IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR Present: Sri.K.Gopalan: President Smt.K.P.Preethakumari: Member Smt.M.D.Jessy: Member Dated this, the 16th day of December 2009 OP.237/2003 1.Joseph Mathew, Kallody Karuvanchal,P.O. Vellad Amsom Naduvil Desom. 2.Mathai, S/o.Mathai,Njarakkatt 3 .Marykutty, W/o.Joseph Njarakkatt Complainants 4. Jaison,S /o.Joseph Njarakkatt 5. Dhanya, D/o.Joseph Njarakkatt 6. Nitto, D/o.Joseph Njarakkatt (Rep. by Adv,M.J.Sidharth) Branch Manager, Oriental Insurance Co, Branch Office, Mariuna Sghopping complex, Opposite party National Highway, Taliparamba (Rep. by Adv,K.Reghunathan) O R D E R Sri.K.Gopalan, President This is a complaint filed under section12 of consumer protection act for an order directing the opposite party to pay a sum of Rs.50, 000/- with 12% interest towards the medical treatment and also to pay Rs.5000/-as compensation towards mental pain and sufferings. The brief facts of the case of the complainant are as follows: the complainant is a medi claim policy holder under the opposite party. During the month February 2002 the complainant had affected with liver disease and he was taken to Kasthurba Medical College, Manipal. He was admitted there on 8.2.02 and after treatment discharged from the Hospital on 12.2.02. Complainant had spent more than Rs.25, 000/- in the hospital. After his return from the hospital complainant had preferred an application for the claim and submitted the Hospital records and bills. Complainant was admitted again for the same illness in KMCHG and treated from there from 11.7.02 to 16.7.02 and met an expense of Rs.25, 000/-. Complainant had submitted claim application together with hospital records and bills. But the opposite party repudiated the claim on the ground that the confidential report from the hospital suggest that the disease of the complaint is Alcoholic Liver disease. The complainant submits that he was never in the habit of using alcohol or any other intoxicant and hence there is no chance for affecting any alcoholic liver disease to him. Complainant caused to send lawyer notice dt.11.9.02. Opposite party send reply refusing the demand of the complainant. Afterwards complainant approached opposite party several time to take back the document and at last it is found missing the medical bills from the Pariyaram Medical college. So complainant returned from the opposite party’s office without taking back any of the documents. On 9.1.03 the complainant sent a lawyer notice to the opposite party to handover the hospital records and medical bills. But the opposite party had refused to give the documents stating some false reasons, which caused much mental agony and physical stress and financial loss. The opposite party is liable to pay the expenses of the medical treatment. Repudiation of claim is only deficiency in service on the part of opposite party. Hence this complaint. Pursuant to the notice opposite party entered appearance and filed version contending as follows: complainant had taken mediclaim policy. He submitted claim form for an amount of Rs.12, 648.95. It is false to say that he had suffered an expense of Rs.25, 000/- in his second admission. Claim of the complainant was repudiated. The disease for which complainant availed treatment was, as per medical records ‘Alcoholic Liver disease’. The disease for which the complainant sought claim is falling within the exclusion clause NO.4.8 of the policy. Under such circumstances opposite party is not liable to honour the claim and hence repudiation is perfectly valid and justifiable. The allegation that opposite party is in custody of certain documents of complainant is false. Documents related to treatment in Pariyaram M.C had not been given to this opposite party. Documents sent to opposite party are only those of treatment of the first admission which cover the period from 8.2.02 to 12.2.02. The amount asked for relief is exorbitant and unreasonable. There is no deficiency of service on the part of opposite party. Hence to dismissed the complaint. On the above pleadings the following issues have been taken for consideration. 1. Whether there is any deficiency on the part of the opposite party? 2. Whether the complainant is entitled for any relief as prayed in the complaint/ 3. Relief and cost. The Supplementary complainants 2 to 5 were imp leaded on the death of the complainant and his wife supplementary complainant No.2 examined as PW1 and marked Exts.A1 to A5 on the side of the complainant. DWs 1 and 2 examined on the side of opposite party and Exts.B1 to B12 marked on this side. Issue Nos. 1 to 3 Admittedly complainant has taken policy from the opposite party. He has also submitted claim form but it was repudiated on the ground that complaint availed treatment for Alcoholic Liver Disease’ which is within the exclusion clause. The main case of the compliant is that he was admitted to Kasthurba Medical college Hospital on 8.2.02 affecting Liver Disease and after treatment discharged from the hospital on12.2.02. He spent more than Rs.25, 000/-. After the discharge he had submitted claim application together with hospital records and bills. He has again admitted to same hospital for same disease from11.7.02 to 16.7.02. This time also he had suffered for an expense of Rs.25, 000/-. He also submitted claim application with all records and bills. But claim was repudiated on the ground that treatment was for Alcoholic Liver diseases. The complainant alleged that he was never in the habit of taking alcohol or any other intoxicant. He further alleges that opposite party refused to return the documents even if lawyer notice was sent which all caused him mental agony and physical stress together with financial loss. On the other hand, the case of the opposite party is that the complainant submitted claim form for an amount of Rs.12, 648.95. Opposite party further contended that in the light of the admission of the complainant in his claim form it is false to say that he had incurred an expense of another Rs.25, 000/- in his second admission in the hospital is false. The main contention of the opposite party is that the claim of the complainant was repudiated because of the reason that the disease for which the complaint availed treatment was “Alcoholic Liver Disease’ which is purely falling within the exclusion clause. Supplemental complainant No.2, the wife of deceased complainant filed affidavit on behalf of supplementary complainants 2 to 6. The evidence given by the affidavit shows that the complainant incurred an expense of more than Rs.12,500/- in Pariyaram Medical college, and thereafter for being not getting better result, he was taken to Kasthurba Medical college, Manipal and treated there from 8.2.02 to 12.2.02. He has incurred there an expense of Rs.25, 000/-. It is further stated that he had submitted claim form together with the hospital bills from the Priyaram MCH and Kasthurba MCH but the claim was repudiated on the ground that the treatment had been taken for the disease due to alcoholic intake. It can be seen that the pleadings of the complainant is that during the month of February 2002 the complainant had affected with liver disease and he was taken to Kasthurba Medical college Hospital, Manipal and was admitted there on 8.2.02 and treated for his illness till his discharge on 12.2.02.There is no whisper about the treatment of Pariyaram Medical college. He has also pleaded that he was incurred an expense of Rs.2, 5000/- for the above treatment. No reason stated in chief affidavit for the omission in the pleading with respect to the treatment of Pariyaram Medical College. Ext.A1 notice sent by the complainant also did not make any mention about the treatment of Pariyaram Medical College. What is stated in the notice is thus: “my client states that he was under treatment as inpatient at KMCH, Manipal for his liver disease and after his return from the hospital he preferred the claim and submitted the application before your company along with the hospital records and bills”. This notice shows that the complainant submitted claim once after the treatment where as the complainant shows the complainant submitted the claim twice i.e. firstly after the first discharge and secondly after the second discharge. There is no mention of second admission in KMCH in Ext.A1. There is also no mention of treatment in the Pariyaram Medical College also. PW1 also admits in her cross examination that the alleged treatment undergone in Pariyaram MCH has not been mentioned neither in the complaint nor in the lawyer notice. In the cross examination PW1 also admitted that in the claim form it was only mentioned about the treatment 8.2.02 to12.2.02.PW1 also admitted that the expense shown in the claim Form is Rs.12,648/-. It was also admitted that no documents has been produced to show that the complainant was treated in Pariyaram Hospital. The main contention of opposite party is that the disease of the complainant is due to the constant alcoholic intake and he has availed treatment for ‘Alcoholic Liver Disease’. Which falls within the exclusion clause of insurance policy? Ext.B1is the Insurance policy. It can be seen that the use of intoxicating drugs or alcohol has been included in the clause 4.8. DW2 Dr.C.Ganesh in his chief examination given evidence to the effect that complainant’s liver was severely damaged at the time of examination on account of constant alcoholic intake. Ext.B11 is the Discharge summary issued from Manipal Hospital. DW2 given evidence that Ext.B11 was prepared by him. The discharge summary in the column Final Diagnosis it written “Alcoholic Liver Disease Cirrhosis”. He also deposed in his cross examination that the complainant told him that he had been consuming alcohol. DW2 categorically stated that the history of the complainant taken by him as well as the test conducted by him shows that the patient was suffering liver cirrhosis on account of constant intake of alcohol. In the light of the above discussion and on going through the evidence with close scrutiny of documents available on record undoubtedly proves that the complainant was treated for the disease ‘Alcoholic Liver Disease Cirrhosis’ which has been developed due to constant alcoholic intake. Since such disease included in the exclusion list the repudiation of claim by the opposite party can only be justified. Hence we hold that there is no merit in the case of the complainant and he is not entitled for the claim. The issues 1 to 3 are answered against complainant. In the result, the complaint is dismissed. No order as to costs. Sd/- Sd/- Sd/- President Member Member APPENDIX Exhibits for the Complainant A1.Copy of the lawyer notice sent to OP A2.Postal receipt and AD A3.Copy of the repudiation letter sent by OP A4.Copy of the layer notice dt.8.1.03 sent to OP A5 Postal receipt and AD Exhibits for the opposite party B1. Copy of the Policy schedule issued to complainant. B2.Letter dt.28.5.02sent to OP B3.Claim form for revised medi claim insurance policy submitted by complainant. 1 B4.Copyof hospitalization claim scrutiny form B5.Annexure of Jan Aroghya medi claim form confidential medical certificate. B6.Copy of the letter dt.,29.7.02 sent to complainant B7.Lawyernotice sent by complainant’s counsel1.9.02 B8. Copy of the Reply notice B9. copy of the repudiation letter sent to complainant B10.Lawyernotice dt.8.1.03 sent by complainant’s counsel B11.Discharge summary issued from Kasturba Hospital Manipal B12. Cash bills Witness examined for the complainant PW1.Marykutty Jose Witness examined for the opposite party DW1.T.G.Sreenivasan Nair DW2.Dr.C.Ganesh Pai. /forwarded by order/ Senior Superintendent Consumer Disputes Redressal Forum, Kannur.
......................GOPALAN.K
......................PREETHAKUMARI.K.P | | 
