Delhi

East Delhi

CC/741/2013

ASHWANI KUMAR - Complainant(s)

Versus

UNITED INDIA INS. - Opp.Party(s)

02 May 2017

ORDER

            DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.        741/2013

                                                                                                   Date of Institution               11/09/2013

                                                                                                   Order reserved on               02/05/2017        

                                                                                                   Date of Order                        04/05/2017                                                                                     

 

In matter of

Mr Ashwani Kumar, adult   

R/o- 1/7002, Shivaji Park,

Shahdara Delhi 110032..………………….……………...…………….Complainant

                             

                                      Vs

 

M/s Manager, United India Insurance Co. Ltd. 

9, Transport Centre, New Rohtak Road,

Nr Punjabi Bagh Circle, Delhi 110035.……………..….…………..Opponent

 

Quorum   Sh Sukhdev  Singh        President

                   Dr P N Tiwari                 Member

                   Mrs Harpreet Kaur      Member                                                                                             

 

Order by Dr P N Tiwari  Member  

Brief Facts of the case                                                                                                

Complainant took Platinum Mediclaim policy at the age of 33 years from OP having tenure from 09/03/2009 to 08/03/2010 for a sum assured (SA) Rs. 1.5 lacs for himself vide policy no. 222701/48/08/97/00001131 with terms and conditions.  The same policy was renewed up to 2010 to 2011 with sum assured. The complainant stated that he opted for higher sum assured value, so OP enhanced the S A to 3 lacs from 10/03/2011 to 09/03/2012. It was stated by the complainant that all the pre existing diseases would be covered. In 2013, he opted for increasing SA, so OP enhanced to 4 lacs in policy no. 222701/48/12/06/00001441 as marked CW1/4 to CW1/8.

The complainant had blood vomiting on 07/01/2013, so was admitted in Sir Ganga Ram Hospital, Delhi and was discharged on 12/01/2013. He paid his hospital bill Rs 1,39,177/- as marked Ex CW1/1, 2 and 3.

It has been stated that after submitting claim, complainant did not get any reply from OP, so visited personally to OP office also. Later complainant received repudiation letter dated 11/04/2013 rejecting his claim under exclusion clause 4.1 based on the discharge summary findings where it was diagnosed a case of “Chronic Liver Disease with PHTN and Port Bleedings”. The discharge summary was marked as Ex CW1/2. 

Complainant filed this complaint alleging deficiency of services of OPs and refund of his treatment cost/hospital bill with harassment and mental agony. 

 

OP after receiving notice submitted their written statement denying allegations of deficiency of OPs. It was submitted that OP1 and OP3 were not a necessary parties, hence replying OP was submitting their version jointly for OP2 and 3. The claim pertaining to medical treatment for a sum of Rs 1,60,445/-was thoroughly checked by the doctors at OP4 and it was found that CLD with PHTN and Portal Bleed and Ascitis were very old complications of liver disease and the complainant had taken treatment in Aug. 2009. It was stated by OP that complainant had Upper GI bleeding Grade III in Feb. 2009 and took treatment from Sir Ganga Ram Hospital.

 

It was submitted that exclusion under clause 4.1 in policy 222701/48/11/06/00001346 with tenure from 12/03/2012 to 11/03/2013 was done based on the information and evidences collected from the treating hospital where complainant had disclosed about his problem of bleeding from GIT and this fact was not disclosed before the OP at the time of taking policy.

More so, complainant had SA of 1.5 lacs up to CW1/5 and terms and conditions under 4.1 exclusion clause were for “Congenital defects - internal and external” whereas complainant had opted for enhancement of SA from 1.5 to 3 lacs as per CW1/6 and then again got enhanced to 4 lacs as per CW1/8. From CW1/6 onwards terms and conditions were changed under exclusion clause 4.1 which state as exclusion of All Pre Existing diseases and the same terms and conditions were sent to the complainant with the policy every time. Also complainant did not mention any words for changing terms and conditions. Thus, from CW1/6 ie policy no. 222701/48/10/06/00001309 having tenure from 10/03/2011 to 09/03 2012, new terms and conditions were applicable and were continued till claim policy as CW1/8. Also complainant did not submit complete policy documents before the Forum.  

OP also clarified that as per exclusion clause 4.1 which reads as –

                             “The company shall not be liable to make any payment under this policy in respect of any expenses of any pre existing condition(s) as defined in the policy, until 48 months of continuous coverage of such insured person has lapsed, since the inception of his/her first policy with the company.”

Pre- Existing condition/disease definition-  

Any condition, ailment or injury or related condition(s) for which insured had signs or symptoms and /or were diagnosed and/or received medical advice/treatment within 48 months prior to his /her first policy with company.”

OP submitted in this case, the inception date was 09/03/2009 and complainant took treatment as indoor patient and also complainant submitted that he took advice in Feb 2009 for bleeding per gastro intestinal tract (GIT), but did not disclose in his policy proposal form before the insurer. This amounts to the concealment of material facts. This fact also violates the contract between the OP which was done in good faith. So, OP had repudiated the claim as per the policy terms and conditions of the said mediclaim policy as marked OPW1/1 and OPW1/2. Hence, this complaint may be dismissed on non disclosure of material facts by the complainant/ insured.   

Complainant filed his rejoinder and evidences on affidavit where he affirmed on oath that all the facts were correct and true. Complainant also submitted evidence of general terms and conditions stating that all the pre existing diseases were covered from day one and OP did not consider their own evidence.  

OP also submitted their evidence on affidavit through Mr Vir Bhan, Sr. Divisional Manager at OP office and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and rejection was done as per terms and conditions of the policy. So, there was no deficiency in their services and repudiation was justified.

 

Arguments were heard from both the parties and order was reserved.

Before coming to the conclusion of this case, we framed three clarifications as under –

1. What is CLD and related complications?
2. Whether repudiation of claim was justified by OP in reference to 4.1?
3. Justification of one Colored evidence?

1-CLD and related Complications- Chronic liver disease/Cirrhosis-

What is cirrhosis? Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the liver from working normally. Cirrhosis is a long-term (chronic) liver disease. The damage to liver builds up over time. The liver is body’s largest internal organ. It lies up under your ribs on the right side of your belly. The liver does many important things including:

• Removes waste from the body, such as toxins and medicines
• Makes bile to help digest food
• Stores sugar that the body uses for energy
• Makes new proteins

When have cirrhosis, scar tissue slows the flow of blood through the liver. Over time, the liver can’t work the way it should. In severe cases, the liver gets so badly damaged that it stops working. This is called liver failure.

What causes cirrhosis?  The most common causes of cirrhosis are:

• Hepatitis and other viruses
• Alcohol abuse
• Nonalcoholic fatty liver disease (this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides, and high blood pressure)

What are the symptoms of cirrhosis? Symptoms may vary, depending on how severe cirrhosis is. Mild cirrhosis may not cause any symptoms at all. Symptoms may include:

• Fluid buildup in the belly (ascites)
• Vomiting blood, often from bleeding in the blood vessels in the food pipe (esophagus)
• Loss of appetite
• Easy bruising
• Low energy and weakness (fatigue)
• Weight loss

How is cirrhosis diagnosed? Tests including:

• Blood tests,
• Liver biopsy,
• CT scan (computed tomography)
• MRI (magnetic resonance imaging)
• Ultrasound
• Upper endoscopy (EGD)

Complications of cirrhosis- Cirrhosis can cause other health problems such as:

• Portal hypertension
• Enlarged blood vessels
• Ascites
• Kidney disease or failure
• Easy bruising and severe bleeding
• Type 2 diabetes
• Liver cancer

Key points about cirrhosis

• Cirrhosis is when scar tissue replaces healthy liver tissue. This stops the liver from working normally.
• Cirrhosis is a long-term (chronic) liver disease.
• The most common causes are hepatitis and other viruses, and alcohol abuse. Other medical problems can also cause it.
• The damage to liver usually can’t be reversed. May require liver transplantation.

So by going through this medical text it is clear that CLD is a very chronic condition and mainly occur due to Alcohol abuse.     

2 -Whether repudiation of claim was justified by OP in reference to 4.1/Pre existing disease?         

Rejection under exclusion clause 4.1 is only justified when OP has properly investigated the pre existing cause and facts as here complainant was having bleeding from GIT and took advice in Feb. 2009 and the evidence was submitted on record by OP. As far as 4.1 exclusion is concerned, OP has taken base from new exclusion terms and conditions under clause 4.1 from when complainant had opted enhancement of SA from 1.5 lacs to 4 lacs where 4.1 exclusion clause clarify for Pre existing diseases and limitation of 48 months was from 2011 onward whereas complainant took treatment from 07/01/2013 to 12/01/2013.

We have also scrutinized the OP evidence as Ex. 1 where it has been written about malena in 2009 and had blood vomiting and the diagnosis was as F/U/C of CLD. All the detail investigations, advice and treatment was taken in Feb 2009 and he took mediclaim policy in March 2009. This clearly proves that complainant had full knowledge of bleeding due to CLD/GIT and did not disclose in the policy proposal form. This amounts to concealment of material fact about his ailment. Thus rejection was justified.   

3- Justification of one Colored evidence submitted by complainant ?

As this evidence was neither submitted on affidavit nor any relevance with OP products, so cannot be relied for consideration in this case.  

Hence, this complaint has no merit as complainant has failed to prove deficiency of OP in rejecting his claim. So, this complaint deserved to be dismissed so dismissed without cost

 

Copy of this order be sent to the parties as per Act and file be consigned to Record Room.

 

(Dr) P N Tiwari  Member                                                                         Mrs  Harpreet Kaur  Member                                                                                                                         

                                      

                                                  Shri  Sukhdev Singh  President