Tamil Nadu

South Chennai

CC/104/2021

Mr.R.A.Saravana Prakash - Complainant(s)

Versus

The Geneal Manager, United India Insurance Co.Ld., and another - Opp.Party(s)

A.Vinoth Raj

29 May 2023

ORDER

                                                       Date of Complaint Filed:22.02.2021

                                                       Date of Reservation     :03.05.2023

                                                       Date of Order              :29.05.2023

          DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,

CHENNAI (SOUTH), CHENNAI-3.

 

PRESENT: TMT. B. JIJAA, M.L.,                                          : PRESIDENT

                    THIRU. T.R. SIVAKUMHAR, B.A., B.L.,          :  MEMBER  I 

                   THIRU. S. NANDAGOPALAN., B.Sc., MBA.,    : MEMBER II

               

CONSUMER COMPLAINT No.104/2021

MONDAY, THE 29^th DAY OF MAY 2023

Mr. Saravana Prakash,

S/o, late Arul Prakash,

No 37,2^nd Block,

Maansarovar Raaja Apartments,

Arcot Road, Porur,

Chennai-600 116.                                                    .. Complainant.

-Vs-

1. The General Manager,

United India Insurance Co. Ltd,

IBA Cell, Vulcan Insurance Building,

77, Veer Nariman Road,

Mumbai-400 020.

 

2.The Manager,

United India Insurance Co. Ltd,

Corporate & Head Office,

24, Whites Road,

Chennai-600 014.

 

3. The Chairman,

 Indian Bank's Association,

HRD Department,

 Corporate Office,

 No.4, Sardarpatel Road,

Guindy, Chennai-600032.                                        .. Opposite Parties.

 

* * * * *

 

Counsel for the Complainant   : M/s.A. Vinoth Raj, M. Gunasekaran

 

Counsel for  1^st & 2^nd Opposite Parties  : M/s. S. Dhakshnamoorthy

 

Counsel for the 3^rd Opposite Party: Exparte on 23.08.2022

 

On perusal of records and upon hearing the oral arguments of the counsel for Complainant and the counsel for the Opposite Parties 1 and 2, this Commission delivered the following:

ORDER

Pronounced by the President Tmt. B. Jijaa, M.L.,

(i)     The Complainant has filed this complaint as against the Opposite Parties under section 35 of the Consumer Protection Act, 2019 and prays to direct the Opposite Parties to pay the Mediclaim of Rs.9,00,000/- with subsequent interest @18% p.a from the date of claim, apart from awarding Rs.2,00,000/- towards compensation for mental agony caused by the unethical repudiation of insurance claim by the Opposite Parties to the Complainant along with cost.

I.  The averments of Complaint in brief are as follows:-

1.     The Complainant submitted that his father Mr.R.Arul Prakasam had taken a Mediclaim Policy No.500100/28/18/P111/682975 issued by the Opposite Parties.   Due to his ill-ness, the Complainant's father was admitted in the Apollo Hospital and was given treatment as an inpatient on 20.02.2019. Then he was referred to PSG Hospitals at Coimbatore on 22.02.2019 from Apollo Hospital, for Cirrohsis treatment, diagnosed and discharged in good condition on 26.02.2019.

2.     In the above said circumstance, as he was again indisposed on 04.03.2019, he was admitted in Apollo Hospitals at Greams Road, Chennai and diagnosed till 07.03.2019 and discharged in good condition. Due to hematemesis, he was again admitted to Apollo Hospitals at Greams road, Chennai on 08.03.2019 and got treatment as an inpatient till 16.03.2019. For further treatment, he was shifted to Sri Ramachandra Hospital Medical Centre at Porur on 16.03.2019 and got treatment as an inpatient till 24.03.2019. Unfortunately, he died in the hospital on 24.03.2019.

3.     The death summary issued by the above hospital shows that the patient is a known case of DCLD, ETOH, hematemesis, variceals/p EVL and sepsis.Since the Complainant had spent Rs. 16,92,362/- towards the treatment of his father, he claimed the insured amount under the policy by producing all the relevant Bills issued by the respective hospitals. Unfortunately, the 1^stOpposite Party had, vide his communication dated 13.05.2019, chosen to repudiate the claim made by the Complainant by citing clause 4.5 of the policy terms and conditions. The narration given by him showed that the 1^st Opposite Party had assumed that the Complainant's father Mr. Arul Prakasam was an alcoholic and he died chronic liver disease caused by his alcohol consumption.

4.     Having received the communication of the 1^stOpposite Party, the Complainant had sent a mail on 28.06.2020 refuting the illogical repudiation of insurance claim and explaining the causes for the death of his father and sought reimbursement under the insurance policy. However, the 1st Opposite Party had not chosen to respond to the mail.

5.     Hence the Complainant had instructed his counsel in the 3^rdweek of March, 2020 to issue a legal notice and to file a complaint before the Consumer Forum. Unfortunately, the Opposite Parties, who received the above notice, had not chosen to make any reply to the above notice as well.

Hence the compliant.

 

II. Written Version filed by the 1^st and 2^nd Opposite Parties in brief are as follows:

6.     The Opposite Party issued a group Mediclaim policy to Indian Banks Association A/C: Lakshmi Vilas Bank under which Complainant's father as an retired employee was covered. The Sum Insured under the said Policy No. 5001002818P111682975 is Rs.4,00,000/- for retired officers and Rs.3,00,000/- for retired employees.

7.     As per the treatment documents the patient was suffering from alcohol related chronic liver ailment. It is evident from the Discharge summary which explicitly states that the patient is diagnosed with “Ethanol Related Decompensated Liver Disease”. Hence the claims were repudiated as per Clause 4.5 of the Exclusion Clause under the Policy terms and conditions.

8.     The Complainant himself has explicitly conceded that the deceased(Complainant's father) was a known case of Decompensated chronic liver disease (DCLD) and EtOH (EtOH stands for ethyl alcohol or ethanol). It is submitted that even the discharge summaries of the Hospital shows that the deceased was diagnosed with “ETHANOL RELATED DCLD". Hence by the medical records, it can be clearly seen that the entire treatment related to the complications in the Liver solely caused due to alcohol consumption by the deceased.

9.     The Opposite Party cannot be expected to settle claims when it is specifically excluded under the terms of the Policy. It is evident from the medical records that the deceased was a alcoholic and the Cirrhosis (Liver disease) was caused by Alcohol consumption.

10.    It is submitted that the beneficiary under the policy can claim only for those Medical expenses that was incurred, are admissible as per the terms of the Policy and further the liability for any admissible claim is limited to the extent of the Sum Insured. Hence, the claims made and quantification claimed does not fall within the scope of coverage provided under the Policy.

11.    The medical records and the death report and even their own averment would show that the deceased was treated for Decompensated chronic liver disease (DCLD) and EtOH (EtOH stands for ethyl alcohol or ethanol). This would manifestly demonstrate that the cirrhosis (Liver ailment) was caused by consumption of Alcohol(alcohol medically called as Ethyl alcohol or ethanol). The rejection of the claim is bonafide and based on the Treatment records. Hence, the Opposite Parties have not committed any deficiency in service. Hence prayed to dismiss the complaint.

III. The 3^rd Opposite Party was set ex parte:-

        Notice was sent to the 3^rd Opposite Party and was duly served to the 3^rd Opposite Party. Despite the notice being served, the 3^rd Opposite Party failed to appear before this Commission either in person or through Counsel on the hearing date(s) and not filed written version on their side.  Hence the 3^rdOpposite Party was called absent and set ex-parte. Subsequently, the case was proceeded to be heard on merits.

IV. The Complainant has filed his proof affidavit and Written Arguments  in support of his claim in the complaint and has filed documents which are marked as Ex.A-1 to A-11. The 1^st and 2^nd Opposite Parties had submitted their proof affidavit and Written Arguments. No document was marked on their side.

V. Points for Consideration:-

 

1. Whether there is deficiency in service on the part of the Opposite Parties?

2. Whether the Complainant is entitled for reliefs claimed?

3. To what other reliefs the Complainant is entitled to?

Point No. 1 :-

12.    The Opposite Party had issued a group Mediclaim policy to Indian Banks Association A/C: Lakshmi Vilas Bank under which Complainant's father as an retired employee was covered. The Sum Insured under the said Policy No. 5001002818P111682975 is Rs.4,00,000/- for retired officers and Rs.3,00,000/- for retired employees, which facts are not disputed.

13.    A perusal of Exs.A-1 to A-7 would show that, the Complainant's father was admitted in the Apollo Hospital and was given treatment as an inpatient on 21.02.2019 and discharged on 22.02.2019 and on the same day he was admitted to PSG Hospitals at Coimbatore, where he was diagnosed for Decompensated Chronic Liver Disease among other ailments and after treatment he was discharged on 26.02.2019.

14.    Again the Complainant’s father was admitted in Apollo Hospitals at Greams road, Chennai on 04.03.2019 and diagnosed “Ethanol related decompensated Liver disease with portal HTN” among others, took treatment till 07.03.2019 and got discharged. It is seen, he was again admitted to Apollo Hospitals at Greams road, Chennai on 08.03.2019 and got treatment as an inpatient till 16.03.2019. Further he was shifted to Sri Ramachandra Hospital Medical Centre at Porur on 16.03.2019 and got treatment as an inpatient and died in the hospital on 24.03.2019.

15.    The death summary issued by the Ramachandra Hospital Medical Centre at Porur, Ex.A-7 shows that the patient is a known case of DCLD, ETOH, hematemesis, variceals/p EVL and sepsis.

16.    According to the Complainant he had spent Rs.16,92,362/- towards the treatment of his father,  and hence made a claim to the 1^st  Opposite Party who by its communication dated 13.05.2019, had repudiated the claim  citing clause 4.5 of the policy terms and conditions. Hence the Complainant had sent a mail on 28.06.2020 explaining the causes for the death of his father refuting illogical repudiation of the claim and sought reimbursement under the insurance policy. However, the 1^st Opposite Party had not chosen to respond to the mail.

17.    A perusal of the medical records and the death summary would show that the Complainant’s father was treated for Decompensated chronic liver disease (DCLD) and EtOH (EtOH stands for ethyl alcohol or ethanol) and as admitted by the Complainant his father was taking treatment for the cirrhosis, Liver ailment caused by consumption of Alcohol.

Clause 4 of  the Policy terms and conditions under the head “Exclusions”  the insurance company is not liable to make payment under the policy in respect of any expenses incurred by the insured in respect of

4.5"Convalescence, rest cure, Obesity treatment and its complications including morbid obesity, treatment relating disorders, Venereal disease, intentional self-injury and use of intoxication drug/alcohol”

18.    The Complainant relied upon the order of the Hon’ble National Commission reported in CDJ 2019 (Cons) Case N0.467, where its earlier order cited in 2015(3) C.P.R.697 was referred in which it was held that the Opposite parties had miserably failed to establish that there is any alcoholic liver cirrhosis ailment to the complainant prior to purchase of the policy. If the said disease was first time located by the doctor after the purchase of the policy, then that will have no affect on the right of the complainant to get the claim of in insurance from the opposite party and reached the conclusion that the opposite parties have illegally arbitrarily repudiated the claim of the Complainant. In the present case the Discharge summary issued by the Apollo Hospitals shows that the complainant’s father was using Ethanol for 20 years which is prior to the taking of policy and the cause of death is also due to decompensated chronic liver disease which is related to the intake of alcohol. Hence the said case is not applicable to the case at hand.

19.    Reliance was also placed on the order of the Hon’ble State Commission, New Delhi, where a young man died after having admitted in the hospital for Alcoholic Liver Disease, Cirrhosis of liver. Since he was insured his legal heir filed a claim which was repudiated by invoking exclusion clause of the policy by taking cause of death as Alcoholic cirrhosis of liver which means that he has been consuming much quantity of alcohol. It was observed that after obtaining certificate from the panel of doctors about sound and  good health  any kind of explanation, excuse or any treatment obtained by the insured for any disease cannot come to the rescue of the Insurance company for invoking the exclusion clause. In the said case the cause of death given by the doctor nowhere suggests even remotely that the respondent had died due to alcoholic cirrhosis of liver. However, in the present case the death summary points out that the cause of death of  the complainant’s father was due to decompensated chronic liver disease, which is related to the consumption of alcohol and hence the said order is not applicable to the present case.

        It is an admitted fact that the Complainant’s father was taking treatment for Cirrhosis. Moreover the sum assured under the policy is Rs.4,00,000/-for retired officers and Rs.3,00,000/- for retired employees. But the Complainant has made a Mediclaim of Rs.9,00,000/- which is more than the sum assured, in any event the liability of the Opposite Parties is limited to the sum assured.

20.    Considering the facts and circumstances of the case, this Commission is of the view that the Opposite Parties had repudiated the claim of the Complainant based on the medical records submitted by the Complainant and as per the terms and conditions stipulated in the policy and hence the repudiation made by the Opposite Party following the terms and conditions of the Policy is legally sustainable. Therefore this Commission is of the considered view that there is no deficiency of service on the part of the Opposite Parties. Accordingly Point No.1 is answered.

Point Nos 2 and 3:

21.    As discussed and decided in Point No.1 that the Opposite Parties had not committed deficiency in service the Complainant is not entitled for the reliefs claimed in the complaint or for any other relief(s). Accordingly Point Nos 2 and 3 are answered.

In the result the complaint is dismissed. No costs.

Dictated to Steno-Typist, transcribed and typed by her, corrected and pronounced by us in the Open Commission, on 29^th of  May 2023.

 

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                  B.JIJAA

         MEMBER II                        MEMBER I                       PRESIDENT

 

 

List of documents filed on the side of the Complainant:-

Ex.A1		Policy issued by the Opposite Parties
Ex.A2	22.02.2019	Discharge summary issued by Apollo
Ex.A3	26.02.2019	Discharge summary issued by Apollo
Ex.A4	07.03.2019	Discharge summary issued by Apollo
Ex.A5	16.03.2019	Discharge summary issued by Apollo
Ex.A6	24.03.2019	Death summary issued by Sri Ramachandra Medical Centre
Ex.A7	09.04.2019	Death certificate
Ex.A8	13.05.2019	Communication of the Opposite Parties
Ex.A9	28.08.2020	Mail sent by the Complainant
Ex.A10	12.10.2020	Legal Notice issued by the Complainant with acknowledgement
Ex.A11	29.12.2020	Legal Heir Certificate

 

List of documents filed on the side of Opposite Parties:-

 

- NIL-

 

S. NANDAGOPALAN               T.R. SIVAKUMHAR                  B.JIJAA

         MEMBER II                        MEMBER I                       PRESIDENT