The patient requested cashless benefit under ICICI Lombard’s Group Health Floater Policy.

Support denied: The patient requested cashless benefit under ICICI Lombard’s Group Health Floater Policy.   | Photo Credit: SHAILESH ANDRADE

State Commission says ICICI Lombard will not have to pay ₹4 lakh for man who consumed alcohol and died

The State Consumer Disputes Redressal Commission recently set aside an order that had directed ICICI Lombard General Insurance Company Limited to pay ₹4 lakh with 9% interest to a man who fell and died after consuming alcohol in 2016.

Randall Miranda worked with Power Exchange India Limited at Bandra Kurla Complex as assistant vice-president, human resources. His employer had purchased a ‘Group Health Floater Policy’ for its employees, valid from August 1, 2011 to July 31, 2012. Mr. Miranda’s 68-year-old father was covered for ₹4 lakh as a beneficiary. He claimed that the father, while descending the staircase in his house, fell and was admitted to Lilavati Hospital. He received medical treatment and requested cashless benefit under the ‘Group Health Floater Policy.’

It was revealed, in the course of communication, that his father had consumed 71.5 mg alcohol which contributed to the fall. The hospital notes mentioned that the patient had consumed alcohol of unknown amount and while walking down the staircase, slipped and injured his head. It was also mentioned that the patient had a history of regular alcohol consumption.

On February 8, 2016, the District Consumer Disputes Redressal Forum directed the insurance company to pay ₹4 lakh to Mr. Miranda with interest of 9% per annum, ₹15,000 for mental agony and ₹5,000 towards proceedings.

The advocate appearing for the company pointed out the exclusion clause of the ‘Group Health Floater Policy’. It is not a life insurance policy but one entered into with the employer assuring compensation in case of injury or death due to accident, he said.

The consumer forum Bench, comprising president Justice A.P. Bhangale and member Dr. S.K. Kakade, said, “We have to bear in mind the difference between a life insurance policy and ‘Group Health Floater Policy’ for which the employer had entered into an insurance contract with the appellant-insurance company. In our view, the employer never intended to enter into an insurance contract for the benefit of employees who would consume alcohol, suffer an accident and claim benefits of the insurance cover. The exclusion clauses in such an insurance contract between the employer and insurance company ought to be given due regard when they are specific and clear. There was no reference to quantity of alcohol consumed in the exclusion clause. The intention appears clear that the use of intoxicated drugs and/or alcohol was the condition binding upon beneficiaries and for any act contrary to the exclusion clause, they cannot claim the benefit of the insurance contract.”

The order says, “The terms and conditions between the employer and the insurance company in the contract are binding and ought to be construed and interpreted strictly,” as it also involves expenditure of public money by or on behalf of insurance companies pursuant to the insurance contract. This, it says, was overlooked by the district forum. In such cases, where the employee met with an accident on account of consumption of alcohol, wherein he had to undergo hospitalisation and die after about a month, “with specific mention of manner of death as natural,” the award (order) could not have been passed in favour of the claimant.

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Printable version | Feb 29, 2020 4:13:55 AM | https://www.thehindu.com/news/cities/mumbai/consumer-court-sets-aside-order-against-insurance-firm/article29104291.ece

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