BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM, IDUKKI Dated this the 29th day of May, 2009
Present: SRI.LAIJU RAMAKRISHNAN PRESIDENT SMT.SHEELA JACOB MEMBER SMT.BINDU SOMAN MEMBER
C.C No.118/2008 Between Complainant : Tiju P Thomas Poovathunkal House, Muttom P.O. Challavayal, Thodupuzha. (By Adv: Lissy M.M.) And Opposite Parties : 1. The Branch Manager, United India Insurance Co. Ltd., Prakash Building, Thodupuzha. 2. The Divisional Manager, United India Insurance Co. Ltd., Muvattupuzha, Ernakulam District. (Both by Adv: Lakshmanan T.J.)
O R D E R
SRI.LAIJU RAMAKRISHNAN(PRESDIENT)
The petition is filed for getting the Insurance amount of the medi-claim policy of the complainants father who is a cancer patient. The complainant has his parents took a medi-claim Insurance policy from the period 17/08/04 onwards. The father of the complainant paid Rs.1,902/- as premium. The amount of coverage is Rs.45,000/-. They renewed the premium till 17/08/06 to 16/08/07. On 12/04/06 father of the complainant was admitted in Amritha Hospital Ernakulam and diagnosed as CA lungs stage IV, for that treatment, the complainant's father spent many lakhs. After the treatment, the complainant's father claimed the treatment expenses from 12/09/06 to 28/09/06. The opposite party replied on 24/11/06 stating that the required information was not submitted and the disease was pre-existing one, so the claim was rejected. Since the complainants father was continuously treating for Ulcerative colitis, the opposite party excempted the claim for treatment from 2006 onwards. Hence the father of the complainant obtained a certificate from Amritha Institute of Medical Science certifying the Ulcerative colitis was not way related to the CA of lungs and it was sent to opposite party for reviewing the decision. On 26/02/07 again a letter was sent from complainant's side but the opposite party repudiated the claim on ground that the patient was a chronic smoker, hence under policy condition 4:8 the opposite party is not liable for giving claim. The patients disease is no way related to policy condition 4:8, and the opposite party willfully repudiated the claim. Moreover the complainants father was suffering from Ulcerative colitis and stopped smoking in the year 2006 itself. The same was also reported to opposite party. The father of the complainant spent a huge amount for treatment, repudiation of the claim made severe mental agony to the complainant and his father. So this petition is filed for getting the medi-claim Insurance amount and also for compensation. 2. As per written version of the opposite party the company repudiated the claim on 24/11/2006 and a letter given to the complainant on 27/02/2007 the condition 5:11 of the policy clearly specify that the company shall disclaim liability to the insured for claim here under, and if the insured shall not within 12 calender months from the date or receipt of notice of such disclaimer, notify the company in writing that he does not accept such disclaimer, and intends to recover the claim from the company, then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder. Here the insured himself admits that the company had repudiated this claim and there is no specific case for the insured that he had informed the company in writing that he does not accept such disclaimer within 12 months from the date of said disclaimer. So the complainant is clearly barred by limitation. As per the discharge summary issued from Amritha Hospital, Ernakulam, he was diagnosed as a case of Ulcerative Colitis and the same was proved 8 years back. It is also written that the patient is a chronic smoker and alcoholic. So as per exclusion condition 4.1 pre-existing diseases are not covered under the scope of policy. Further more company is not liable to make payment in respect of any diseases due to use of intoxication drugs, alcohol. The said condition clearly specified under exclusion clause 4.8 of the policy. The opposite parties had never caused any pain, hardship or mental agony to the insured as alleged in the complaint. Hence the petition is not entitled for any compensation for the same.
3. The point for consideration is whether there was any deficiency in service on the part of the opposite party; if so, for what relief the complainant is entitled to?
4. The evidence consists of the oral testimony of PW1 and Exts.P1 to P8 on the side of the complainant and Ext.R1 on the side of the opposite parties.
5. The POINT:- The medi-claim policy of the complainant is admitted by the opposite parties. The father of the complainant was treated in Amritha Institute of Medical Science, Ernakulam for cancer and it is now in the chronic stage. The claim is repudiated by the opposite party for the reason of pre-existing disease, and the insured was a chronic smoker and Alcoholic. The complainant was examined as PW1. PW1 deposed that the policy was taken by his father from 17/08/04 and continued to review the premium till 17/08/06 to 16/08/07. Ext.P1 is the copy of the same. Father of PW1 was affected with "CA lungs stage IV-Liver and Extensive Skeletal Metastasis". The discharge summary from the Amritha Institute of Medical Science is marked as Ext.P2. The treatment expenses were very high, the claim was repudiated by opposite party by the reason that it was pre-existing disease. Ext.P4 is the repudiation letter from the opposite party, dated 24/11/2006. But the complainant produced the certificate from Amritha Institute of Medical Science stating that this disease is not connected with any pre-existing disease which is Ext.P5.
6. As per the written version and the cross examination of the learned counsel, there was letter written from opposite party to the complainant on 27/02/07 in which the claim was repudiated. But no reply was given to that letter by the complainant. So the petition is barred by the conditions 5.11 of the policy.
As per 5.11 of the policy conditions, "If the Company shall disclaim liability in the Insured for any claim hereunder and if the Insured shall not within 12 calendar months from the date of receipt of the notice of such disclaimer notify the Company in writing that he does not accept such disclaimer and intends to recover his claim from the company then the claim shall for all purposes be deemed to have been abandoned and shall not thereafter be recoverable hereunder".
But as per PW1, a letter was given to the opposite party by the complainants father on 26/02/2007 which is Ext.P6 stating that the certificate from the doctor which is Ext.P5 already given to the company and the manager of the company convinced that a re-enquirey would be conducted for the consideration of the Insured's claim. And it is also requested in the letter that the insured is in very need of money for his treatment expenses, which is received by the opposite party on 28/02/2007. The AD card for the same is produced as Ext.P7. It is not challenged by the opposite party, further more his father was seriously affected at hospitalized at that time.
7. As per the Ext.P5 certificate issued from Dr.T.S Ganesan who is a professor, chairman and medical Oncologist, of Amritha Insititute of Medical Science, states that "The disease is not related with Ulcerative Colitis or amyloidosis". Therefore the contension of the opposite party, that the insured was having a pre-existing disease of Ulcerative colitis with Amyloidosis and related diseases, cannot sustain. The other intension is that insured is as a chronic smoker and alcohilic. So it is against the policy condition. But as per PW1 his father has already stopped smoking in the year 2006. The 62 years old chronic cancer patient suffered serious mental agony because of non-availability of insurance amount for his treatment expenses. The mediclaim insurance policy is introduced for getting the treatment expenses for diseases. Even after receiving premium, by giving all the assurances for the same, the company is trying to find out reason for repudiating the claim. It is the duty of the company to disburse the amount for the treatment of a person expecting death, who duly paid the premium. The company is initiating to find out reason for repudiating the claim. Before issuing the policy the company ought have investigated the previous history of the patient, whether he is a chronic smoker or alcoholic. So we think that the repudiation of the claim is a gross deficiency in the part of opposite party. And the insured is entitled to get the insurance amount. Hence the petition allowed. Opposite party is directed to pay the maximum insurance amount to the complainant for the medi claim policy as per Ext.P1 with 12% interest from the date of this petition. The opposite party is also directed to pay Rs.2,000/- for the cost of this petition within one month of receipt of a copy of this order, failing which the outstanding amount shall carry 12% interest from the date of default.
Pronounced in the Open Forum on this the 29th day of May, 2009.
Sd/- SRI.LAIJU RAMAKRISHNAN(PRESIDENT) Sd/- SMT.SHEELA JACOB(MEMBER)
Sd/- SMT.BINDU SOMAN(MEMBER) APPENDIX
Depositions : On the side of Complainants : PW1 - Tiju P Thomas On the side of Opposite Party : nil Exhibits: On the side of Complainants: Ext.P1 - Copy of Policy conditions Ext.P2 - Copy of discharge summary from Amritha Institute of Medical Sciences Ext.P3 - Copy of Medical Report Ext.P4 - Copy of letter from the opposite party dated 24/11/2006. Ext.P5 - Copy of certificate from Amritha Institute of Medical Sciences dated 13/10/09. Ext.P6 - Copy of letter dated 26/02/2007. Ext.P7 - Acknowledgement Card dated 28/02/2007 Ext.P8 - Copy of letter from United India Insurance Co. Ltd., dated 27/02/2007. On the side of Opposite Party : Ext.R1 - True copy of Medical Record from Amrita Institute of Medical Sciences
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