DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, PALAKKAD
Dated this the 31st day of May, 2023
Present : Sri. Vinay Menon V., President
: Smt. Vidya A., Member
: Sri. Krishnankutty N.K., Member Date of Filing: 28/10/2021
CC/181/2021
Raju Menon,
S/o. Late Govindankutty Nair,
No.17, R.G. Kazi Manzil,
Mohili Village, Sakinaka, Andheri,
Mumbai – 400 072
Presently residing at
Thiruvathira, Perumkulam,
Alathur, Palakkad - Complainant
(By Adv. B. Kamal Chand)
Vs
The Authorised Signatory,
HDFC Standard Life Insurance Co.Ltd.,
13th Floor, Lodha Excelus,
Appolo Mills Compound,
NM Joshi Marg,
Mahalakshmi, Mumbai – 400 011 - Opposite party
(O.P.s by Adv. M/s. Saji Issac & Ullas Sudhakar)
O R D E R
By Sri. Vinay Menon V., President
- Lengthy pleadings, reduced to essentials portrays that the complainant was a beneficiary under a policy issued by the O.P. During the subsistence of a valid policy, the complainant was hospitalized for critical illness (Ischemic heart disease) for which there was policy cover. But the O.P. repudiated the claim on the ground the condition suffered by the complainant was not covered. Aggrieved thereby, this complaint is filed.
- The opposite party filed version admitting the existence of the policy, but defended repudiation on the ground that the conditions suffered by the complainant was not included in the 19 critical illnesses covered by the policy. There was a delay in considering the claim in view of the limited staff and functioning due to covid pandemic regulations. Repudiation was based on the terms and conditions of the policy. The complainant is not entitled to the reliefs claimed and sought for dismissal of the complaint.
- Pleadings and counter pleadings considered, the following issues were framed by this Commission.
- Whether the complainant’s disease fall within the critical illness coverage of the policy?
- Whether there is any deficiency in service or unfair trade practice on the part of the O.P. in repudiating the complainant’s claim?
3. Whether the complainant is entitled to the reliefs claimed ?
4. Reliefs as to cost and compensation?
4. (i) Evidence on the part of complainant comprised of proof affidavit and Exts. A1 to A13.
(ii) OPs also filed proof affidavit. Documents filed by opposite parties were marked as Ext.B1 to B3.
Marking of documents of opposite party was objected to on the ground they were photocopies. Since this Commission is not bound by the principles of Indian Evidence Act and that the said documents are already in the array of documents marked by the complainant, complainant’s objection is over looked.
Issue No.1
5. Pleadings and facts are not disputed. The only question that requires consideration is whether the conditions suffered by the complainant falls within the ambit of 19 critical illness covered by the policy.
6. Ext.A3 is a copy of discharge summary issued from Nanavathy Super Specialty Hospital wherein the complainant had undergone his treatment. Diagnosis of the complainant’s conditions is as follows:
ISCHEMIC HEART DISEASE – UNSTABLE ANGINA; ANTERIOR WALL ISCHEMIA; CAG (25/11/2019) ; MID LAD 100% STENOSIS;
7. Ext.A1 is the certificate of insurance alongwith policy schedule. The critical illnesses covered are shown in appendix B. The critical illnesses are
1) Cancer 2) Coronary artery bypass graft surgery
3) Heart attack 4) Kidney failure
5) Major Organ Transplant as recipient 6) Stroke
7) Apallic Syndrome 8) Benign Brain Tumor
9) Coma 10) End stage liver disease
11)End stage lung disease 12) Heart Valve surgery
13) Loss of independent existence 14) Loss of limbs
15) Loss of sight 16) Major burns
17) Major Head trauma 18) Paralysis / paraplegia
19) Surgery of Aorta
It is the case of the opposite party ischemic heart disease suffered by the complainant does not fall within the aforesaid 19 critical illness.
8. Stedman’s Medical Dictionary (28th Edition) defines Ischemia as “local loss of blood supply due to mechanical obstruction (mainly arterial narrowing or disruption) of the blood vessel”. Ischemic is defined as “relating to or affected by ischemia”. From a reading of Ext.A3 and the definition given by Stedman’s Medical Dictionary, a basic assumption that can be formed is that the complainant was suffering from narrowing of blood vessels leading to loss of blood supply. Such a condition does not find place in the 19 critical illnesses covered by Ext.A1 policy schedule.
9. Observations in paragraph 8 supra apart, it was the duty of the complainant to prove his case that his condition was one that was covered under the 19 critical illnesses by adducing cogent evidence. The complainant has not adduced evidence to prove his case.
10. Hence, we hold that complainant has failed to prove his case that ischemic heart disease falls within the meaning of critical illness as contemplated under the policy.
Issue No.2
11. In view of the conclusion in Issue No.1 we hold that there is no deficiency in service or unfair trade practice on the part of the opposite party.
Issue Nos.3 & 4
12. Resultantly, we hold that the complainant is not entitled to any of the reliefs sought for. Accordingly the complaint is dismissed.
13. In the facts and circumstances of the case, parties are directed to bear their respective costs.
Pronounced in open court on this the 31st day of May, 2023.
Sd/-
Vinay Menon V
President
Sd/-
Vidya.A
Member
Sd/- Krishnankutty N.K.
Member
APPENDIX
Exhibits marked on the side of the complainant :
Ext.A1 – Original certificate of insurance
Ext.A2 – Copy of coronary angiography report
Ext.A3 – Copy of discharge summary
Ext.A4 - Copy of communication dated 7/9/2020
Ext.A5 - Copy of member enrolment form
Ext.A6 – Copy of communication dated 15/9/2020
Ext.A7 – Printout of e mail communication dated 16/9/2020
Ext.A8 – Printout of e mail communication dated 30/11/2020
Ext.A9 – Printout of e mail communication dated 2/12/2020
Ext.A10 - Copy of e mail communication dated 4/12/2020
Ext.A11 – Copy of declaration dated 19/4/2021
Ext.A12 – Copy of repudiation letter dated 30/4/2021
Ext.A13 – Copy of communication dated 10/5/2021
Exhibits marked on the side of the opposite party:
Ext.B1 – Copy of Ext.A1
Ext.B2 – Copy of Ext.A3
Ext.B3 – Copy of Ext.A12
Court Exhibit: Nil
Third party documents: Nil
Witness examined on the side of the complainant: Nil
Witness examined on the side of the opposite party: Nil
Court Witness: Nil
NB : Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Regulation 20(5) of the Consumer Protection (Consumer Commission Procedure) Regulations, 2020 failing which they will be weeded out.
