Smt.Seema Arora and others, complainants has filed the present complaint U/S 12 of the Consumer Protection Act, 1986 (hereinafter called 'the Act') has praying for necessary directions to the opposite parties to pay Rs.1,50,000/- as claim amount with interest @ 18% P.A. w.e.f. 13.12.2013 from the date of filing of the claim till its actual payment. Opposite parties be also directed to pay Rs.50,000/- as damages for harassment and mental agony caused to him by the opposite parties alongwith Rs.11,000/- as litigation expenses.
2. The case of the complainant in brief is that Sh.Lalit Kumar son of Sh.Sudarshan Kumar got himself medically insured from the opposite parties through opposite party no.3 for the period from 17.5.2013 to 16.5.2014 for a sum of Rs.1,50,000/- vide policy No.36050334130100000025 alongwith his other family members i.e. his wife, son and daughter and paid the entire premium of the said insurance policy to the opposite party and completed all other formalities for obtaining the abovesaid insurance policy from the opposite party and thus they are the consumer as defined in the Consumer Protection Act,1986. They have further pleaded that all of a sudden in the first week of December, 2013 Sh.Lalit Kumar developed multifarious physical disorders and he had to be hospitalized in the Fortis Escorts Hospital Majitha Verka Bye Pass Road, Amritsar on or about 8.12.2013. The said Lalit Kumar diagnosed with ACUTE NECROTISING PANCREATITIS- MODERATE CTSI SCOR 10, FATTY LIVER, MILD ASCITES, BILATERAL, MILD PLEURAL EFFUSION WITH BILLATERAL BASAL ATELECTASIS and ultimately he died on 13.12.2013 due to cardiac arrest as reported by the said hospital in the death certificate dated 13.12.2013 issued by the said hospital. They have next pleaded that soon after the death of Sh.Lalit Kumar they lodged their claim with the opposite parties who repudiated their claim on the basis of some alleged report of Raksha TPA Pvt. Ltd. dated 6.2.2014 on the ground that the death of deceased Lalit Kumar occurred not on account of an acute attack of pancreatitis and ARF but due to the intake of alcohol which caused acute chronic pancreatitis with renal failure which led to cardiac arrest. The alleged report of the said firm is absolutely wrong, false and has been obtained by the opposite party to repudiate their claim. Complainant no.1 after coming to know about the rejection of claim approached the opposite party no.2 and apprised the fact that Sh.Lalit Kumar never consumed alcohol during his life time and thus the sudden attack was not due to alcoholism and it was a natural death caused due to sudden failure of certain parts of the body as mentioned in the report of the above mentioned hospital but the opposite party absolutely filed and ignored the said representation made by them. The opposite parties repudiated their claim arbitrarily and without any reason and cause and on the basis of an absolutely illegal report dated 6.2.2014 of the above mentioned agency namely Raksha TPA Pvt. Limited which is absolutely false, frivolous, baseless and without any basis which amounts to deficiency in service on their part, hence, the present complaint with the desired relief duly prayed therein.
3. Upon notice, opposite parties appeared and filed their joint written reply through their counsel, raising the preliminary objection that the complaint is bad for necessary party as such the complaint is liable to be dismissed on this ground. The claim is repudiated by M/s.Raksha TPA Pvt. Ltd., 2nd Floor, SCO 181, Sector 7C, Chandigarh which is processing unit of the opposite party as such complaint is bad for non joinder of necessary party and M/s.Raksha TPA Pvt. has processed the claim as per terms and conditions of the policy. During processing and documents procure by him as well as History Sheet of the insured prepared by the Fortis Escorts, Amritsar the deceased had H/o chronic alcoholism and decease caused due to alcohol which falls under permanent exclusion of the policy and repudiated the claim on this ground on 6.1.2014 and intimation of the same was given to complainant. As such the opposite party has no deficiency in service. The claim the complainant was repudiated as per clause 4.4.6 of the policy permanent exclusion clause of the policy. On merits, it was submitted that M/s.Raksha TPA Pvt. Limited is processing unit of opposite parties duly appointed to timely settle the claims. Accordingly a request for cashless was received through Fortis Health Management, Amritsar on 9.12.2013 when the patient was admitted at Fortis Escort which was repudiated on 11.12.2013 as patient suffered from Acute Pancreatitis and as per query reply from the Hospital, Patient is chronic alcoholic. Alcohol is the main contributing factor in causing Pancreatitis. As such cashless had been denied as per clause 4.4.6 of the policy. After that the complainant filed a claim for reimbursement on 3.1.2014. The processing unit of the opposite parties review the documents submitted by the complainant and as per history sheet and physical sheet of the patient, patient had H/o chronic alcoholism and disease caused due to alcohol and case falls under exclusion of the policy. As such the claim was repudiated as per clause 4.4.6 and intimation of the same was given to the complainant on 6.1.2014. The case of the complainant falls under the exclusion clause and opposite party acted as per terms and condition of the policy as such having no deficiency in service. Other averments made in the complaint have been denied. Lastly, the complaint has been prayed to be dismissed with costs.
4. Smt.Seema Arora, complainant tendered into evidence her own affidavit Ex.CW1/A, along with the other documents exhibited as Ex.C1 to Ex C9 and closed the evidence.
5. On the other hand, Sh.Shiv Lal Branch Manager of OPs tendered into evidence his own affidavit Ex.OP-1 and of Sh.Vijay Sharma Working in Raksha TPA Pvt.Ltd. Ex.OP10, along with the other documents exhibited as Ex.OP2 to Ex.OP9 and closed the evidence.
6. We have carefully gone through the pleadings of both the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purpose of adjudication of the present complaint.
7. We observe with the judicial precision that the complainants’ insurance claim has been repudiated for of the sole reason that the insured life has been reported to have the H/o (history of) chronic alcoholism and thus falling under the exclusionary clause 4.4.6 of the related policy. However, the OP insurers have neither proved the H/o (history of) chronic alcoholism nor could prove the same to be the cause of the death of the DLA (deceased life assured) at the face of the flat refusal (paragraph ‘6’ of the Ex.CW1/A) by the widowed complainant of any ‘intake of alcohol’ by the DLA during his life time. Ex.C2 Death Certificate mentions the immediate cause of death as: ‘Cardiac Arrest’ and antecedent cause as: Ac. Pancreas with ARF (renal failure). Ex.C3 Death Summary: mentions H/o chronic alcoholism but without any evidence of the same and simply on the strength of the patients’ attendants’ statement i.e., hearsay statement of a 3rd person without any corroboration through some cogent independent evidence. Further the same exhibit Ex.C3 mentions the cause of death as: Cardio Pulmonary Arrest; that proves the alleged ‘alcoholism’ as not being the cause of death. Even Ex.C8 mentions H/o chronic alcoholism with No H/o DM/HTV/Br.A/TB etc these not being the result of any investigations etc but simply as per the attendant’s hearsay statement etc. Even the medical treatment received at the Hospital (for which the claim has been filed) was provided for the ailment of the Pancreas and not for the treatment of ‘alcoholism’ or its collaterals etc. Even the Ex.OP2 mentions that the patient suffered from ‘pancreatitis, ARF’ and expired. It is further added sans any medical evidence that alcohol is the ‘cause’ of Pancreatitis and Renal failure; that is not true as there can be other medical reasons also and there has been no ‘strict proof’ corroborating the ‘wild guess’ made by the TPA (third party administrators) and blindly believed by the OP insurers being a convenient tool to repudiate the otherwise a valid insurance claim. Ex.OP2 to Ex.OP7 have been incoherently repeating H/o chronic alcoholism without putting forth any cogent evidence for the same whereas the Death Certificate Ex.OP8 (same as Ex.C2) clearly states the causes of death being other than ‘chronic alcoholism’ as already discussed above. Moreover, the ‘chronic alcoholism’ also does not stand proved anywhere on the record of the proceedings. The opposite party has filed the affidavit of TPA official( Ex OP 10) but we find that no designation of the TPA official is mentioned . It is not mentioned as to who conducted all investigations nor his name is disclosed.No medical expert opinion is produced nor even the affidavit of any Doctor filed to support of their(OP) case.Thus, we find that the impugned repudiation by the OP insurers has not been judicious and indicates ‘deficiency in service’ on their part and in turn has indeed infringed the consumer rights of the complainants.
8. From the entire above discussion, we are of the considered view And hold the OP insurers’ claim repudiation-decision as arbitrary, and thus ORDER them to settle and pay to the complainant the full insurance-claim amount of Rs.1,50,000/- as eligible under the extant terms of the Policy besides to pay him Rs.5,000/- as compensation and Rs.3,000/- as cost of litigation; within 30 days of receipt of the copy of these orders, otherwise the aggregate awarded amount shall become payable with interest @ 9% PA form the date of filing of the complaint till actually paid.
9. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned. .
(Naveen Puri)
President
ANNOUNCED: (Jagdeep Kaur)
March 31 2015. Member
*MK*
