By. Sri. A.S. Subhagan, Member:
Facts of the case in brief:-
1. The complaint has been filed by the Complainant under section 12 of the Consumer Protection Act 1986.
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2. The Complainant is the holder of a Medi Claim Insurance Policy No.76220134162500000001 issued by the Opposite Party Insurance company, covering the period from 16.01.2017 to 15.01.2018. The Complainant had been taking Medi Claim Policies for more than the last eleven years continuously. The original coverage of the policy was Rs.1,25,000/- and its coverage including no claim addition was Rs.1,37,500/-. Initially the Complainant was admitted in LEO Hospital, Kalpetta but the disease was not properly diagnosed and no proper treatment was given from there. A claim was preferred there for cashless treatment and only an amount of Rs.20,000/- was paid by the Opposite Party No.1 and the remaining portion of the bill was paid by the Complainant. Later on 26.12.2017 the Complainant was admitted in Aster MIMS Hospital, Kozhikode and after proper diagnosis and treatment he was discharged on 05.01.2018. Consequently a claim was preferred by the Complainant for treatment and expenses. The records were entrusted with Opposite Party No.2. On enquiry it was informed that the same was forwarded to “Vidal Health Insurance TPA Private Limited”, the insurance Third Party Administration of the Opposite Parties. Thereafter, the certified indoor case papers, Doctor’s Certificate, detailed discharge summary, breakup bill, original of scan test reports etc were sent to TPA
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of Opposite Parties, as per direction of the Opposite Party. Even then the claim was not settled by the Opposite Parties but TPA informed the Complainant over phone that the claim was rejected. The reason for rejection of claim stated was “injury caused is due to consumption of Alcohol”. The Opposite Parties also intimated the same reason. In fact the Complainant had no privity of contract with the TPA and there was no intimation to the Complainant that the Opposite Parties were engaging TPA.
3. The Complainant was not treated for any injury and the reason stated was baseless only to escape from making payment of the claim. Hence the Opposite Parties are liable to settle the claim amount with costs and compensation to the Complainant. The first Opposite Party renewed the medi claim policy for another year and the second Opposite Party renewed the same for another one year up to January 2020. The very same policy was renewed by the Opposite Parties without any further conditions and accepted about Rs.40,000/- as renewal amount. The Opposite Parties are only interested in collecting policy premiums and not acting with responsibility in settling the claim. The non settling of claim amount saying lame excuses by Opposite Parties is clear
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deficiency in service and unfair trade practice. Hence the Complainant has filed this complaint with the following prayers to direct the Opposite Parties
a. To pay the claim amount of Rs.1,03,214/- to the Complainant with 12% interest p.a from 26.12.2017 till payment,
b. To pay Rs.1,50,000/- as compensation for deficiency of service,
c. To pay Rs.10,000/- as cost of the complaint and
d. To grand such other relief that the Commission deems fit.
4. The Commission registered a case and notices were issued to the Complainant and Opposite Parties. The Opposite Parties entered appearance and detailed version was filed. In the version filed, the Opposite Parties had admitted the existence and validity of the Medi Claim Policy taken by the Complainant. According to the Opposite Parties, the Complainant was admitted in Aster MIMS Hospital, Kozhikode for Alcohol withdrawals with portal vein-thrombosist pancreatic calcified (septicemia, calcific pancreatitis). This illness was caused by use of intoxicating alcohol. The claim form along with relevant medical records submitted by the Complainant was scrutinized by the Vidal Health Insurance TPA (P) Limited. On scrutiny it was found that the hospitalization of the Complainant
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was due to the ailment caused due to the consumption of alcohol. As per the policy exclusion No.4.4.6.1 “No claim will be payable under this policy for the following:- convalescence, general debility, run-down condition or rest cure, obesity treatment and its complications, treatment relating to all psychiatric and psychosomatic disorders, infertility, sterility, venereal disease, intentional self injury and illness or injury caused by the use of intoxicating drug/alcohol”. There is alcohol induced portal vein thrombosis and pancreatic calcifications. The diseases are complications of alcohol abuse. The illness of the Complainant is an intentional self injury, ie. illness caused by the use of intoxicating alcohol comes under the policy exclusion clause. Hence the claim was repudiated and therefore the Opposite Parties rejected the claim. The rejection was intimated to the Complainant. Moreover the Complainant was a known diabetic since 14 years, the pre-existing disease. The Complainant suppressed this material fact while taking the policy.
5. The Opposite Parties also affirm that the name of TPA Vidal Health Insurance TPA Limited was mentioned in the policy itself and there is no deficiency of service on the part of the Opposite Parties as alleged in the
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complaint. The Opposite Parties have rejected the claim of the Complainant based on the policy exclusion clause 4.4.6.1 and therefore the Complainant is not entitled to get the relief as prayed for. On the basis of the above version the Opposite Parties prayed to disallow the prayer in the complaint with compensatory cost of the Opposite Parties.
6. Affidavit was filed by the Complainant and documents Ext.A1 series, A2 and Ext.X1 series were marked from his side. He was examined on 23.09.2020 as PW1. Proof affidavit was filed by the Divisional Manager of New India Assurance Company Limited, Kalpetta on behalf of Opposite Parties and he was examined on 11.10.2020 as OPW1. The complaint was finally heard on 15.10.2020.
7. On perusal of complaint, version, affidavits filed, documents marked and oral evidence adduced in examination of witnesses, the Commission raised the following points for consideration:-
1. Whether there has been any deficiency in service on the part of
the Opposite Parties?.
2. Whether the Complainant is entitled to get compensation as
prayed for?
3. Whether the Complainant is entitled to get cost of the complaint?.
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8. Point No.1:- It is the admitted fact that the Complainant was the holder of a Medi Claim Policy issued by the Opposite Parties as stated in the complaint and during the existence of the policy he was admitted in LEO Hospital, Kalpetta and afterwards he was admitted in Aster MIMS Hospital, Kozhikode on 26.12.2017 and was discharged on 05.01.2018. According to the Complainant he was admitted in Aster MIMS Hospital as his disease was not properly diagnosed and as no proper treatment was given from LEO Hospital. He also alleged in examination that he was admitted in Aster MIMS Hospital and treated for septicemia, SOL-liver-Bx- suppurative inflammation, portal vein thrombosis infective etiology, and chronic calcific pancreatitis. He also reiterated that he was not admitted for treatment of any alcohol induced diseases or for diabetics.
9. On the other hand, the allegation of the 1st Opposite Party is that the Complainant was admitted in MIMS Hospital for treatment of Alcohol withdrawal with portal vein thrombosist pancreatic calcified which is a self induced injury resulted from consumption of alcohol which is coming under the exclusion clause No.4.4.6.1 of the policy conditions. Moreover the Complainant was a known diabetic since 14 years, the pre-existing disease. The Complainant
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suppressed this material fact while taking the policy and hence the Complainant is not entitled to get any claim, compensation or cost as prayed for.
10. On a careful scrutiny and analysis of the complaint, version, affidavits, documents marked by the parties and the evidences adduced in examination of witnesses the Commission observes the following facts.
(a). The Complainant was admitted in Aster MIMS Hospital on 26.12.2017 and discharged from there on 05.01.2018 and at the time of his treatment he had a Medi Claim Policy with the Opposite Parties.
(b). Though the Complainant was admitted in Aster MIMS on 26.12.2017, on page number 11 of the X1 series of documents marked, which is the physicians order record dated 27.12.2017 the very next day of his admission is seen noted against diagnosis as “alcohol withdrawal with portal vein- thrombosist pancreatic calcified”. Most of the other non Drug orders and investigations are seen ordered or done afterwards; for example Liver biopsy, CBC, creat CRP 2912 on 28.12.2017 (Page 14 of X1 series); OGD
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Scopy on 29.12.2017 (page 15 of X1 series); PT/INR, CBC, CRP ON 01.01.2018 (Page 17 of X1 series); INR on 03.01.2018 (Page 20 of X1 series); and like that. Moreover, the Complainant in oral evidence on examination of PW1 has stated that the recording on page number 11 is made by the Doctor in MIMS Hospital at the time of admission in MIMS on the basis of the recordings of the Doctor in LEO Hospital. So the Commission observes that mere writing of diagnosis as alcohol withdrawal at the time of admission cannot be
presumed to be apt and final without completing subsequent tests and investigation results.
(c). On page number 23 of the X1 series, which is the discharge summary dated 04.01.2018 and on page number 28 of X1 series which is the discharge summary dated 05.01.2018 prepared and issued by the Aster MIMS Hospital, final diagnosis has been recorded as septicemia-burkholderia cepacia related SOL- Liver- Bx-Suppurative inflammation, portal vein thrombosis, infective etiology, chronic calcific pancreatitis. On page number 27 of X1 series which is a Certificate issued by Dr. Anish kumar. MD; DM
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(HOD- Department of Gastro entomology, MIMS Hospital on 24.07.2018 declares that the Complainant was admitted on 26.12.2017 with fever, slurring in speech and drowsiness. He was evaluated and diagnosed to have chronic calcific pancreatitis, septicemia- Burkhoholderia cepacia related and SOL liver and portal vein thrombosis. This Certificate issued by the treated doctor also does not show that the Complainant was treated for Alcohol withdrawal or diabetics. Nowhere in any of the records including both the final discharge summaries has recorded that the disease caused is alcohol induced one. To prove the disease as alcohol induced one, the Opposite Parties have not examined the treated doctors of LEO Hospital or Aster MIMS Hospital for taking expert opinion. Moreover the diagnosis shown on page 11 of the X1 series on admission of Complainant in MIMS hospital cannot be presumed to be final before making supportive medical examinations and investigations and without considering the results of the medical examinations and investigations. So, on the final discharge sheet and the Certificate issued by the treated Doctor as it
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has not been specified as alcohol induced diseases and as the doctors who treated the patient are not examined in witness to substantiate the allegation of the Opposite Parties, the Opposite Parties have failed to prove that the diseases are resulted from the consumption of alcohol. Moreover the Opposite Party himself in evidence has reiterated that he has not seen any recording as to the treatment for alcohol withdrawal in the Doctors treatment records. The Opposite Party has also given evidence in oral examination that TPA has rejected the claim of the Complainant without specifying that on which document the TPA has depended to come to a conclusion to reject the claim of the Complainant. On the above circumstances we cannot believe that the disease caused to the Complainant is resulted from the consumption of alcohol and was treated for self induced injury resulted from the consumption of alcohol. Therefore the Opposite Parties cannot reject the claim of the Complainant on the basis of this contention.
(d). Another contention of the Opposite Party is that the Complainant was a known diabetic since 14 years, the pre existing
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disease and the Complainant suppressed the material fact while taking the policy. But the Complainant has contented that the recording as “diabetic since ‘14’years” has been recorded from the record prepared by the doctor in LEO Hospital is wrong and he has been diabetic since four years only. He also contented that he did not seek any clarification as to this as the disease for which he was treated was not caused due to diabetics nor he was treated for diabetics. Nowhere in the documents (treatment records –X1 series) the Commission could find that the disease for which the Complainant was treated was caused due to diabetics. So we are of the view that mere suppression of a fact which is not a cause of the disease for which the Complainant was treated cannot be considered as suppression of a material fact and hence the Opposite Parties cannot reject the claim on the basis of such a contention. Hence point number one is proved to be in favour of the Complainant as there is deficiency in service on the part of the Opposite Parties as they have rejected the claim of the Complainant without any valid reasons.
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11.Point No.2:- As point number one is proved to be in favour of the Complainant he is entitled to get compensation.
12.Point No.3:- As point number one and two are in favour of the Complainant he is entitled to get cost of the complaint.
In the result, the complaint is allowed and the Opposite Parties are directed to pay the Complainant:
- Rs. 1,03,214/- (Rupees On Lakh Three thousand two hundred and fourteen only) with 7% interest from 05.01.2018 from the date on which the Complainant was discharged from the Aster MIMS hospital.
- Rs. 25,000/- (Rupees Twenty Five thousand only) as compensation for the deficiency in service and for mental shock.
- Rs. 5,000/- (Rupees Five thousand only) as cost of the Complaint.
The Opposite Parties are directed to pay the above amounts within 30 days
from the date of receipt of a copy of this order failing which the Complainant shall have the right to recover the amounts by due process of law.
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Dictated to the Confidential Assistant, transcribed by him and corrected by me and Pronounced in the Open Commission on this the 6th day of November 2020.
Date of Filing: 03.03.2017.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the complainant:-
PW1. N. K. Vinod. Advocate.
Witness for the Opposite Parties:-
OPW1. K. Somanathan. Divisional Manager.
Exhibits for the complainant:
A1(a). Copy of Cancelled Cheque.
A1(b). Copy of Medi Claim Schedule. Dt:15.01.2017
A1(c). Copy of Medi Claim Schedule. Dt:15.01.2017.
A1(d). Copy of Test Report. Dt:08.01.2018.
A1(e). Copy of Claim Form. Dt:19.06.2018.
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A1(f). Copy of Claim Form Part B.
A1(g). Bill Payment Details.
A1(h). Bill Payment Details.
A1(i). Discharge Bill.
A1(j). Bill.
A1(k). Pharmacy Bill. Dt:05.01.2018.
A2. Copy of letter. Dt:25.06.2018.
X1(Series). File containing Claim File with Medical records, Policy conditions attached to policy, Proposal Form signed by the complainant and Copy of Letter of Repudiation (111 Pages).
Exhibits for the opposite parties:-
Nil.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
SENIOR SUPERINTENDENT,
CDRC, WAYANAD.
