CONSUMER DISPUTES REDRESSAL FORUM, KOTTAYAM.
Present
Sri. Santhosh Kesavanath P. President
Smt. Bindhu M. Thomas, Member
CC No.342/09
Monday, the 28th day of February, 2011
Petitioner : Jose Santho,
Kuzhikombil,
Poovarany PO,
Pala.
(Adv. K.T. Joseph)
Vs.
Opposite party : The Manager,
New India Assurance Co., Pala.
(Adv. Girija P.G)
2) M/s.Medi Assist,
Medi Assist India Pvt.Ltd,
3rd Floor, No.49, First Main Road,
Sarakki Industrial Layout, JP Nagar
Third Stage, Bangalore 78.
O R D E R
Smt. Bindhu M. Thomas, Member
The complainant’s case is as follows.
The complainant is Medi Assist policy holder of the second opposite party through the first opposite party ever since 19-03094. The complainant has availed 50% cumulative bonus as he had not claimed any amount for treatment under the various polices till 2008 from the beginning. The complainant had taken policy number 761502/34/06/20/00000034 for the period 19-3-2007 to 18-3-2008. The complainant had taken policy number 761502/34/07/11/00000096 from the first opposite party which covered the period 19-3-2008 to 18-3-2009. The complainant had undergone treatment for pancreatitis at Carithas Hospital from 17-2-2008 to 20-2-2008 and from there he was admitted at PVS Memorial Hospital, Ernakulam from 20-2-2008 to
10-3-2008. The complainant had lodged a claim before the first opposite party claiming Rs.69390.35. The complainant had undergone treatment from 6-5-2008 to 10-5-2008. The complainant filed a claim for Rs.13,151/- but only a sum of Rs.8720/- was allowed. The second opposite party repudiated the first claim under clause 4.8 for use of intoxicating drugs or alcohol. Dr. G.N. Ramesh MD, DM had given a certificate to the complainant to the effect that there was no evidence of intoxication at the time of admission. The certificate also states that the complainant had stopped alcohol consumption for the last fifteen years and that his alcohol history is related to his regular intake of alcohol thirty years back. According to the complainant he is entitled to get a sum of Rs.69390.85 as per first claim and a sum of Rs.4431/- towards balance from the second claim. Hence the complainant filed this complaint claiming Rs.93, 821.85 with 12% interest and cost.
The opposite parties entered appearance and the first opposite party alone file version with the following main contentions.
i) The complainant had undergone treatment for ‘Alcoholic Pancreatitis’. The certificate dated 4/4/08 issued by Caritas Hospital shows that the complainant was treated for “Alcoholic Pancreatitis” in that hospital from 17/2/08 to 20/2/08 and got discharged against medical advice. Further, the discharge summary from PVS Memorial Hospital Ltd., Cochin shows that the complainant had a history of consuming alcohol regularly for thirty years and the diagonosis is ‘Acute severe Pancreatitis’. Therefore on a scrutiny of the medical records it was found that the illness of the complainant was due to regular intake of alcohol for the past thirty years. Therefore the claim was repudiated as per exclusion clause 4.8 in the policy stating the reason. Since the expenses on treatment arose out of use of alcohol, the claim is not payable.
ii) The certificate mentioned in para 6 of the complaint is fabricated and forged to make illegal gain out of it, after repudiation of the claim.
iii) There is no unfair trade practice or deficiency in service on the part of opposite parties. Hence the opposite party prayed to dismiss the complaint with compensatory costs to them.
Points for consideration are:
i) Whether there is any deficiency in service or unfair trade practice on the part of opposite parties?
ii) Reliefs and costs?
Evidence consists of affidavits filed by both parties and exhibits A1 to A3 and exhibits B1 to B5 and exhibit X1.
Point No.1
It is not in dispute that the complainant had taken a mediclaim policy vide policy no.76100/34/07/11/00000096. Ext.A1 is the mediclaim policy issued by the opposite party to the complainant. The complainant submitted the mediclaim in connection with his treatment and claimed Rs.69390.35/- by way of treatment expenses incurred for Pancreatitis treatment done at Carithas Hospital from 17-2-2008 to 20-02-2008 and at PVS Memorial Hospital, from 20-02-2008 to 10-03-2008. But the said claim was repudiated by the opposite party by Ext.A2 repudiation letter dtd 13-05-08. The ground stated for repudiating the claim was that the claim pertains to the expenses on treatment of diseases arising out of or in consequence to use of intoxicating drugs / alcohol are not payable. The claim was repudiated under the exclusion clause 4.8 of the mediclaim policy.
The opposite party produced the original discharge summary from PVS Hospital and it is marked as Ext.B2.. In paragraph 1 of exhibit B2, it is stated that the complainant gave a history of consuming alcohol regularly for thirty years. The very same hospital issued a certificate dtd 14-06-2008. The copy of the said certificate issued by Dr.G.N.Ramesh is also produced and marked as exhibit A3. In exhibit A3. Dr.G.N. Ramemsh certified that the complainant’s alcohol history is related to his regular intake of alcohol thirty years back. It is further certified that the complainant has stopped alcohol consumption for the last fifteen years. From Ext.A3 certificate, it is understood that the 50 years old complainant stopped alcohol consumption at his 35th year. Equating Ext.A3 certificate with the history revealed by the complainant himself in Ext.B2 discharge summary, it is to be presumed that the complainant might have started consuming alcohol at the age of 5 years. A prudent man cannot believe this presumption. Moreover the doctor who issued the A3 certificate is not produced before the forum, examined and proved.
The case record of PVS Memorial Hospital was called for, produced and marked as Ext.X1. On page 4 of the Ext.X1 it is stated that “consumes alcohol regularly for thirty years”. Further on page 8 of Ext.X1, on 7-03-08, the statement by a Psychologist is recorded which reads as under
“Talked to the patient. Convinced about the problems of addiction. Given counselling. To maintain contact with the deaddiction centre near house”.
From the aforesaid statement it is clear that on 07-03-08 also, the complainant was an addict of alcohol. As mentioned in Ext.A3 certificate, if the complainant has stopped alcohol consumption for the last fifteen years, what is the need of convincing the complainant about the problems of addiction, and advising him to maintain contact with the deaddiction centre near house.
From the facts and circumstances of the case, we come to the conclusion that during the year 2008 also, the complainant was an addict of alcohol. So no deficiency of service can be attributed against the opposite party for repudiating the claim. Point no.1 is found accordingly.
Point No.2
In view of the findings in point no.1 the complaint is dismissed. From the facts and circumstances of the case no cost and compensation ordered.
Smt. Bindhu M. Thomas, Member Sd/-
Sri. Santhosh Kesavanath P. President Sd/-
Appendix
Documents of the complainant
Ext.A1-Policy issued by the first opposite party
Ext.A2-Copy of repudiation letter dtd 13-05-08
Ext.A3-Copy of the certificate of Dr.G.N. Ramesh
Documents of the opposite party
Ext.B1-Copy of the policy with conditions
Ext.B2-Discharge summary of the complainant from PVS hospital
Ext.B3-Medical certificate issued by Dr. Tom Kurian of Carithas Hospital
Ext.B4-Certificate dtd 4/4/08 from Carithas hospital
Ext.B5-Letter dtd 13/8/08 issued by 2nd OP to the complainant
Ext.X1
Ext.X1-Treatment record called for from PVS Hospital
By Order,
Senior Superintendent
