BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.116  of 2014

Date of Institution: 28-02-2014

Date of Decision: 27-05-2015  

Mr.Paras Dilawri son of Sh.Satish Kumar Dilawri, resident of Dilawri Street, Putlighar, Amritsar. 

Complainant

Versus

The New India Assurance Company Limited, through its Chairman/ Managing Director/ Principle Officer service  through its Branch Office at 80, Court Road, Amritsar through its Branch Manager.  

Opposite Party

Complaint under section 12 and 13  of the Consumer Protection Act, 1986 as amended upto date.

Present: For the Complainant: Sh. Deepinder Singh, Advocate

              For the Opposite Party: Sh. P.N.Khanna, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Mr.Paras Dilawri  under the provisions of the Consumer Protection Act alleging therein that he purchased mediclaim policy) hospitalization and domiciliary hospitalization benefit policy) bearing No.360500/34/10/13/00000555 for himself, his wife Smt.Minakshi Dilawri and two children Nargis Dilawri and Sarang Dilwri from Opposite Party valid  for the period from 23.12.2010 to 22.12.2011. Complainant alleges that unfortunately son of the complainant namely Sarang Dilawri fell ill and was hospitalized at EMC Hospital and  the claim of the said hospitalization was paid by the Opposite Party. Later on, son of the complainant again fell ill and was taken to PGI, Chandigarh for the hospitalization and remained admitted there from 29.8.2011 till 2.9.2011 and was again taken to Medanta Hospital, Gurgaon where he remained admitted from 3.9.2011 till his unfortunate death on 8.9.2011. The complainant filed the claim of medical treatment taken for his deceased son with Opposite Party which is more than Rs.4 lacs, but restricted his claim to the policy amount of Rs.2 lacs. The Opposite Party disallowed the genuine claim of the complainant on the frivolous grounds that the son of the complainant was suffering from  Genetic Disorder and the same was covered under the exclusion clause vide their letter dated 1.3.2012. Said repudiation of the genuine claim of the complainant without ascertaining the correct facts by the Opposite Party is arbitrary act of the Opposite Party.   Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite party to pay the amount of Rs.2 lacs alongwith interest @ 12% per annum from 1.3.2012 till realization.  Compensation and litigation expenses were also demanded.
2. On notice, opposite party appeared and filed written version in which it was submitted that the claim preferred by the complainant has already been repudiated by Raksha (TPA) Private Limited who is duly authorized to deal with the claim by he Insurance Regulatory & Development Authority. Said authority on scrutiny of the papers received from the complainant observed that patient suffered from Wilson’s Disease with Sub Acute Liver Failure. He got hospitalized in PGI in PGI from 29.8.2011 to 2.9.2011 and in Medanta Hospital from 3.9.2011 to 8.9.2011. Conservative management was done, but could not survive and was declared dead on 8.9.2011. Wilson’s disease  is an autosomal recessive genetic disorder the treatment for gentic disorder comes under permanent exclusions of he policy in question and hence the claim is not payable under clause No. 4.4.16 of the policy regarding the Wilson’s disease. So, the claim of the complainant was repudiated by TPA vide their letter dated 1.3.2012. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C-1 alongwith documents Ex.C2 to Ex.C5 and closed the evidence on behalf of the complainant.
4. Opposite Party tendered into evidence affidavit of Sh.Sunil Mahajan, Senior Divisional Manager Ex.OP/1 alongwith documents Ex.OP/2 to Ex.OP/8  and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant purchased mediclaim policy) bearing No.360500/34/10/13/00000555 (Ex.C2) for himself, his wife Smt.Minakshi Dilawri and two children Nargis Dilawri and Sarang Dilawri from Opposite Party valid  for the period from 23.12.2010 to 22.12.2011. Minor son of the complainant Sarang Dilawri insured fell ill and he was hospitalized at EMC Hospital and  the claim of the said hospitalization was paid by the Opposite Party. Later on, Sarang Dilawri son of the complainant again fell ill and was taken to PGI, Chandigarh where  he remained admitted from 29.8.2011 till 2.9.2011from where he was taken to Medanta Hospital, Gurgaon where he remained admitted from 3.9.2011 till his death on 8.9.2011. The complainant filed the claim of medical treatment of his deceased son amounting more than Rs.4 lacs, but the insured amount in the policy was Rs.2 lacs only. However, the Opposite Party disallowed the claim of the complainant on the ground that son of the complainant was suffering from Genetic Disorder and the same is not payable under the exclusion clause vide their letter dated 1.3.2012 Ex.C3. Ld.counsel for the   complainant  submitted that  the Opposite Party has not ascertained the correct facts which amounts to deficiency in service on the part of the Opposite Party qua the complainant.
7. Whereas the case of the opposite party is that Raksha (TPA) Private Limited is duly authorized  by the Opposite Party  to deal with the claim as per instructions of  Insurance Regulatory & Development Authority. Said TPA after scrutiny of the papers received from the complainant observed that patient suffered from Wilson’s Disease with Sub Acute Liver Failure. He was hospitalized in PGI from 29.8.2011 to 2.9.2011 and in Medant Hospital from 3.9.2011 to 8.9.2011. Conservative management was done, but could not survive and was declared dead on 8.9.2011. Wilson’s disease  is an autosomal recessive genetic disorder the treatment for gentic disorder comes under permanent exclusions of the policy in question and hence the claim is not payable under clause No. 4.4.16 of the policy regarding the Wilson’s disease.  Ld.counsel for the Opposite Party submitted that Opposite Party has rightly repudiated the claim of the complainant. As such, there is no deficiency of service on the part of the Opposite Party qua the complainant.
8. From the entire above discussion, it stands fully proved on record that complainant got mediclaim policy from the Opposite Party bearing No.360500/34/10/13/00000555 (Ex.C2) for the period from 23.12.2010 to 22.12.2011 covering  himself, his wife Smt.Minakshi Dilawri and two children Nargis Dilawri and Sarang Dilawri.  Sarang Dilawri son of the complainant fell ill and he was  hospitalized at PGI, Chandigarh for the period from 29.8.2011 till 2.9.2011 and thereafter at  Medanta Hospital, Gurgaon from 3.9.2011 to  8.9.2011 i.e. till the death of Sarang Dilawri. The patient was diagnosed as suffering  from Wilson’s Disease with Sub Acute Liver Failure. Conservative management was done, but he could not survive and was declared dead on 8.9.2011. Complainant alleges that he spent  huge amount i.e. more than Rs.4 lacs on the medical treatment of Sarang Dilawri, deceased life assured ( in short ‘DLA’), but the policy was restricted upto Rs.2 lacs only. The claim was lodged with the Opposite Party, but the Opposite Party repudiated the claim of the complainant on the ground that Wilson’s disease  is an autosomal recessive genetic disorder the treatment for gentic disorder comes under permanent exclusions of the policy in question and hence the claim is not payable under clause No. 4.4.16  of the policy. Opposite Party produced the report of Dr.Sunil Grover, M.D. Associate Professor, Sri Guru Ram Dass Hospital, Vallah, Amritsar Ex.OP7 which was duly proved by Dr.Sunil Grover through his affidavit Ex.OP6 who after going through the entire record of  DLA submitted that Wilson’s disease  is an autosomal recessive genetic disorder the treatment for gentic disorder comes under permanent exclusions of the policy in question. This witness further deposed that as far as parents question about liver biopsy not being done, sometimes during hepatic factum and platelets counts & PTE and risk of bleeding, liver biopsy is avoided. He further explained that after going through the screening studies of the parents with ATP BP Gene sequencing, both were found to be negative, but it is written in the report itself that some unknown modifiers play an important role in pathogenesis of Wilson disease. Dr.Sunil Grover further deposed through his affidavit Ex.OP6 that after considering all the aforesaid facts and detailed medical legal expert opinion he has given this report Ex.OP7 recommending the Opposite Party  that mediclaim in question is not payable as the same comes under clause 4.4.16 of the insurance policy. The complainant neither cross examined this witness nor submitted any expert report, rebutting the report submitted by Dr.Sunil Grover, MD, Associate Professor, Sri Guru Ram Dass Hospital, Vallah, Amritsar. So, it stands fully proved on record that DLA Sarang Dilawri was  suffering from Wilson’s disease which is an autosomal recessive genetic disorder the treatment for gentic disorder and as such, the claim is not payable under   clause No. 4.4.16 of the policy.
9. Consequently, we hold that the Opposite Party was justified in repudiating the claim of the complainant vide letter dated 1.3.2014 Ex.OP4.
10. Resultantly,  the complaint is without merit and the same is hereby dismissed with no order as to costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 27-05-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member