Punjab

Ludhiana

CC/15/224

Rajesh Kumar - Complainant(s)

Versus

National Ins.Co.ltd - Opp.Party(s)

Vikram Monga Adv.

12 Oct 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

Consumer Complaint No.224 of 01.04.2015

Date of Decision          :   12.10.2016

 

Rajesh Kumar son of Shri Bal Krishan Kapila, resident of C/o Balsons, Subhash Bazar, Khanna, District Ludhiana.

….. Complainant

Versus 

 

1.National Insurance Company Limited, G.T.Road, Khanna, District Ludhiana through its Manager.

2.National Insurance Company Limited, Regd., Office:3, Middleton Street, Post Box No.9229, Calcutta-700071 through its Managing Director.

..…Opposite parties

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

MRS. VINOD BALA, MEMBER

 

COUNSEL FOR THE PARTIES:

 

For Complainant                     :       Sh.Vikram Monga, Advocate

For OPs                         :       Sh.D.R.Rampal, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Complainant availed   Parivar Mediclaim policy from Ops vide  policy No.404004/48/14/8500000199 for the period from 30.7.2014 to 29.7.2015 for insured sum of Rs.2 lac on payment of premium of Rs.5126/-. Besides, the complainant and his family members consisting of his wife namely Smt.Poonam Kapila, two sons namely Arjit Kapila and Sanyam Kapila were also insured. Complainant had been availing the policies regularly from Ops since the year 2008. At the time of issuance of the policy, officials of Ops satisfied themselves about each and every aspect including the medical fitness of the complainant and thereafter, issued and renewed the policy from time to time. Complainant suddenly fell ill and was taken to GMC, Shimla, from where, he was shifted to Fortis Heart Institute Multispecialty Hospital, Sector 62, Mohali, where he remained admitted for treatment during the period from 26.8.2014 to 2.9.2014. An amount of Rs.1,56,143/- was spent on his treatment by the complainant during policy period. After discharge from the hospital, complainant provided the relevant documents to Ops, but despite that medical claim has not been reimbursed. Ops procrastinating the matter and ultimately, complainant received letter dated 11.11.2014, vide which, Ops refused to disburse the claim amount on flimsy grounds. Ops took false ground that disease of the complainant was due to alcoholic intake. However, discharge summary of Fortis Hospital clearly reveals that doctor nowhere opined in the discharge summary that the disease was due to alcoholic intake. Complainant  after  availing  policies  since  2008                                               never lodged claim, which clearly shows that claim of the complainant is genuine one and disease was sudden. By pleading deficiency in service and adoption of unfair trade practice on the part of Ops, prayer made for disbursal of the claim amount with interest. Compensation for mental harassment of Rs.50,000/- and litigation expenses of Rs.20,000/- + counsel fee of Rs.22,000/- more claimed.

2.                In joint written statement filed by Ops, it is pleaded interalia as if complaint is not maintainable in the present form; complaint bad due to non-joinder and mis-joinder of necessary parties; complainant suppressed the material facts from this Forum; complainant estopped by his own act and conduct from filing this complaint and in view of involvement of intricate question of law and facts requiring elaborate evidence, the matter needs  be decided by civil court of competent jurisdiction. Claim of the complainant was found not payable by Raksha TPA by holding that Acute Pancreatitis disease occurred due to alcoholic intake. Alcohol is the main contributing factor in causing disease and as such, claim does not fall under the terms and conditions of the policy. Specific reference to clause 4.4.6 has been made by claiming that repudiation of the claim vide letter dated 10.11.2014 is justified, in view of the recommendation of Raksha TPA submitted after minute scrutiny of the claim. Admittedly, Parivar Mediclaim policy was issued, but it is denied that the complainant regularly availing the policies since from 2008. Insurance policies are always issued on good faith. No test of the complainant was ever conducted by any doctor and complainant has concocted a false and frivolous story in that respect. Complainant is alcoholic and in view of sufferance of disease on account of alcohol consumption, claim duly repudiated. Discharge summary of the complainant issued by Fortis Hospital also shows that he was diagnosed as a case of Acute Pancreatitis Grade D, Non Necrotizing Etiology Alcohol Obesity Dyslipidemia. Each and every other allegation of the complaint denied by claiming that it is not a case of deficiency in service. Rather, it is claimed that such type of cases are being dealt with by Raksha TPA Pvt. Ltd., and that is why papers submitted by the complainant were sent to the same. Competent doctor of Raksha TPA Pvt. Ltd after minute scrutiny of  claim of the complainant and after going through records as well as the discharge summary, submitted opinion that the claim is not payable because disease caused due to alcoholic intake.

3.                Counsel for the complainant tendered in evidence affidavit Ex.CA of complainant along with documents Ex.C1 to Ex.C12 and thereafter, closed the evidence.

4.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Sh.P.S.Makkar, Deputy Manager of Ops; affidavit Ex.RB of Dr.Rakesh Kalra, Regional Head of M/s Raksha TPA Pvt. Ltd along with documents Ex.R1 to Ex.R8 and then closed the evidence.

5.                Written arguments not submitted by any of the parties. Oral arguments alone addressed and those were heard. Records gone through minutely. 

6.                Undisputedly, the policy in question Ex.C3=Ex.R7 was purchased by the complainant from Ops for self and his wife and two sons with the validity period w.e.f.30.7.2014 to 29.7.2015. This policy is for Parivar Mediclaim, but before that complainant had been purchasing Mediclaim Hospitalization Benefit Policies for period from 30.7.2008 onwards till issue of policy in question EX.C3=Ex.R7. This is reflected by contents of Ex.C6 to Ex.C10. So, certainly the earlier policy was purchased mediclaim policy for hospitalization benefit, but now Parivar Mediclaim Policy was purchased by the complainant. The terms and conditions of the policy in question produced on record as Ex.R8. Perusal of clause 4.8 of Ex.R8 reveals that the insurance company shall not be liable to make any payment under the policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxicating drugs/alcohol. So, this exclusionary clause 4.8 of Ex.R8 provides that in case, disease contracted due to intake of intoxicating drugs/alcohol, then insurance company not liable to pay the medical claim.

7.                Bone of contention remains as to whether Ops able to prove that Acute Pancreatitis disease, for which, the complainant got treatment from Fortis Hospital resulted due to intake of alcohol by him or not? Ex.C1, Ex.C2 and Ex.C5 are the bills of expenses incurred on treatment of complainant during period from 26.8.2014 to 2.9.2014. So, certainly the treatment for Acute Pancreatitis got by the complainant during subsistence of the policy in question Ex.C3=Ex.R7.

8.             Repudiation of claim took place through letter dated 11.11.2014. Copy of the same has been placed on record as Ex.C11=Ex.R6. If in this repudiation letter, mention  made that claim not payable because of clause 4.4.6 of the      terms and conditions of the policy, but in fact the same is clause 4.8 of Ex.R8, then the same does not make any difference because detailed reasons for repudiating the claim recorded in Ex.C11=Ex.R6 to the effect that as Acute Pancreatitis disease caused due to alcoholic intake and as such, claim does not fall within the scope of the policy. Wrong mentioning of the clause in repudiation letter not enough to hold that claim rejected erroneously because inadvertent or typographical or clerical mistake liable to be ignored.

9.                In discharge summary of complainant submitted on record as Ex.C12=Ex.R2, it is specifically mentioned that Acute Pancreatitis Grade D, Non Necrotizing disease diagnosed for Etiology Alcohol Obesity Dyslipidemia. The word “Etiology” is derived from the Greek word αἰτιολογία, aitiologia. This word used for in medical and philosophical theories for referring to the study of why things occur, or even the reasons behind the way that things act. In medicine, etiology refers to the many factors coming together to cause an illness. So, use of word etiology and reference of word alcohol in Ex.C12=Ex.R2 connotes that Acute Pancreatitis disease diagnosed due to alcoholic intake by the complainant. Word Obesity connotes is a condition, where a person has accumulated so much body fat that it might have a negative effect on the health. As cause of Acute Pancreatitis Grade D found in this case through discharge summary Ex.C12=Ex.R2 due to alcoholic obesity and as such, the same enough to reflect as if the complainant was having a negative effect on his health due to alcoholic obesity. In such circumstances, report of Raksha TPA Pvt. Ltd. Ex.R3 is quite appropriate that after going through produced record, they found the ailment of Acute Pancreatitis to be caused due to alcohol intake. So, even if the complainant may not have been examined by the doctor of Raksha TPA Pvt. Ltd., but they had taken into consideration the record of discharge summary and all other documents collected by said Raksha TPA from the complainant after issue of notice Ex.R1. Obesity for alcohol has caused the disease of Acute Pancreatitis suddenly and as such, repudiation of claim is as per clause 4.8 of terms and conditions of insurance policy produced on record as Ex.R8.

10.              As cause of disease found after keeping in view the record of the discharge summary of Fortis Hospital and as such, even if there may be other causes for Acute Pancreatitis disease including that of ingested medicines or high triglyceride levels in the blood or high calcium levels in the blood or high alcohol consumption, despite that particular opinion qua this case of Raksha TPA being based on the record of discharge summary leans exclusively in favour of Ops for holding that Acute Pancreatitis disease suffered by the complainant due to alcoholic obesity i.e. heavy alcohol consumption.

11.              Affidavit Ex.RB of Dr.Rakesh Kalra, Regional Head of M/s Raksha TPA Pvt. Ltd., specifically points out to the records taken into consideration for finding the cause of the disease in question and as such, report Ex.R3 of Raksha TPA is correct, particularly when the rebuttal not adduced to show that this report is incorrect. The doctor who treated the complainant in Fortis Hospital has not been produced and nor any other expert evidence produced by the complainant to establish that Acute Pancreatitis disease caused for any reason other than that of heavy alcohol consumption. So, the repudiation of claim by keeping in view the report Ex.R3 of Raksha TPA is fully justified.

12.              After going through para no.14, 15 and 18 of ratio of case titled as National Insurance Co.Ltd. vs. Kanta Kansal and others-2009(1)CPJ-260(Rajasthan State Consumer Disputes Redressal Commission, Jaipur), it is made out that the insurance company modifies their existing mediclaim policy for incorporating the exclusionary clause 4.1 with stipulation that pre-existing disease shall be covered after four continuous claim free policy years. In view of that specific clause in the amended policy, it was held that in case the claim not stacked for four years continuously during the subsistence of the policy, then repudiation of claim on the ground of pre-existing disease not permissible. That is not the position in the case before us because here the claim repudiated not on account of pre-existing disease, but on account of surfacing of Acute Pancreatitis disease due to heavy consumption of alcohol by the complainant as per provision of clause 4.8 incorporated in Ex.R8.

13.              Therefore, as a sequel of the above discussion, complaint dismissed with no order as to costs. Copies of order be supplied to the parties free of costs as per rules.

14.                        File be indexed and consigned to record room.

 

                      (Vinod Bala)                                (G.K.Dhir)

                       Member                                          President

Announced in Open Forum

Dated:12.10.2016

Gurpreet Sharma.

 

 

 

 

                                                                                                                              

 

 

 

 

Rajesh Kumar vs. National Insurance Co.Ltd.     CC/224/01.04.2015

 

Present:       Sh.Vikram Monga, Advocate for complainant.

                   Sh.D.R.Rampal, Advocate for Ops.

 

                   Arguments heard. Vide separate detailed order of today, complaint dismissed with no order as to costs. Copies of order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Vinod Bala)                                     (G.K.Dhir)                                         Member                                             President

                                                                                      12.10.2016