Haryana

Ambala

CC/240/2022

Sunita Verma - Complainant(s)

Versus

New India Assurance Co Ltd. - Opp.Party(s)

Tarun Mehta

16 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	240 of 2022
Date of Institution	:	27.06.2022
Date of decision	:	16.09.2024

 

1. Sunita Verma aged about 43 years widow of late Sh. Rajesh Verma, r/o 24, Prabhu Prem Puram, Ambala Cantt-133001
2. Master Ajay Verma (minor aged about 15 years) son of late Sh.Rajesh Verma, through her mother & natural guardian Smt.Sunita Verma, r/o 24, Prabhu Prem Puram, Ambala Cantt- 133001
3. Ms. Umisha Verma (minor aged about 17 years) daughter of late Sh.Rajesh Verma, through her mother & natural guardian Smt.Sunita Verma, r/o, 24, Prabhu Prem Puram, Ambala Cantt- 133001
4. Smt. Veena Devi wife of Sh. Ramesh Chander Verma, (mother of deceased), r/o 24, Prabhu Prem Puram, Ambala Cantt-133001

          ……. Complainants

                                                Versus

1. New India Assurance Co.Ltd., D.O.: 172-C, Laxmi Niwas, Rai Market, Ambala Cantt-133001
2. Raksha Health Insurance TPA Pvt. Ltd., c/o Escorts Corporate Centre, 15/5, Mathura Road, Faridabad (Haryana)

                                                                                                    ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                    Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Tarun Mehta, Advocate, counsel for the complainants.

                     Shri Mohinder Bindal, Advocate, counsel for OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainants have filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) prayed that OPs may be directed, to pay Rs.3,00,000-00 (the sum of amount insured) out of total amount of about Rs.5,00,000-00 spent on the treatment, alongwith interest @ 12% per annum from 19.07.2021. To pay Rs.50,000-00 as compensation for the mental agony and physical harassment suffered by the complainants and Rs.10,000/-, as litigation expenses.  

2.             Brief facts of the case are that the complainant No.1 (Customer Id: PO50177179) got New India Floater Mediclaim Policy No.35350034212800000024 for her family w.e.f 19.05.2021 to 18.05.2022 from OP No.1 by renewal of Previous Policy No.35350034202800000024 w.e.f 19.05.2020 to 18.05.2021 for a sum of Rs.200000-00 with Cumulative bonus of Rs. 100000-00. As per the Medi-claim policy, OP No.1 undertook that if during the period of continuance of the validity of the policy, the insured i.e. family of Complainant No.1 consisting of her spouse late Rajesh Verma, complainant No.1 to complainant No.3 shall contract any disease or suffers from any illness or sustain any bodily injury etc. the company will indemnify the loss suffered by the insured. The deceased Rajesh Kumar was running his own business of manufacturing of corrugated boxes in the name 7 style as M/S R.K.Packaging and was earning more than Rs.35,000-00 per month from the business. The family of the deceased late Rajesh Verma son of Sh.Ramesh Verma, consists of complainant No.1 to 4 being his wife, son, daughter and mother who were dependent upon him. In  the 2nd week of May' 2021, the husband of complainant No.1 Rajesh Verma s/o Ramesh Chander Verma aged about 48 years having DOB:06.11.73, г/о 24, Prabhu Prem Puram, Ambala Cantt suffered health problem by having fever, body-ache & sore throat with cough which increased within 2/3 days despite taking home remedies and rest. Then on 15.05.2021, when Covid Pandemic was on its peak in the country and from the sample collected on 15.05.2021, he was found Covid positive on 16.05.2021 and he did not recover which was getting aggravated despite treatment & medication. Therefore he was admitted in higher institution Mukut Hospital & Heart Institute, SCO 47-49, Sector 34A, Chandigarh on 22.06.21 for management, then on 25.06.21 at Jagadhri Medical Centre, Jagadhri and on 26.06.21 then in Civil hospital Ambala Cantt but seeing his precarious condition, he was Referred to PGI, Chandigarh where he was admitted on 27.06.21 and again in EMOPD on 18.07.21 vide C.R.No.202102397929. However, on 19.07.2021 due to complications precipitated/manifested on account of Covid he died in Emergency OPD of PGI, Chandigarh. The deceased remained in the hospital and home from 16.05.2021 to 19.07.2021 with follow up advise regularly which he had been adhering to till he died. The complainant No. 1 as per policy lodged the claim for reimbursement of the amount spent by her and family submitted the entire documents required for payment of the claim but the payment was not made. The complainant No.1 had been requesting the OPs for settlement of the claim but the claim was not settled and paid nor any information was given. Since, the concerned persons/officials of OP No.1 were not listening to her helplessness to settle her claim, for 10-11 months, despite the fact that the complainants completed all the formalities for indemnifying the complainants w.r.t. the expenses incurred by the complainants for treatment and there was no impediment for the grant of the same but for some extraneous reason the claim of the complainant has not been settled. Feeling aggrieved a legal notice dated 20.04.2022 was served upon the OPs No.1 & 2 reminding them for payment of her claim amount but to no avail. Only from the response to the said legal notice, Sh.Shiv Bhalla, Advocate Faridabad on behalf both the OPs vide reply dated 05.05.2022 conveyed that the medi-claim of the deceased was denied on account of 'Encephalopathy, unspecified and admission in the Jagadhri Medical Centre, Jagadhri under clause No.4.4.6.1 as per the policy terms and conditions of the company', which was the first and the last information given to the counsel of the complainants by the OPs and it was absolutely frivolous ground contrary to the record and the health problem encountered by the deceased Rajesh Verma. However in somersault, Sh.Mohinder Bindal, Advocate Ambala on behalf of OP No.1 vide reply dated 12.05.2022 in response to legal notice conveyed that the medi-claim of the deceased was denied on account of 'exclusion clause 4.4.6.1 which says that 'Convalescence, general debility, run down condition or rest cure..... illness or injury caused by the use of intoxicating drugs/alcohol rejected by TPA', whereas TPA has entirely different reasons. This clearly shows frivolous ground contrary to the record and the health problem encountered by the deceased Rajesh Verma. Thus, a unilateral decision by the insurance Co. conveying rejection of claim vide their letter dated 05.05.2022 & 12.05.2022 by two advocates for frivolous reason is absolutely wrong. The insured did not had any problem till 2nd week of May 2021. The disease manifested only on 16.05.2021, which was diagnosed and treated and there was no indication of it at all before that. By not paying the genuine claim, the OPs have committed deficiency in service. Hence the present complaint.
3.           Upon notice, OPs appeared and filed written version raising preliminary objection to the effect that the complaint is not maintainable; the complainants have not approached this Commission with clean hands and has suppressed the material facts;   the present complaint is ex-facie misconceived, vexatious, untenable and devoid of any merit; the present complaint has been filed without any cause of action etc.  On merits, it has been stated that all the claims under the Health Insurance Policies related to OP no. 1 are being entertained and processed by an independent and IRDA approved agency consisting of medical experts namely M/S Raksha Health Insurance TPA Pvt. Ltd., the OP no. 2, on behalf of OP no. 1-that has been authorized to deal with such claims independently and the payments are made only as per their approval, recommendations and assessment. It is not out of place to mention here that the entire medi-claims are independently being processed and approved by such TPA companies on behalf of all the insurance companies being team of specialized doctors to deal with such claims. In the present case, the request/claim under the instant policy was received from the complainant sand the claim alongwith submitted papers was forwarded to the Raksha TPA to deal and process against the alleged treatment undergone by the insured Late Sh. Rajesh Verma at Mukut Hospital, Chandigarh, Jagadhari Medical Centre, Jagadhari, PGI, Chandigarh and Civil Hospital, Ambala Cantt where he remained under treatment in a very casual manner leaving one hospital after another on dally basis that too against medical advice of the concerned hospitals. Since as per the treatment record/papers submitted and availed from the said hospital, said patient Sh. Rajesh Verma was diagnosed and treated for Hepatic Parenchymal Disease, Chronic Liver Disease and as per the case summary not for the corona as alleged and it was found that patient Sh. Rajesh Verma was chronic alcoholic leading to his chronic liver disease. As per the policy conditions, treatment of diseases with alcohol etiology are not covered hence not payable, therefore, the claim in question was held non payable as per exclusion clause 4.4.6.1 which says that "Convalescence, general debility, run down condition or rest cure.................. Illness or injury caused by the use of intoxicating drugs/alcohol" are not payable, so after pursuing the treatment record, the said claim was denied and rejected by the said TPA with necessary information vide their letter dated 08.09.2021. The insurance policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainants have accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. Upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy; its terms have to be strictly construed to determine the extent of liability of the insurer. It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy. It is a matter of contract and in terms of the contract, the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance, they have to rely on the terms of the contract. Hence, the Insurance Company and the Insured are to follow all terms and conditions of the Insurance Policy correctly. The complainants although being very much aware about the fate of their claim due to concealment of necessary information, misrepresentation and his alcohol related ailment has filed this false and frivolous complaint by exploiting the process of law in order to put undue pressure; hence the present complaint deserves dismissal. Rest of the averments of the complainants were denied by the OPs and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainants tendered affidavit of the complainant no.1 as Annexure C-A alongwith documents as Annexure C-1 to C-18 and closed the evidence on behalf of the complainants. On the other hand, learned counsel for the OPs tendered affidavit of Mona Bagga, Sr. Divisional Manager/Authorized Signatory of OPs Company- The New India Assurance Company Limited, Ambala Cantt. as Annexure OP-A alongwith documents as Annexure OP-1 to OP-8 & OP1/A  and closed evidence on behalf of the OPs.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainants submitted that despite the fact that the treatment of corona was taken by the insured, under subsistence of the policy in question and he died because of corona, yet, by repudiating the genuine claim of the complainants filed by them, legal heir of the deceased insured, on all together different ground, the OPs are deficient in providing service. 
7.           On the contrary, learned counsel for the OP No.1 submitted that since as per the treatment record/papers submitted and availed from the said hospital, Sh. Rajesh Verma was diagnosed and treated for Hepatic Parenchymal Disease, Chronic Liver Disease and as per the case summary not for the corona as alleged and it was found that patient Sh. Rajesh Verma was chronic alcoholic leading to his chronic liver disease. He further submitted that under these circumstances, the claim of the complainants was rightly repudiated by OP No.1, strictly as per terms and conditions of the policy in question, as such, the OPs are neither deficient in providing service nor adopted any unfair trade practice.
8.           Since, neither the issuance of the policy in question by OPs as per details given in the complaint by the complainants; nor the fact that the insured had died in the PGIMER, Chandigarh; nor the fact that claim filed by the complainants have been repudiated by the OPs vide letter dated 08.09.2021, Annexure OP-2 are in dispute, as such, the only moot question which falls for consideration is, as to whether,  the OPs were justified in rejecting the claim or not. It may be stated here that the claim in question has been repudiated by the OPs, by placing reliance on clause 4.4.6.1 of the insurance policy, Annexure OP1/A, which reads as under:-

“….4.4.6.1 Convalescence, general debility, 'Run-down' condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, Venereal disease, intentional self-injury and Illness or Injury caused by the use of intoxicating drugs/alcohol…..”

 

9.           Under above circumstances, this Commission has to find now, as to whether, the insured had died because of COVID-19 or because of some other disease or with chronic liver disease i.e. ALD (Alcohol-associated liver disease) as alleged by the OPs. It is significant to mention here that Alcohol-associated liver disease (ALD) represents a spectrum of liver injury resulting from alcohol use, ranging from hepatic steatosis to more advanced forms. ALD is a type of liver disease caused by chronic heavy alcohol consumption. From the death certificate of the insured, Annexure C-9 having been issued by the PGIMER, Chandigarh, the immediate cause of death has been mentioned as Refractory Septic Shock with antecedent cause-Decompenstated Chronic Liver Disease with Acute Kidney Injury-Left Lower Limb Cellulitis. However, before the treatment taken by the insured in the PGIMER, Chandigarh, he has also got treatment in Civil Hospital, Ambala vide CR No.8225, Annexure C-5 starting from 28.06.2021, he was found to be suffering from ALD also. Under these circumstances, a conjoint reading of day care admission file issued by Civil Hospital, Ambala Annexure C-5 and also medical certificate of cause of death of the insured, Annexure C-9 having been issued by the PGIMER, Chandigarh, it can easily be said that it was due to ALD with which the insured was suffering from that he died because of Decompenstated Chronic Liver Disease with Acute Kidney Injury-Left Lower Limb Cellulitis i.e. Injury caused by the use of intoxicating drugs/alcohol and as such, the same attracts the exclusion clause 4.4.6.1  of the policy in question.  At the same time, the complainants have failed to place on record any evidence to prove that the insured had taken treatment for COVID-19 and died thereof.  Our this view is supported by the ratio of law laid down by the Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) wherein it was held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”. In this view of the matter, the OPs have rightly rejected the claim filed by the complainants, by placing reliance on clause 4.4.6.1 of the insurance policy
10.           In view of peculiar facts and circumstances of this case, it is held that because the complainants have failed to prove their case, therefore, no relief can be given to them.  Resultantly, this complaint stands dismissed with no order as to cost. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.

  Announced:- 16.09.2024                    

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President