Chandigarh

DF-I

CC/150/2021

Dr. Subhash Sethi - Complainant(s)

Versus

Cholamandlam MS General Insurance Co. Ltd. - Opp.Party(s)

U.K. Agnihotri

05 Apr 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/150/2021
Date of Institution	:	08/03/2021
Date of Decision	:	05/04/2023

 

Dr. Subhash Sethi age 71 years son of late Sh. Balwant Rai Sethi, r/o H.No.316, Gobind Vihar, Baltana, Tehsil Dera Bassi, Distt. SAS Nagar Mohali.

… Complainant

V E R S U S

1. Cholamandlam MS General Insurance Company Ltd., 319, Old No.154, Shah Wallace Building, 2^nd Floor, Thambu Chetty Street, Parry’s Corner, Chanai 600001 through its General Manager.
2. The Regional Manager, Chola M/s General Insurance SCO No.2463-64, 1^st Floor, Sector 22-C, Chandigarh.
3. Bank of Baroda, Jandli, Ambala 134003 through its Branch Manager.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. U.K. Agnihotri, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs 1 & 2
	:	None for OP-3

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Dr.Subhash Sethi, complainant against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant is the account holder of OP-3/bank since long and the said bank had floated a scheme providing group insurance to its account holder/consumers. Earlier the complainant alongwith his wife had obtained a policy from National Insurance Company, but, in the year 2019 as OP-3/bank had tie up with OPs 1 & 2 Insurance Company, the group insurance was provided by OP-3 to the complainant and his wife through OPs 1 & 2, who issued insurance policy (Annexure C-1) namely family floater (Plan opted Family health 500) for the period w.e.f 2.8.2019 to 1.8.2020 (hereinafter referred to as “subject policy”) by getting premium amount of ₹14,316/- including GST.  It is further alleged that on 24.1.2020, when the subject policy was in operation, wife of the complainant namely Smt. Neelam Sethi had fallen ill and as her condition deteriorated, she was hospitalized as indoor patient at Alchemist Hospital, Sector 21, Panchkula around 2:20 p.m. and she remained there upto 3.2.2020, on which date she was shifted to Fortis Hospital, Mohali in view of her serious condition.  She remained hospitalized at Fortis Hospital till 12.2.2020 where her condition did not improve and again she was shifted from there to Alchemist Hospital, Panchkula on 12.2.2020 and on 21.2.2020 unfortunately she had expired in the said hospital.  It is further alleged that in this manner, wife of the complainant remained admitted in the Hospital from 24.1.2020 to 21.2.2020.  During her treatment, wife of the complainant was diagnosed with Pencytopenia disease.  In fact, she was never suffering from the said disease earlier, though she had been suffering from Rheumatoid Arthritis, which is a common problem in aged persons as she was 68 years at the time of her death, and the same had no co-relation with the treatment of Pencytopenia, which was also opined by the Medical Officer who had given treatment to the deceased.  During her treatment as indoor patient at Alchemist Hospital, Panchkula, complainant had paid ₹3,38,912/- as medical expenses and in addition to that he had also paid an amount of ₹6,14,008/- to the Fortis Hospital, Mohali for the treatment of his wife. Not only this, when the wife of the complainant was again hospitalized at Alchemist Hospital from 12.2.2020 to 21.2.2020, he again paid an amount of ₹4,17,000/- to the said hospital and in this manner had spent total amount of ₹13,69,920/- for the treatment of his wife.  As the complainant and his wife were insured with OPs 1 & 2, and his wife died when the subject policy was in subsistence, complainant is entitled for the medi-claim.  The complainant had submitted medi-claim alongwith the requisite papers with OPs 1 & 2 for the reimbursement of the claim, but, the same was illegally repudiated by them vide letter dated 23.7.2020 (Annexure C-8) on the ground that the insured had signs and symptoms of Rheumatoid Arthritis since 20 years prior to the inception of the subject policy and she has died due to the said disease. The aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs 1 & 2. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs 1 & 2 resisted the consumer complaint and filed their written version, inter alia, alleging that as the insured persons have concealed material facts from the answering OPs, by not disclosing about the ailment of Pencytopenia and Rheumatoid Arthritis, from which the deceased was suffering for the last so many years, the claim of the complainant was rightly repudiated as per the terms and conditions of the policy.  However, it is admitted that the complainant and his wife were insured with the answering OPs vide the subject policy.  It is also denied that the complainant had spent an amount of ₹13,69,920/- for the treatment of his wife.  It is further denied that the ailment of Rheumatoid Arthritis is a common disease at the age of 68 years, though it is admitted that the deceased was insured with the answering OPs for ₹5,00,000/- by alleging that in fact the claim of the complainant was repudiated as per terms and conditions of the policy and the general exclusion clause 3.2 of the policy schedule.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. OP-3 in its separate written version admitted that the complainant is its account holder and also that the complainant and his wife were insured under the group insurance policy with OPs 1 & 2.  However, it is alleged that the complainant is consumer of OPs 1 & 2 regarding payment of insured amount and compensation etc.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the complainant, OPs 1 & 2 and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and his wife Smt. Neelam Sethi were insured under the subject policy (Annexure C-1) with OPs 1 & 2 and the same was valid w.e.f 2.8.2019 to 1.8.2020 with sum insured of ₹5,00,000/- each, the case is reduced to a narrow compass as it is to be determined if the insured Smt. Neelam Sethi, wife of the complainant, had died due to pre-existing disease from which she was allegedly suffering for the last more than 20 years at the time of inception of the subject policy and OPs 1 & 2 are justified in repudiating the claim of the complainant, as is the defence of OPs 1 & 2, or if OPs 1 & 2 are unjustified in repudiating the claim of the complainant by wrongly holding that the deceased was suffering from pre-existing disease and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant.
   2. Thus, in view of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy as well as the medical record, having been relied upon by both the parties, showing the disease from which the deceased Smt. Neelam Sethi was suffering and the same resulted into causing her death.
   3. So far as the terms and conditions of the subject policy (Annexure C-1) are concerned, the relevant portion of the exclusion clause 3.2 of the policy is required to be scanned carefully and the same is reproduced as under for ready reference :-

“4.Waiting Periods & Important Exclusions :

(please refer to the master policy wordings available with Bank of Baroda for complete list of exclusions)

The Company will not pay for any claim in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to:

1. Accidental Injury covered from Day one. Initial Waiting period of 30 days for claims due to illness.
2. Pre-existing diseases/conditions covered after a waiting period of 2 years with Chola MS
3. One year waiting period from the date of commencement of cover for the following disease: Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, internal congenital disease, Sinusitis and related disorders
4. A waiting of 9 months from the date of commencement of policy for the Insured is applicable for Maternity coverage
5. Pre- and post-hospitalisation expenses under maternity are not covered.”
   4. Both the parties have also proved the medical record issued by the aforesaid hospital where the deceased Smt. Neelam Sethi was admitted for her treatment before her death.  Perusal of the discharge on request summary card (Ex.OP-1&2/2) issued by the Alchemist Hospital, and heavily relied upon by the OPs, indicates that the deceased was diagnosed with Rheumatoid Arthritis. The relevant portion of the same showing the brief history of illness is reproduced as under for ready reference :-

        “She is known case of Rheumatoid Arthritis from last 20 years and now she again started on Folitrexate and Folic acid from last few days. Then after she had developed Generalised weakness, Bodyache, shortness of Breath and was evaluated on OPD basis and was detected to have Pancytopenia and was admitted for further evaluation and management.”

 

5. Thus, one thing is clear from the aforesaid record, having been admitted by both the parties that the deceased Smt. Neelam Sethi was a known case of Rheumatoid Arthritis for the last 20 years when she was admitted at Alchemist Hospital on 24.1.2020, making it further clear that even at the time of inception of the subject policy, which was issued on 2.8.2019 by OPs 1 & 2, she was suffering from the said disease.
6. However, the next question for determination in this case is whether the disease Rheumatoid Arthritis was the cause of death of insured Smt. Neelam Sethi which is very relevant for the determination of real controversy between the parties. 
7. In support of his argument learned counsel for the complainant, at the time of arguments, has produced the extract from the medical jurisprudence (Annexure CX) which clearly explains the causes of Pencytopenia from which the deceased/insured was suffering and was diagnosed with, by the medical officer during her treatment before her death and the same is reproduced as under :-

        “Table 13-11. Causes of pancytopenia.

Bone marrow disorders

Aplastic anemia

Myelodysplasia

Acute leukemia

Myelofibrosis

Infiltrative disease : lymphoma, myeloma, carcinoma, hairy cell leukemia

Megaloblastic anemia

Non marrow disorders

Hypersplenism

Systemic lupus erythematosus

Infection : tuberculosis, AIDS, leishmaniasis, brucellosis.”

      

8. On the other hand, learned counsel for OPs 1 & 2 drew our attention to para 2 of the written arguments submitted by him where he has made reference of page 947 of Stedman’s medical dictionary 23^rd edition, and the relevant portion of the same is reproduced as under for ready reference :-

        “… Neutropenia has been defined as Neutrophilic leukopenia, the presence of abnormally small number of neutrophils in the circulating blood and it is caused by ‘infectious diseases e.g. stomatitis, cutaneous ulcers, furuncles, arthritis, and others…….”

 

9. The learned counsel for complainant contended with vehemence that as it stands proved on record that the disease of Pencytopenia has no connection with Rheumatoid Arthritis, from which the deceased was suffering since last more than 20 years prior to her death, the same cannot be said to be a pre-existing disease as the medical officer has categorically opined that the deceased has died due to Pencytopenia and not due to the disease of Neutropenia, which fact has also been endorsed by the medical officer in his report (Annexure C-3) where he has specifically stated that the patient had history of Rheumatoid Arthritis from last 20 years.  The present ailment is Pencytopenia (2 months) for which she was under evaluation and the present illness has no relation with her past illness. 
10. On the other hand, learned counsel for OPs 1 & 2 contended with vehemence that as it is clear from the Stedman’s medical dictionary that Neutropenia has also been caused due to arthritis, it is clear that the deceased was suffering from pre-existing disease and the complainant is not entitled for any relief.
11. There is no force in the contention of learned counsel for OPs 1 & 2 as it stands proved on record from the medical certificate (Annexure C-3) as well as the definitions which have been given in the medical dictionary, having been relied upon by both the parties, as discussed above, that the deceased/ insured was suffering from Pencytopenia just two months before 21.2.2020, and not from Neutropenia and the same has no relation with the past illness of Rheumatoid Arthritis from which she was suffering.  Thus, it is unsafe to hold that the deceased/insured Smt. Neelam Sethi was suffering from pre-existing disease which resulted in causing her death, rather it is safe to hold that the deceased started suffering from the aforesaid disease of Pencytopenia only after about 4-5 months of the issuance of the subject policy by OPs 1 & 2.  Hence, the complainant has successfully proved the deficiency in service on the part of OPs 1 & 2 in repudiating his genuine claim and the present consumer complaint deserves to be allowed.
12. As it is an admitted case of the parties that the deceased was covered with insured sum of ₹5,00,000/-, complainant is entitled for the said amount though he had spent much more than that on the treatment of his wife.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1 & 2 are directed as under :-

1. to pay ₹5,00,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 23.7.2020 till realization of the same.
2. to pay an amount of ₹50,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/-  to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-3, therefore, the consumer complaint qua it stands dismissed with no order as to costs. 
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 05/04/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member
			Sd/- [Suresh Kumar Sardana] Member