Tamil Nadu

South Chennai

CC/444/2015

M/s.K.R.krishnan - Complainant(s)

Versus

Royal Sundaram., Alliance Insurance Co ltd - Opp.Party(s)

05 Nov 2019

ORDER

                                                                               Date of filing      : 19.11.2015

                                                                               Date of Disposal : 05.11.2019

                                                                                  

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, CHENNAI (SOUTH)

@ 2^ND Floor, T.N.P.S.C. Road, V.O.C. Nagar, Park Town, Chennai – 3.

 

PRESENT: THIRU. M. MONY, B.Sc., L.L.B, M.L.                    : PRESIDENT

TR. R. BASKARKUMARAVEL, B.Sc., L.L.M., BPT., PGDCLP.  : MEMBER

 

C.C. No.444/2015

DATED THIS TUESDAY THE 05^TH DAY OF NOVEMBER 2019

                                 

K.R. Krishnan,

S/o. Mr. K. Rangachari,

“Devinarayans Apartments”,

No.94, Karpagam Avenue,

R.A. Puram,

Chennai – 600 028.                                                        .. Complainant.

                                                                                                ..Versus..

 

1. Royal Sundaram Alliance Insurance Co. Ltd.,

Represented by its Manager,

No.21, Patullos Road,

Chennai – 600 002.

 

2. Paramount Health Services (TPA) Pvt. Ltd.,

Represented by its Manager,

No.442, Road No.28, MIDC Industrial Area,

Wagale Estate Ramnagar,

Vithal Rukmani Mandir,

Thane (West),

Mumbai.                                                                 ..  Opposite parties.

 

Counsel for the complainant           : Mr. S. Natarajan

Counsel for the 1^st opposite party  : M/s. M.B. Gopalan & others

2^nd opposite party                           : Ex-parte

 

ORDER

THIRU. M. MONY, PRESIDENT

       This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act, 1986 prays to refund a sum of Rs.2,29,700/- being expenses incurred for such hospitalization and treatment besides other charges and to pay a sum of Rs.10,00,000/- towards compensation for deficiency in service, mental agony and pain with cost of Rs.30,000/- to the complainant.

1.    The averments of the complaint in brief are as follows:-

The complainant submits that he is a policy holder of Health Shield Insurance Policy bearing Policy No.HOE0005501000101 with the 1^st opposite party from 2011 onwards.  The complainant submits that the said policy was renewed from time to time periodically for the period from 19.02.2015 to 18.02.2016.  The said medical claim policy of the complainant covers the family members also.  On 30.04.2015, the complainant went to Kauvery Hospital, Mylapore, Chennai with a complaint of pain in abdomen.   After due diagnosis and several test it was traced out that Upper G1 bleed, Esophangeal varices grade III with rcs, 4 columns of Eso varices banded, Type II diabetes mellitus DKA, Chronic liver disease with Portal hypertension and Systematic hypertension not resulting from alcoholism. The complainant was treated symptomatically with antibiotics, analgesics, beta blockers and other supportive medication.  The complainant made claim for cashless policy with the opposite parties and was denied on 03.05.2015 by the 2^nd opposite party.  After due recovery, the complainant was discharged from the hospital on 08.05.2015.   The complainant made a claim for a sum of Rs.2,29,700/- on 27.07.2015 which was repudiated by the 1^st opposite party on 26.08.2015 stating that

“The company shall not be liable under this policy for any claim in respect of:  Use of intoxicating drugs, alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from or related to such abuse or addiction”.

2.     The complainant submits that the clause in policy excludes only treatment for de-addiction and not otherwise as stated by the 2^nd opposite party.  The complainant was shocked by the denial of entire claim made had informed the opposite party that his claim cannot summarily repudiated under exclusion clause.  The opposite parties clutching at imaginary straw, repudiated the genuine claim, without any basis.  The act of the opposite parties amounts to deficiency in service and unfair trade practice which caused great mental agony.  Hence, the complaint is filed.

3.      The brief averments in the written version filed by 1^st opposite party is as follows:

The 1^st opposite party specifically denies each and every allegation made in the complaint and put the complainant to strict proof of the same.    The 1^st opposite party states that admittedly, the complainant availed Health Shield Standard Policy for the period commencing from 19.02.2015 to 18.02.2016 subject to terms and conditions.  The complainant claimed to have been hospitalized from 30.04.2015 to 08.05.2015.  The 1^st opposite party states that the complainant is a known case of Liver Cirrhosis 5 years ago, he also took medicine for the same for 6 months and stopped, Chronic Alcoholic – stopped 5 years back, Tobacco chewer.   The 1^st opposite party states that it can be evidenced from the internal case papers that the complainant is a chronic alcoholic patient.  The 1^st opposite party states that as per the exclusion clause 22 the alcoholism is excluded.  There by, the 1^st opposite party has rightly repudiated the claim.  Therefore, there is no deficiency in service on the part of the 1^st opposite party and the complaint as against the 1^st opposite party is liable to be dismissed.

4.     Inspite of receipt of notice, the 2^nd opposite party has not appeared before this Forum and hence, the 2^nd opposite party is set ex-parte.

5.     To prove the averments in the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A6 are marked.  Proof affidavit of the 1^st opposite party is filed and documents Ex.B1 to Ex.B7 are marked on the side of the 1^st opposite party.  

6.      The points for consideration is:-

1. Whether the complainant is entitled to get refund of a sum of Rs.2,29,700/- expended towards hospitalization and treatment as prayed for?
2. Whether the complainant is entitled to a sum of Rs.10,00,000/- towards compensation for deficiency in service, mental agony and financial suffering etc with cost of Rs.30,000/- as prayed for?

 

7.      On point:-

The 2^nd opposite party after due service of notice not appeared in this Forum and filed in written version and hence, the 2^nd opposite party set    ex-parte.   The 1^st opposite party filed written arguments.  The complainant has not filed any written argument and not turned up to advance any oral argument also.   Heard the 1^st opposite party’s Counsel.  Perused the records namely; the complaint, written version, proof affidavits and documents.  The complainant pleaded and contended that he is a policy holder of Health Shield Insurance Policy bearing Policy No.HOE0005501000101 with the 1^st opposite party from 2011 onwards.   It was not denied.  Further the contention of the complainant is that the said policy was renewed from time to time periodically for the period from 19.02.2015 to 18.02.2016 as per Ex.A1.   The said medical claim policy of the complainant covers the family members also.  On 30.04.2015, the complainant went to Kauvery Hospital, Mylapore, Chennai with a complaint of pain in abdomen.   After due diagnosis and several test it was traced out that Upper G1 bleed, Esophangeal varices grade III with rcs, 4 columns of Eso varices banded, Type II diabetes mellitus DKA, Chronic liver disease with port hypertension and Systematic hypertension as per Ex.A2, Discharge Summary.  The complainant was treated symptomatically with antibiotics, analgesics, beta blockers and other supportive medication.  The complainant made claim for cashless facility with the opposite parties and was denied on 03.05.2015 by the 2^nd opposite party.  After due recovery, the complainant was discharged from the hospital on 08.05.2015.   The complainant made a claim for a sum of Rs.2,29,700/- on 27.07.2015 as per Ex.A4 which was repudiated by the 1^st opposite party on 26.08.2015 as per Ex.A5 stating that

“The company shall not be liable under this policy for any claim in respect of usage of intoxicating drugs, alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from or related to such abuse or addiction”.

8.     Further the complainant contended that the said repudiation is bad in law.  The complainant undergone various treatment as per the terms and conditions of the policy which excludes only treatment for addiction and not otherwise.  The denial of claim and repudiation is arbitrary.  On a careful perusal of Ex.B1, terms and conditions of the policy which reads as follows:-

D. EXCLUSION

3(b) 22. “Use of intoxicating drugs alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from, or related to, such abuse or addiction”

proves that the said exclusion clause is not applicable in the complainant’s case.  Because as per Discharge Summary, Ex.A2 there is nothing about alcoholism proves the deficiency in service on the part of the opposite parties.  

9.     Further it is also seen from the documents filed by the opposite party that in Ex.B4 it is very clear that

a. “The complainant is a known case of Liver Cirrhosis 5 years ago, he also took medicine for the same for 6 months and stopped.

b. Chronic Alcoholic – stopped 5 years back

c. Tobacco chewer”

shall not attract the exclusion clause as per the policy since the policy is actually from 2011  onwards.

 Further the contention of the complainant is that the complainant has expended a sum of Rs.2,29,700/- towards hospitalization and medical expenses as per Ex.A2 and compensation.

10.    The learned Counsel for the 1^st opposite party would contend that admittedly the complainant availed Health Shield Standard Policy for the period commencing from 19.02.2015 to 18.02.2016 subject to terms and conditions as per Ex.B1.  The complainant claimed to have been hospitalized from 30.04.2015 to 08.05.2015 as per Ex.B2.  On a careful scrutiny of medical documents and internal case papers submitted by the complainant it was primarily observed from the Discharge Summary that the complainant is known case liver Cirrhosis as per Ex.B3.   Further the contention of the 1^st opposite party is that the complainant is a known case of Liver Cirrhosis 5 years ago, he also took medicine for the same for 6 months and stopped, Chronic Alcoholic – stopped 5 years back, Tobacco chewer as per Ex.B4.   On a careful perusal of Ex.B5, ‘Cross Consultation Sheet’ from the hospital wherein the complainant took treatment shows that the complainant is a known case of liver Cirrhosis. 

11.    Further the contention of the 1^st opposite party is that it can be evidenced from Ex.B6 that the complainant is a chronic alcoholic patient.  But it is very clear from the Discharge Summary that the complainant consumed the Alcohol 5 years back.   As per the policy, the exclusion is only for 2 years.  Further the contention of the 1^st opposite party is that as per the exclusion clause 22 the alcoholism is excluded.  There by, the 1^st opposite party has rightly repudiated the claim as per Ex.B7.   But as per the exclusion class the alcoholism is exempted for 2 years.  As per Ex.A2, Discharge Summary and Ex.B4, it is very clear that

a. “The complainant is a known case of Liver Cirrhosis 5 years ago, he also took medicine for the same for 6 months and stopped.

b. Chronic Alcoholic – stopped 5 years back

c. Tobacco chewer”

proves the exclusion clause is not applicable in this case.   Considering the facts and circumstances of the case, this Forum is of the considered view that the opposite parties 1 & 2 are jointly and severally shall pay a sum of Rs.2,29,700/- and a sum of Rs.30,000/- towards compensation for mental agony with cost of Rs.10,000/- to the complainant.

In the result, this complaint is allowed in part.  The  opposite parties 1 & 2 are jointly and severally are directed to refund a sum of Rs.2,29,700/- (Rupees Two lakhs twenty nine thousand and seven hundred only) and to pay a sum of Rs.30,000/-  (Rupees Thirty thousand only) towards compensation for mental agony with cost of Rs.10,000/- (Rupees Ten thousand only) to the complainant.

The aboveamounts shall be payablewithin six weeks from the date of receipt of the copy of this order, failing which, the said amounts shall carry interest at the rate of 9% p.a. to till the date of payment.

Dictated  by the President to the Steno-typist, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the 05^th day of November 2019. 

 

MEMBER                                                                                PRESIDENT

 

COMPLAINANT SIDE DOCUMENTS:-

Ex.A1	19.02.2015	Copy of mediclaim policy with annexures
Ex.A2	08.05.2015	Copy of discharge summary and bill
Ex.A3	03.05.2015	Copy of letter of the 2nd opposite party
Ex.A4	27.07.2015	Copy of claim details
Ex.A5	26.08.2015	Copy of repudiation letter
Ex.A6		Copy of renewal details

 

 

1^ST OPPOSITE PARTY SIDE DOCUMENTS:-  

Ex.B1		Copy of Health Shield Insurance Policy with terms and conditions
Ex.B2	06.07.2015	Copy of Claim Form
Ex.B3		Copy of discharge summary
Ex.B4	30.04.2015	Copy of Doctors Oder – case sheet of the complainant from the treated hospital
Ex.B5	04.05.2015	Copy of cross consultation sheet of the complainant form the treated hospital
Ex.B6	30.04.2015 to 08.05.2015	Copy of internal case papers of the complainant
Ex.B7	26.08.2015	Copy of repudiation letter

 

 

 

MEMBER                                                                                                                                                PRESIDENT