By. Smt. Renimol Mathew, Member:
The complaint is filed under section 12 of the Consumer Protection Act against the opposite parties to get the claim amount with cost and compensation.
2. Brief of the complaint:- The complainant is a policy holder of the Family Health Optima Insurance issued by the first opposite party as per policy No. P/181315/01/2013/000415 commencing from 31.05.2012 to 30.05.2013 and this complainant was a policy holder from 31.05.2010 onwards. The complainant and his wife renewed the above said policy on 28.05.2012 by paying Rs.8,714/-. As per the scheme the policy covers 2 adults and floater sum insured was Rs.2,00,000/-. On 22.01.2013 the complainant admitted in Kasturba Hospital Manipal for the treatment of liver Cirrhosis and other ailments for 12 days and again he admitted in the same hospital on 12.03.2013 and treated for 4 days for the same decease. The expanse incurred for the treatment comes nearly Rs.40,000/-. The complainant demanded the treatment expense from opposite parties by submitting claim form along with Medical bills and other documents within the stipulated time. But the opposite parties repudiated the claim with the reason that (1). Diabetes mellitus and related complications specifically excluded under the schedule and (2). Alcohol related complications not covered. The doctor who treated the complainant, not stated in the claim form that the decease was due to use of Alcohol. Liver Cirrhosis can be affected to the body of any person who are not consuming alcohol. The reason stated for repudiating the claim is not sufficient and the complainant have absolute right of reimbursement. Hence the repudiation of the claim is a clear deficiency of service on the part of the opposite parties. Hence filed this complaint.
3. Notice served to opposite parties and they filed version stating that there was no deficiency of service on the part of the opposite parties as the sickness for which the complainant admitted was for an exclusion clause under the policy which is clear from the case records of the complainant. The complainant had taken Family Health Optima Insurance Policy from this Opposite Parties from 31.05.2010 to 30.05.2011 which was further renewed up to 30.05.2013 covering the complainant and his wife for a sum insured of Rs.2 lakh. The policy was issued after excluding Diabetes Mellitus for Mr. M.J.John as per the standard procedures. It is admitted that the complainant had intimated two claims numbered as 166451 & 195589. As per the claim.166451, the complainant was admitted at Kasturba Hospital, Manipal on 22.01.2013 and diagnosed cirrhosis of liver with Portal Hypertension, and underwent treatment. After discharge, the complainant submitted a completed claim form with medical bills and lab reports. The discharge summary submitted by the complainant records that he was under chronic alcoholism & in the past history column it has been recorded "reformed alcohol 2 years ago". Moreover in the last para of discharge summary ie, the course of treatment in the hospital it has been noted that the complainant had taken psychological consultation for alcoholic deaddiction. He had underwent treatment for Diabetes Mellitus also, which is a specifically excluded condition.
4. It is submitted that in claim No.195589 again the complainant was admitted in the same hospital on 12.03.2013 for the same illness & discharged on 14.03.2013.The discharge summary submitted by the complainant shows that the complainant used to consume more than 1/2 litre alcohol per day. Consumption of alcohol is the most common cause for injury to liver cells and cirrhosis. Since proximate cause of present disease is due to use of alcohol, this Opposite Parties rejected both claims based on exclusion clause No.10 of the policy which was informed to the complainant on 23.05.2013 and there is no deficiency of service from the part of them and prayed to dismiss the complaint.
5. On perusal of complaint, version and documents the Forum raised the following points for consideration:-
1. Whether there is any deficiency of service from the side of opposite parties?
2. Relief and cost.
6. Point No.1:- Complainant and opposite parties filed affidavit and examined as PW1 and OPW1 respectively. Ext.A1 to A4 documents were marked from the side of complainant. Ext.B1 to B5 documents were marked from the side of opposite parties. Ext.A1 is the Policy Schedule. Ext.A2 series are the claim repudiation letters. Ext.A3 is the Copy of Death Certificate. Ext.A4 is the Family Membership Certificate. Ext.B1 is the Authorization letter. Ext.B2 series are the Family Health Optima Insurance Plan schedule. Ext.B3 is the Discharge Summary. Ext.B4 series are also the discharge summary. Ext.B5 series are the Repudiation letters. Heard both the counsels. On going through the evidences and records the Forum found that complainant is a policy holder of opposite parties from 2010 onwards. In the Ext.A1 in pre existing disease column it is mentioned that diabetes mellitus and its related complications and any conditions contributed or aggravated by diabetes mellitus are excluded from this policy given to this complainant. That means the complainant accepted the present policy and its previous one after disclosing his pre-existing disease of Diabetes Mellitus. Opposite party again argued that as per the exclusion clause 11 of policy exclusions "the company shall not be liable to make any payments under, this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of convalescence, general debility, Run down condition or rest cure, psychosomatic disorder, congenital external disease or defects or anomalies, infertility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol”. Opposite parties admitted that the complainant had intimated two claims numbered as 166451 & 195589. As per the claim. 166451, the complainant was admitted at Kasturba Hospital, Manipal on 22/01/2013 and diagnosed cirrhosis of liver with Portal Hypertension, and underwent treatment. After discharge, the complainant submitted a completed claim form with medical bills and lab reports. The discharge summary submitted by the complainant records that he was under chronic alcoholism & in the past history column it has been recorded "reformed alcohol 2 yrs ago". Moreover in the last para of discharge summary ie, the course of treatment in the hospital it has been noted that the complainant had taken psychological consultation for alcoholic deaddiction. He had underwent treatment for Diabetes Mellitus also, which is a specifically excluded condition.
7. On perusal of Ext.B3, B4(1) and B4(2) discharge summaries the Forum found that the argument put forth by the learned counsel for the opposite parties are true. As per Repudiation letter Ext.B5(1) and B5(2) we found that opposite parties repudiated the claim of complainant of two reasons:- (1). Diabetes Mellitus and its relative complications. (2). Alcohol related complications not covered. On going through the evidences we opine that the proximate cause of present disease is due to use of alcohol and as per exclusion clause 11 of policy the company shall not be liable to make any payments under this policy in respect of expenses incurred by the insured person in connection with or in respect of use of intoxicating drugs/alcohol. Hence complainant is not entitled to get claim amount from the opposite parties. The Points are found accordingly.
In the result, the complaint is dismissed.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Forum on this the 17th day of August 2015.
Date of Filing: 24.08.2013.
PRESIDENT :Sd/-
MEMBER :Sd/- MEMBER :Sd/-
/True Copy/
Sd/-
PRESIDENT, CDRF, WAYANAD.
APPENDIX.
Witness for the complainant:-
PW1. Lal John. Complainant No.4.
Witness for the Opposite Parties:-
OPW1. Manu Mohan. Executive Officer, Claims, Star Health Insurance Co Ltd,
Thiruvananthapuram.
Exhibits for the complainant:
A1. Family Health Optima Insurance Police Schedule.
A2(a). Copy of Repudiation letter. Dt:23.05.2013.
A2(b). Copy of Repudiation letter. Dt:23.05.2013.
A3. Copy of Death Certificate.
A4. Family Membership Certificate. Dt:19.07.2014.
Exhibits for the opposite parties:-
B1. Authorization Letter. Dt:16.07.2015.
B2(1). Family Health Optima Insurance Police Schedule.
B2(2). Endorsement Schedule.
B2(3). Family Health Optima Insurance Police Schedule.
B2(4). Family Health Optima Insurance Police Schedule.
B2(1). Family Health Optima Insurance Plan.
B3. Discharge Summary.
B4(1). Discharge Summary.
B4(2). Discharge Summary.
B5(1). Repudiation letter. Dt:23.05.2013.
B5(2). Repudiation letter. Dt:23.05.2013.
Sd/-
PRESIDENT, CDRF, WAYANAD.
a/-
