IN THE DISTRICT CONSUMERS’ DISPUTES REDRESSAL FORUM AT MYSORE<br /> PRESENT: 1. Shri.A.T.Munnoli<br /> B.A., L.L.B (Spl.) - President <br /> <br /> 2. Smt.Y.V.Uma Shenoi<br /> M.Sc., B.Ed., - Member<br /> 3. Shri. Shivakumar.J.<br /> B.A., L.L.B., - Member<br /> <br /> CC 265/09 DATED 06.10.2009<br /> ORDER<br /> Complainants 1. Smt.I.H.Nayana, <br /> W/o Late I.S.Himesh<br /> 2. I.H.Vilas Chengapp, <br /> S/o Late I.S.Himesh, <br /> Rep. by his natural guardian mother 1st complainant.<br /> Both are R/at D.No.HIG, 1519, 3rd Main, 6th Cross, Vivekanandanagara, Mysore.<br /> (By Sri. S.V.Nagendra, Advocate)<br /> Vs. <br /> Opposite Parties 1. The Divisional Manager, United India Insurance Company Limited, Divisional Office No.1, Prince of Wales Road, Chamarajapuram, Mysore-05.<br /> 2. Manager, <br /> The Family Health Plan Limited, Millers Point, No.1, 2nd Floor, 11th Main, Vasanathnagar, Bangalore-52.<br /> (By Sri. Jaganath Suresh Kumar, Advocate for O.P.1 <br /> and O.P.2 - EXPARTE)<br /> Nature of complaint : Deficiency in service<br /> Date of filing of complaint : 23.07.2009<br /> Date of appearance of O.P. : 11.08.2009<br /> Date of order : 06.10.2009<br /> Duration of Proceeding : 1 MONTH 26 DAYS<br /> <br /> <br /> PRESIDENT <br /> <br /> <br /> <br /> MEMBER<br /> <br /> <br /> MEMBER<br /> <br /> <br /> Sri. A.T.Munnoli,<br /> President<br /> <br /> 1. Under Section 12 of the Consumer Protection Act, the complainants have filed the complaint against the opposite parties, seeking direction to pay a sum of Rs.74,300/- with interest regarding medical expenses of the deceased insurance policy holder and also a sum of Rs.2,00,000/- compensation for mental agony, loss and sufferings due to deficiency in service by the opposite parties.<br /> <br /> 2. In the complaint, it is alleged that, husband of the first complainant and father of second complainant was holder of mediclaim insurance policy No.070603/48/06/20/00000069 covering hospitalization benefits for self and family members relating disease, sickness or injury. The policy was valid from 10.05.2006 to 09.05.2007. He was admitted to Apollo BGS Hospital, Mysore on 09.03.2007 with a complaint of external dyspnoea. The condition was stable till 13.03.2007. On the next day, he developed sudden sensorium and paucity of movements of right upper limb and lower limb. He was shifted to MICU. The level of sensorium was deteriorating, he was taken for surgery. He was incubated and was put to ventilator. On 16.03.2007, the condition was poor. He continued to deteriorate. Scanning showed extensive brain stem infarct. With permission of the attendant of the patient, life support was withdrawn and was declared dead on 16.03.2007. The complainants submitted claim along with records and bills to opposite parties. Second opposite party denied the claim, on the basis of death summary issued by Apollo BGS Hospital, Mysore, coming to the conclusion “Case of AWMI”. It is baseless inference drawn by the second opposite party. Deliberately claim was repudiated under Clauses 4(1) and 4(8) of the policy. It is highly arbitrary and unjust. The reasons given by the opposite parties are not related to the cause of death of the deceased. The death is, because of brain stem failure, malignant cerebram oedema and cerebro vascular accident. The death is nowhere related to the reason AWMI. Brain stem failure is a sudden stroke to the brain. It has caused the death. The known case of alcoholism is not related to the cause of death. There is deficiency in service on the part of the opposite parties in rejecting the claim of the complainants on wrong and unjustifiable reasons. The complainants are entitled for entire medical expenses of Rs.74,300/- from the opposite parties. On these grounds, it is prayed to allow the complaint.<br /> <br /> 3. The first opposite party in the version amongst other facts has contended that, the second opposite party is third party administrator and independent body empowered to deal with health insurance services. The liability of the company under the policy is strictly as per terms and conditions. Pre-existing diseases are not covered under the policy. With reference to the death certificate issued by Apollo BGS Hospital, Mysore amongst other facts, it is stated that the patient was diagnosed as a case of brain stem failure, malignant cerebram oedema and cerebro vascular accident (large left MCA territory infract) old case of AWMI and was diagnosed as alcoholic dilated cardio myopathy with LV dysfunction etc., The patient was a known case of chronic alcoholic since long time and hence, as per the terms and conditions of the policy, repudiation of the claim is just and proper. Hence, it is prayed to dismiss the complaint.<br /> <br /> 4. The second opposite party despite due service of notice, has remained absent. Hence, it is set exparte.<br /> <br /> 5. To prove the facts alleged in the complaint, first complainant has filed her affidavit and certain documents are produced. On the other hand, for the first opposite party, Assistant Manager has filed his affidavit and produced certain documents. For the complainant written arguments with citations are filed. We have heard both the learned counsel and perused the material on record.<br /> <br /> <br /> 6. Now the points arises for consideration are as under:-<br /> 1. Whether the complainants have proved any deficiency in service on the part of the opposite parties and that they are entitled to any reliefs?<br /> 2. What order?<br /> <br /> 7. Our findings are as under:-<br /> Point no.1 : <br /> Point no.2 : As per the order.<br /> <br /> REASONS<br /> <br /> 8. Point no. 1:- From the facts, it is found that, deceased Himesh on the date of death was covered by the mediclaim policy is proved and admitted. The claim has been repudiated by the opposite parties under Clauses 4(1) and 4(8) of the policy.<br /> <br /> 9. Clause 4(1) provides that, “All diseases/injuries, which are pre-existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of the initial mediclaim policy taken from any of the Indian Insurance Company shall be taken, provided the renewals have been continuous and without any break.<br /> <br /> 10. Clause 4(8) provides that, “Convalescence, general debility; run-down condition or rest cure, congenital external disease or defects or anomalles, sterility, venereal disease, intentional self injury and use of infoxlcation drugs/alcohol.<br /> <br /> 11. The death summary copy that was submitted by the complainant to the opposite parties along with claim, is on record. From this death summary, it is found that Mr.Himesh was admitted on 09.03.2007 with a complaint of external dyspnoea since 15 days. He was an alcoholic. He was diagnosed as Alcholic dilated cardio myopathy with LV dysfunction with mild pulmonary oedema and alcoholic hepatitis. On 14th March, patient developed sudden altered sensorium and paucity of movements of right upper limb and lower limb. He was shifted to MICU. He was diagnosed to have a left MCA territory stroke. On the next day, his liver of sensorium was deteriorating and scan showed a large left LCA infarct and was taken for surgery. Subsequently, he was incubated and was put on ventilator. Repeated scan showed extensive brain stem infarct. He was diagnosed as brain stem failure with malignant cerebram oedema. Later, with consent life support was withdrawn and declared dead on 16th March.<br /> <br /> 12. Advocate for the first opposite party has produced medical literature in respect of dyspnoea, which means shortness of breath or uncomfortable respiratory sensations. Alcoholic hepatitis means inflammation of the liver due to excessive intake of alcohol. Symptoms are ---- fatigue and hepatic encephalopathy (brain dysfunction due to liver failure). Defintion of alcoholic cardio myopathy is a disorder in which drinking too much alcohol over a long period of time weakens the heart muscle so that it cannot pump blood efficiently. Alcoholic cardio myopathy is a form of a condition, in which the heart becomes enlarged and the heart muscle thins due to alcohol abuse. It may lead to heart failure. As regards, the stroke/cerebro vascular accident, it is stated, a stroke is rapidly developed in loss of brain function due to disturbance in the blood supply to the brain. It was referred to as “CVA”. Myocardial infarction (MI) or acute myocardial infarction (AMI) commonly known as a heart attack is the interruption of the blood supply to a part of the heart. Heart attack are the leading cause of death and important risk factors are tobacco smoking ------ extensive alcohol consumption.<br /> <br /> 13. Hence, with reference to the medical literature referred to above and the death summary issued by the Hospital, which is admittedly produced by the complainants, prima-facie established that the deceased was an Alcoholic and he was diagnosed as Alcoholic dilated Cardio Myopathy with LV dysfunction with mild pulmonary Oedeme and alcohol hepatitis. Consequently, the claim has been repudiated mainly with reference to clause 4.8. Dence, under the circumstances, repudiation of the claim of the complainants cannot be termed as “unjust or illegal”.<br /> <br /> 14. Though, the advocate for the complainants vehemently argued that unilaterally the opposite parties repudiated the claim, here, it is important to note that the opposite parties to repudiate the claim of the complainants, relied on the admitted documents that the complainants themselves had produced and relied upon to make the claim. It is not that the opposite parties have obtained different opinion of the experts and have come to a different conclusion. Rejection of the claim is based on the documents of the complainants.<br /> <br /> 15. Advocate for the complainants relied on certain rulings. In (2001) NCT 580, repudiation of the claim was set aside on the ground that no incorrect information was supplied by the insured. In the case on hand, as noted here before, from the documents of the complainants, it is made out that clause 4.8 is attracted. In (2003) NCJ 708, there was no documentary or oral evidence to substantiate the contention that material fact was not disclosed. Such are not the facts of the case on hand. In (2003) NCJ 496, claim was repudiated on the ground of suppression of ailment. In the case on hand, the claim has been repudiated not only under clause 4.1, but, also clause 4.8. In {1998) NCJ 401, repudiation was for the reason insured withheld correct information, as regards his health. As noted above, in the case on hand, repudiation is also under clause 4.8. For the same reason, the ruling in (1998) NCJ 665 is not helpful to the complainants. (1999) NCJ 314 is relied upon, wherein company had failed to prove insured had concealed the fact in the proposal. But, in the case hand, as noted above, the documents placed on record by the complainants support the contention of the opposite parties to repudiate the claim. Hence, these rulings are not helpful to the complainants.<br /> <br /> 16. Considering the facts, evidence and the discussion made here before, we are of the opinion that the complainants have failed to prove deficiency in service on the part of the opposite parties. <br /> <br /> 17. Accordingly we answer the point in negative.<br /> <br /> 18. Point No. 2:- Considering the discussion made above and conclusion arrived at, we pass the following order:- <br /> <br /> ORDER<br /> <br /> 1. The Complaint is dismissed.<br /> 2. There is no order as to cost.<br /> 3. Give a copy of this order to each party according to Rules.<br /> <br /> (Dictated to the Stenographer, transcribed by her, transcript revised by us and then pronounced in the open Forum on this the day 6th October 2009)<br /> <br /> <br /> <br /> <br /> <br /> (A.T.Munnoli) <br /> President <br /> <br /> <br /> <br /> (Y.V.Uma Shenoi)<br /> Member<br /> <br /> <br /> <br /> (Shivakumar.J.)<br /> Member<br /> <br />