Punjab

Ludhiana

CC/19/401

Monika - Complainant(s)

Versus

United India Insurance Company Limited - Opp.Party(s)

Kunal Vohra Adv.

07 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:401 dated 21.08.2019.                                                         Date of decision: 07.11.2023.

 

Monika wife of Late Sh. Raj Kumar, R/o. H. No.1931/78/18D, St. No.10, Gandhi Nagar, Gurudwara Wali Gali, Bagga Kalan, Ludhiana.                                                                                                               ..…Complainant

                                                Versus

United India Insurance Company Ltd., Divisional Office-1 at SCO-18-19-C, First Floor, Canal Colony, Near Nehru Sidhant Kendra, Pakhowal Road, Ludhiana, through its Manager./Authorized Signatory.                                                                                                                            …..Opposite party

Complaint Under section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Kunal Vohra, Advocate.

For OP                           :         Sh. Rajneesh Lakhanpal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that Sh. Raj Kumar Dang, husband of the complainant had been availing one Medical Insurance under the Family Medicare Policy Plan from the OP since the year 2008 vide different policy numbers. Even policy No.2007002818P108351455 under the Family Medicare Policy Plan from the OP was in existence having validity till 23.09.2019 vide which the complainant and her family was fully medically insured with assurance to provide full insurance claim in case of any medical ailments. The complainant further stated that in the month of November 2018, the complainant suffered an acute liver problem and resultantly she remained hospitalized at DMC Hospital, Ludhiana w.e.f. 08.11.2018 to 20.11.2018. She approached the OP regarding her medical claim but the OP told her husband to pay all the related expenses from his own pocket with assurance to reimburse the same later on, upon which her husband spent Rs.1,41,110/- as hospital bill and Rs.52,209/- as medicine expenses from his own pocket. The complainant further stated that her husband got hospitalized in DMC Hospital w.e.f. 15.01.2019 to 24.01.2019 and intimation was given to the OP through their agent Mr. Shaminder Singh. The husband of the complainant spent Rs.49,765/- and Rs.10,233/- from his own pocket on hospital bills and medicines.  Unfortunately, the disease of the husband of the complainant was not cured and he died on 06.03.2019. The complainant lodged the claim along with documents with the OP who assured to reimburse all the amount within short span. The complainant many times requested the OP for reimbursement of claim amount by ending reminders in writing as well as orally but they did not accede to her genuine request. The complainant served a legal notice upon the OP but no response was given. Hence this complaint, whereby the complainant has prayed for issuing direction to the OP to pay the requisite claim of Rs.2,53,317/- along with compensation of Rs.1,00,000/- and litigation expenses.  

2.                Upon notice, the opposite party filed written statement and assailed the complaint by taking preliminary objections on the ground of maintainability of complaint; suppression of material facts etc.  The OP stated that the claim of Mr. Raj Kumar Dang was rightly denied/repudiated after due consideration and taking into account all the relevant facts including terms and conditions and exclusion clause of the policy. The claim was found to be in contravention of the terms and conditions of the health insurance policy and it falls within the permanent exclusion clause of the policy bearing No.4.9.  The OP further stated that it observed that the patient admitted with C/o DM Type 2 with Hypoglycemic seizure with chronic liver disease with chronic alcoholic and chronic smoker which falls within the exclusion clause bearing No.4.9, which is reproduced as under:-

“Convalescence, general debility; run-down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxication drugs/alcohol."

According to the OP, the complainant has mentioned two claims in the complaint but only one claim for the period of 08.11.2018 to 20.11.2018 was lodged with them.

                   On merits, the OP reiterated the crux of averments made in the preliminary objections and facts of the case. The OP has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of her claim, the complainant tendered her affidavit Ex. CA in which she reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of Aadhar card of the complainant, Ex. C2 is the coy of Aadhar card of Raj Kumar Dang, Ex. C3 is the copy of insurance policy, Ex. C4 is the copy of discharge summary dated 20.11.2018,  Ex. C5 is the copy of hospital bill dated 20.12.2011, Ex. C6 to Ex. C113 are the bills of medicines, Ex. C114 is the copy of discharge summary dated 24.01.2019, Ex. C115 to Ex. C144 are the bills of medicine, Ex. C145 is the copy of death certificate, Ex. C146 to Ex. C151 are the copies of reminders issued by the complainant, Ex. C152 is the coy of death summary of Deepak Hospital, Ex. C153 is the copy of legal notice, Ex. C154 is the postal receipt, Ex. C155 is the copy of detailed hospital bill dated 24.01.2015 and closed the evidence.

4.                On the other hand, counsel for the OP tendered affidavit Ex. RA of Ms. Lipi Moitra, Assistant Manager of the OP along with documents Ex.  R1 is the copy of report of detective, Ex. R2 to Ex. R4 is the copy of discharge summary of Raj Kumar, Ex. R5 is the copy of insurance policy w.e.f. 24.09.2018 to 23.09.2019, Ex. R6 is the copy of repudiation letter dated 05.04.2019 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with documents produced on record by both the parties.

6.                Complainant Smt. Monika being wife of one Raj Kumar Dang has filed the present complaint stating therein that the deceased was a subscriber of Family Medicare Policy Plan from the opposite party since the year 2008. It was lastly renewed for a period from 24.09.2018 to 23.09.2019 Ex. C3 = R5 having a coverage of Rs.3,00,000/-. On 08.11.2018, Raj Kumar Dang was admitted in Dayanand Medical College & Hospital, Ludhiana and remained hospitalized till 20.11.2018 and an expenses of Rs.1,41,110/- as hospital expenses and Rs.52,209/- as medicine expenses were incurred on his treatment. Raj Kumar Dang was discharged on 20.11.2018 vide discharge summary Ex. C4 = R2 with the following diagnosis:-

                   1. DM Type-II

                   2. Hypoglycemic Seizure

                   3. Recurrent Hypoglycemia

                   4. CLD CTP 6A with portal hypertension

                   5. AKI (Resolving)

                   6. COPD

                   7. Chronic Alcoholic

                   8. Chronic Smoker

7.                Secondly, Raj Kumar Dang was admitted in Dayanand Medical College & Hospital, Ludhiana on 15.01.2019 and remained hospitalized till 24.01.2019 and an expenses of Rs.49,763/- as hospital expenses and Rs.10,233/- as medicine were incurred on his treatment. Raj Kumar was discharged on 24.01.2019  vide discharge summary Ex. C114 with the following diagnosis:-

                   1. Chronic Alcoholic

                   2. Chronic Liver Disease (Alcohol Related) with ASCITES

                   3. Esophageal Varices

                   4. Benign Duodenal Ulcer

                   5. Diabetes Mellitus Type-II

                   6. Right Submandbular Abscess

Unfortunately, on 06.03.2019, Raj Kumar Dang died at Deepak Hospital, Ludhiana. Death summary is Ex. C152 was issued by Deepak Hospital, Ludhiana mentioning cause of death as “Respiratory Failure with Shock” with final diagnosis of CLD with PHT with ascites with hepatic encephalopathy – grade III with renal dysfunction with respiratory failure. As per death summary Ex. R152, Raj Kumar Dang was a known case of DLD/PHTN/Ascites/HE grade – II (Duodenal ulcer with adema- DM-II x 3 years (on regular Rx) as well as history of surgery Lap. Cholecystectomy since 2008.

8.                Admittedly, out of two claims, only one pertaining to first hospitalization i.e. 08.11.2018 to 20.11.2018 with DMC & Hospital, Ludhiana was submitted, which was declined by the opposite party vide repudiation letter dated 05.04.2019 Ex. R6 by invoking clause 4.9 of the policy. The exclusion clause 4.9 of the policy terms and conditions reads as under:-

“Convalescence, general debility; run-down condition or rest cure, obesity treatment, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self-injury and use of intoxication drugs/alcohol."

The opposite party deputed Raksha Health Insurance TPA Pvt. Ltd., Chandigarh for investigating the claim regarding hospitalization of Raj Kumar Dang, who submitted its report Ex. R1 by making following observation and opinion:-

1. Patient admitted with C/o. DM Type-2 with Hypoglycemic seizure with Chronic Liver Disease with Chronic Alcoholic and Chronic Smoker,
2. As the patient is Chronic Alcoholic and Disease due to Alcohol and its complications falls under permanent exclusion of the policy.

3.Hence claim is recommended to be non-payable as per clause 4.9.

From the perusal of the evidence on record, especially with regard to the treatment given to Raj Kumar Dang by Dayanand Medical College & Hospital, Ludhiana vide discharge summary Ex. C4 as well as discharge summary Ex. C114, it emerges that the patient aged about 50 years at the time of his aforesaid hospitalizations was suffering from multiple medical problems such as DM Type-2 with Hypoglycemic seizure with Chronic Liver Disease with Chronic Alcoholic and Chronic Smoker etc. All these conditions cannot be said to have been developed overnight or within few days prior to his hospitalization on 08.11.2018. Rather, from the condition described in the death summary Ex. C152, it can be safely inferred that Raj Kumar Dang must have been suffering from the diseases for quite some time.

9.                The claim has been repudiated invoking clause 4.9 of the policy which refers to mis-abuse of drug, alcohol or use of intoxicating substance. In the instant case, though the deceased was a chronic alcoholic as well as chronic chain smoker and the health conditions/ailments are stated to be induced by smoking. Therefore, the deceased being a chronic alcoholic as well as chronic smoker, comes within the ambit of clause 4.9 of the policy. Therefore, in our considered view, the repudiation of the claim on the basis of clause 4.9 of the policy cannot be said to be unjustified.

10.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.            

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:07.11.2023.

Gobind Ram.