DISTRICT CONSUMER DISPUTES REDRESSAL FORUM  PALAKKAD

Dated this the  30^th   day of August 2017

Present   : Smt.Shiny.P.R. President

               : Smt.Suma.K.P.  Member                                 Date of filing:  03/01/2017

               : Sri.V.P.Anantha Narayanan, Member

                                                      (C.C.No.08/2017)         

1.  P.Venugoalan

2.  M.A.Girija Devi,

     Residing at Devi Anjana, F-4,

     Thulasi Apartments,                                           -        Complainant

     Coimbatore Bye Pass Road,

     Kalpathy Po, 678 003.

(Adv.K.Lakshminarayanan)

 V/s

1.  Authorized signatory,

     Royal Sundaram Alliance Insurance                     -       Opposite party

     Company Limited, 21, Pattuloss Road, Chennai  

     600 002.     

 (Adv.P.Prasad)

O R D E R

By Smt.Suma.K.P. Member,

The complainants are insured person under the policy No. HSP0001051000107 issued by the opposite party for the period from 21.08.2005 to 20.08.2016.  The 2^nd applicant had suffered a heart problem and referred by his family doctor Shri.Ramaswami, Sai Nursing home for better treatment to Thankam Hospital.  On investigation it is found that the complainant is having Cardiac problem and the doctors advised to undergo angiogram.  They confirmed that there is a block in the heart and had advised to undergo treatment for the same.  As per the advice of the doctor the complainant was hospitalised and necessary treatments were taken.  Later he was relieved with advice to continue treatment and complete bed rest.  Since the applicants has mediclaim under the above said policy under the opposite party they preferred a claim for reimbursement as per the terms and conditions in the policy.  The said claim was rejected by the opposite party as per the letter dated. 16.11.2015. The reason stated for the same is that the complainant is a chronic smoker.  The complainant submits that there is no findings by the doctor that this is the reason for the Cardiac problem and he is not a chronic smoker as stated by the opposite party.  The rejection stating that since he is using tobacco, and that is the cause of heart problem and so the company is not liable, cannot be accepted.  This is not a condition stated in the policy.  Further the rejection of the claim is illegal and against the terms and conditions in the policy which amounts to deficiency in service.  The complaint further submits that they are entitled to get reimbursement of the total amount spent for the treatment along with compensation for the mental agony suffered by them and for the deficiency in service on the part of the opposite party.  Hence the complainant had approached before the Forum, seeking an order directing the opposite party to pay a sum of Rs.1,50,000/- towards the medical expenses and compensation towards the deficiency in service along with cost of this complaint. 

Opposite party contended that the claim of the complainant was rightly repudiated by the opposite party, being a clearly named exclusion under the policy.  It was submitted that on perusal of the claim records, it was found that the first complainant was a chronic smoker and that the present ailment for which the 1^st complainant was hospitalized was heart condition which is a named exclusion as per the policy terms and conditions for tobacco abuse.  The same was also recorded in the indoor case papers of the 1^st complainant obtained from the hospital records.   Since the 1^st complainant being a chronic smoker which falls under the definition of tobacco abuse, the ailment of the complainant mainly heart disease, clearly falls within the scope of the policy exclusion No.24.  In the claim repudiation letter dated. 16.11.2015 sent to the complainant, it is clearly stated and explained about the nature of the policy exclusion with respect to the prior smoking history of the 1^st complainant.  The insurance being a contract of indemnity subject to the terms and conditions of the policy, the liability of the insurer has to be strictly construed, the terms binding both the insurer and the insured.  The opposite party has acted within the scope of the policy terms and condition, and the position of law in repudiation and hence there is no deficiency of service or unfair trade practice.  Therefore the complaint has to be dismissed. 

Complainant filed chief affidavit.  Opposite party also filed chief affidavit along with documents.  Exts. A1 to A3 was marked from the side of the complainant.  Exts. B1 to B5 were marked from the side of the opposite party.  Evidence was closed and the matter was heard. 

The following issues that arise for consideration are.

1.Whether there is any deficiency of service from the part of opposite parties ?

2.If so what are the relief and cost?

Issues 1 & 2

          According to the opposite party the insurance being a contract of indemnity has to be construed strictly as per the policy terms and conditions.  The complainant was a chronic smoker and that the ailment for which the complainant was hospitalized was chest pain (Heart condition) and the discharge summary (Exts.B3 & B4) reveals smoking and shows that he is a chronic smoker.  The complainant being a chronic smoker which falls under the definition of tobacco abuse, the ailment of the complainant, heart disease clearly falls within the scope of the policy exclusion No.24 of the policy condition.  All type of premalignant conditions such as cancer, oral cancer, cancer of esophagus, Stomach, Kidney are all due to tobacco abuse only.  Hence there is no deficiency of service on the part of the opposite party. 

          According to the complainant there is no finding by the doctor that this is the reason for the cardiac problem.  The complainant is not a chronic smoker as stated by the opposite party.  It is true that the complainant used to smoke occasionally.  The rejection stating that since the use of tobacco is the cause of heart problem so the opposite party is not liable cannot be accepted because cardiac problem may occur due to so many other reason other than the tobacco use.  There are no evidences or documents before the opposite party to come to the conclusion that the cause of cardiac problem is due to use of tobacco.  More over this is not a condition stated in the policy.  Heart Blocks are due to cholesterol as known to everybody and tobacco will not cause cholesterol.  None of the records produced by the opposite party will prove their contentions.  Complainant has also contended that the opposite party was not justified in repudiating the claim on the ground that the heart problem suffered by the complainant was caused by the habit of smoking.  There is no merit in this contentions.  Smoking is a common habit and it is not necessary that a person having such a habit would always suffer a heart problem.  Therefore, the argument advanced by the opposite party is farfetched and is liable to be rejected. 

          In view of the above discussion, it is clear that the opposite party has committed a grave error in repudiating the genuine claim of the complainant on unreasonable grounds.  Hence the complaint is allowed and we direct the opposite party to pay an amount of Rs.57,000/- (Rupees fifty seven thousand only) being the amount spend for medical expenses along with Rs.10,000/- (Rupees ten thousand only) as compensation for the mental agony suffered due to the deficiency of service and unfair trade practice by the opposite party.  We also direct the opposite party to pay Rs.3,000/- (Rupees three thousand only) as cost of this litigation.     

          The afore said amount shall be paid within one month from the date of receipts of this order failing which complainant will be entitled to realize interest at the rate of 9% p.a from the date of order till realization. 

Pronounced in the open court on this the 30^th   day of August 2017.

                                                                                         Sd/-

                      Shiny.P.R.

                      President 

                          Sd/-

                      Suma.K.P.

                      Member

                          Sd/-

    V.P.Anantha Narayanan

                    Member

Appendix

Exhibits marked on the side of complainant

Ext.A1  -  Photo copy of Discharge Summary of the complainant issued by Thankam

               Hospital, Palakkad dated. 06.10.2015

Ext.A2   –  Photo Copy of the medical bills of the complainant issued by Thankam

                Hospital, Palakkad dated. 06.10.2015

Ext.A3   –  Repudiation letter dated. 16.11.2015 issued by the opposite party to the

               Complainant

Exhibits marked on the side of Opposite parties

Ext. B1         - Medical Insurance Policy Certificate of Insurance issued by opposite party

Ext.B2 - Health Insurance Claim Form Issued by the opposite party dated.13.10.2015

Ext.B3 -  Discharge Summary of the Complainant issued by Thankam Hospital, Palakkad

Ext.B4 - Indoor case papers of the complainant

Ext.B5 - Repudiation letter issued by the opposite party to the complainant

Witness examined on the side of complainant

Nil

Witness examined on the side of opposite party

Cost :  

          Rs. 3,000/-