Tamil Nadu

StateCommission

FA/1044/2011

K. ISSAC SOUNDARAPANDIAN - Complainant(s)

Versus

FAMILY HEALTH PALN LTD., MANAGING DIRECTOR - Opp.Party(s)

N. ISHTIAQ AHMED

16 Mar 2015

ORDER

 

BEFORE THE STATE CONSUMER DISPUTES REDRESSAL COMMISSION,CHENNAI

                                      BEFORE :  HON’BLE THIRU JUSTICE R.REGUPATHI                     PRESIDENT

                                                          THIRU.J.JAYARAM                                                         JUDICIAL MEMBER

                                                          TMT.P.BAKIYAVATHI                                                     MEMBER                                                                                                    

F.A.NO.1044/2011

(Against the order in CC.No.813/2009, dated 11.10.2011 on the file of DCDRF, Chennai (South)

DATED THIS THE 16^th DAY OF MARCH 2015

Mr.K.Issac Soundarapandian,

S/o.Karuppasamy,

No.6/464. Rajeswari Nagar,                                       Appellant / Complainant

I Main Road, Pozhichalur,

Chennai 600 074.                         

- Vs

1.  Family Health Plan Ltd,

    Rep.by its Managing Director,

    Plot No.25, MCH No.8-2-334,

    Road No.3, Azam colony,                                 Respondents / Opp.parties

    Banjara Hills, Hyderabad -34

2.  The National Insurance Corporation,

     Rep.by its General Manager,

     Guindy Branch,    

     S-7, Thiru.Vi.Ka.Industrial Estate,

     Chennai 600 032.

          This appeal coming before us for final hearing on 02.03.2015 and on hearing the arguments on both sides and upon perusing the material records, this Commission made the following order:

Counsel for Appellant/ Complainant     :      M/s.N.Ishtiaq Ahmed           

Counsel for 1^st Respondent/ 1^st Opp.party :  Served called absent

Counsel for 2^nd Respondent/ 2^nd Opp.party :  M/s.N.Vijayaraghavan

J.JAYARAM,  JUDICIAL MEMBER

ORDER

1.     This appeal is filed by the opposite party against the order of the District Forum, Chennai (South) in C.C.813 of 2009 dated 11/10/2011; dismissing the complaint.

2.       The case of the complainant is that he had joined the Group health Insurance with the 2^nd  opposite party and when the policy was in force , on 24/07/2008 he vomited blood and was admitted in Venkateswara Hospital,Tirunelveli as in patient from 24/07/2008 till 29/07/2008 and thereafter he was referred to Vijaya Hospital,Chennai for further treatment, where he took treatment as an inpatient from 06/08/2008 to 13/08/2008 and following this, he had his treatment at Lakshmi Nursing Home,Pallavaram as an inpatient  from 20/10/2008 to 21/10/2008 and again for the evaluation and management of the same ailment, he was admitted in Medindia Hospital,Valluvarkottam, Chennai on 10/02/2008,26/12/2008 and 13/01/2009. His claim under the insurance policy was repudiated by the 2^nd opposite party, which amounts to deficiency in service and hence the complaint.

3.       According to the 2^nd opposite party the claim was declined, since he had taken treatment for an ailment caused due to intake of alcohol which comes under the Exclusion Clause of the policy conditions and so he is not entitled to the benefits under the policy and hence his claim was rejected for valid reason and there is no deficiency in service on their part.

4.       The District Forum considered the rival contentions and dismissed the complaint, holding that there is no deficiency in service on the part of the 2^nd opposite party.

5.       Aggrieved by the impugned order, the complainant has preferred this appeal.

6.       The contention of the complainant /appellant is that he is entitled to claim compensation from the 2^nd opposite party.

7.       Per contra, the 2^nd opposite party/2^nd respondent would contend that as per the Exclusion Clause 7 of the policy conditions (4.8) the appellant/claimant is not entitled to get compensation under the policy.

8.       Clause 7 of the conditions in the policy Ex.B1 is as follows:-

“Convalescence, general disability” Run-down” condition or rest cure. Congenital external disease or defects or anomalies, infertility, venereal disease, AIDS, International self-injury and use of alcohol/intoxicating drugs”.

9.       On perusal of the Hospital Discharge Certificate Ex.B-3(series) of Venkateswara Hospital and the Discharge summary issued by Vijaya Hospital, we come to know that the appellant had treatment for “CIRRHOSIS OF LIVER” and that risk factor is alcohol and that the patient is a known alcoholic and therefore it is evident that the appellant is an alcoholic and that he had treatment for an ailment related to intake of alcohol and so we hold that the appellant’s claim is hit by the Exclusion Clause of the policy conditions and that the appellant’s claim is repudiated by the 2^nd opposite party for valid reasons.  Therefore we hold that there is no deficiency in service on the part of the 2^nd opposite party.

10.     The District Forum has come to the right conclusion that there is no deficiency in service on the part of the second opposite party and has rightly dismissed the complaint.

11.     There is no infirmity in the order of the District Forum and we agree with the finding and the decision of District Forum.

12.     In the result, the appeal is dismissed confirming the order of the District Forum dismissing the complaint .  No order as to costs in the appeal.

 

P.BAKIYAVATHI                           J.JAYARAM                                 R.REGUPATHI

     MEMBER                                  (J) MEMBER                                  PRESIDENT