National Consumer Disputes Redressal
Kamlesh Gupta vs Icici Lombard General Insurance ... on 18 February, 2016
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI FIRST APPEAL NO. 1450 OF 2014 (Against the Order dated 20/11/2014 in Complaint No. 17/2013 of the State Commission Punjab) 1. KAMLESH GUPTA W/O. SHRI PARAMJIT GUPTA, R/O. 2563, PHASE-I, URBAN ESTATE, DUGRI ROAD, LUDHIANA, PUNJAB ...........Appellant(s) Versus 1. ICICI LOMBARD GENERAL INSURANCE COMPANY LTD. & 2 ORS. GENERAL INSURANCE COMPANY LTD., REGD. OFFICE: ICICI TOWERS, BANDRA, KOTLA COMPLEX, MUMBAI-400051 MAHARASHTRA 2. M/S. ICICI LOMBARD THROUGH ITS BRANCH MANAGER, GENERAL INSURANCE COMPANY LTD., FLOOR, SCO NO. 24-25, SECTOR-8-C, MADHYA MARG, CHANDIGARH-160017 3. M/S. INDIA BULLS FINANCIAL SERVICES LTD. 16/17, FIRST FLOOR, FORTUNE CHAMBERS, FEROZE GANDHI MARKET, LUDHIANA-141001 PUNJAB ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE V.K. JAIN, PRESIDING MEMBER HON'BLE DR. B.C. GUPTA, MEMBER For the Appellant : Mr. D. K. Sharma, Advocate For the Respondent : For Respondent Nos. 1&2 : Mr. Anuj Chauhan, Advocate For Respondent No. 3 : Ms. Juhi Chawla, Proxy Counsel for Ms. Kanika Agnihotri, Advocate Dated : 18 Feb 2016 ORDER JUDGMENT JUSTICE V.K.JAIN, PRESIDING MEMBER (ORAL) Late Sh. Loveleen Gupta, son of the complainant/petitioner took a loan of Rs. 76 lakhs from the respondent no. 3, Indiabulls Financial Services Ltd. The financer made a deduction towards payment of the premium, which was paid to ICICI Lombard GIC Ltd. for taking an insurance cover in the name of the borrower Mr. Loveleen Gupta. The coverage of the insurance taken in the name of the insured, Mr. Loveleen Gupta, was as under:-
No. Coverage Sum Insured Section Insured Even Applicable I Major Medical Illness & Procedures
a) Diagnosis of the following Illnesses, namely:
List of covered illnesses: Cancer, End Stage Renal Failure, Multiple Sclerosis
b) Undergoing of the following surgical procedures:
List of covered procedures: Major Organ Transplant, Heart Valve Replacement or Coronary Artery Bypass Graft.
c) Occurrence of the following Medical Events:
List of covered events: Stroke, Paralysis and Myocardial Infarction 2,082,118 II Personal Accident
a) Death of the Insured on account of an Accident;
b) Permanent Total Disablement of the Insured on account of Accident;
III Loss of Job (Only for Salaried) Loss of employment of the insured 3 EMI's
2. Late Sh. Loveleen Gupta, who at that time was aged about 28 years, suffered from dengue fever and was admitted in Satguru Partap Singh Apollo Hospitals at Ludhiana, where he died on 28.09.2008. The death summary, to the extent it is relevant, reads as under:-
HOSPITAL COURSE:
After admission initial blood investigations revealed severe thrombocytopenia TLC: 4400, Platelet: 0.16lakh, PTTK-60sec. INR: 1.4. SGOT: 1040, SGPT: 1268, IgG- Not Detected, IgM-weakly positive. USG abdomen showed borderline hepatosplenomegaly with altered hepatic echo texture & thickened edematous gall bladder. X-ray chest showed Bilateral pleural effusion more on right side with underlying collapse/consolidation right lung. Patient was transfused 2 units of SDP on day one and later also SDP were transfused according to regular monitoring of platelet count (subsequent platelet count & other blood investigations are attached along with). As the condition of patient deteriorated patient was shifted to ICU where as his condition further deteriorated patient was intubated and connected to ventillatory support. In spite of the best efforts of treating physicians condition of patient kept deteriorating patient went into renal failure not responding to conservative therapy so on recommendation of nephrologists. Patient was haemodialysed three times on alternate days. Due to hypotension inotropic support started. Though his renal parameters and platelet count showed some improvement pit his general condition kept deteriorating on 28/09/2008 had sudden cardiac arrest. In spite of all timely and proper resuscitative measures patient could not be revived. Patient declared dead on 28.09.2008 at 10.30pm."
3. A claim for payment in terms of the insurance policy taken in the name of the deceased was submitted by his widow. The claim, however, was repudiated by the insurer vide letter dated 03.01.2009, which, to the extent it is relevant, reads as under:-
"On processing of the above documents it is evident that the loss suffered by insured was, Dengue Fever with severe thrombocytopenia, which is evident from copy of death summary from Satguru Pratap Singh Apollo Hospitals, which falls within 90 days from the Policy inception date. The ailment falls outside the purview of the nine major medical illnesses and procedures defined and covered under the Policy.
As per Exclusion clause 2.1.4 EXCLUSIONS APPLICABLE TO SECTION 1(MAJOR MEDICAL ILLNESS & PROCEDURES) point c) "The Company shall not be liable to make any payment under this Policy in connection with or in respect of any Insured event, as stated in this Section, occurred or suffered before the commencement of the Period of Insurance or arising within the first 90 days of the commencement of the Period of Insurance.
In view of the above and inter-alia the reasons stated we regret our inability to pay your claim. However we remain committed to you and assure you the best services at all times."
4. Being aggrieved from the rejection, the mother of the deceased namely Smt. Kamlesh Gupta approached the concerned State Commission by way of a complaint. The complaint was resisted by the insurer primarily on the same grounds on which the claim had been repudiated.
5. Vide its order dated 20.11.2014, the State Commission dismissed the complaint. Being aggrieved, the complainant is before us by way of this First Appeal.
6. The first question, which arises for our consideration is as to whether the deceased had died on account of any of the illnesses or had undergone any of the procedures covered in the insurance policy taken in his name. The contention of the learned counsel for the appellant is that not only had the deceased suffered end stage renal failure, he had also suffered myocardial infarction leading to cardiac arrest. The learned counsel has relied upon the description of myocardial infarction given in Wikipedia, where it is, inter-alia, stated that a myocardial infarction may cause heart failure, an irregular heartbeat or cardiac arrest. However, in the present case, cardiac arrest suffered by the deceased before he died was not on account of a myocardial infarction. Myocardial infarction is heart attack which occurs when blood flow stops to a part of the heart, causing damage to the heart muscle. However, in the present case, the deceased was suffering from dengue fever, which could not be controlled, as a result of which his platelets came down. Since his condition kept on deteriorating, he was shifted to ICU, where he was kept in ventilator. Despite efforts made by the doctors, his condition did not improve and he went into renal failure, not responding to the treatment given by nephrologist. He suffered sudden cardiac arrest on 28.09.2008 and expired on the same date. It is, therefore evident that cardiac arrest followed an uncontrolled dengue fever which had led to multiple organ failure, including renal failure. It is myocardial infarction and not a cardiac arrest, which was covered under the insurance policy, taken in the name of the complainant and since no myocardial infarction was suffered by him, it cannot be said that the death due to cardiac arrest suffered by him was covered under the insurance policy.
7. Coming to the question as to whether the deceased had suffered from end stage renal failure, no medical literature has been produced before us to show that a renal failure, on account of an uncontrolled dengue fever, can be said to be end stage renal failure. In our opinion, if a person suffers from chronic kidney disease (CKD) and eventually the said illness leads to end stage renal failure and causes his death, such a renal failure would come under the illness covered under the insurance policy taken by the deceased. It is where the renal disease leads to eventual renal failure and consequent death of the patient that the illness would be covered. Renal failure on account of illness other than a chronic kidney disease, in our opinion, would not be covered under the said policy.
8. Another important reason why the complainant is not entitled to any payment from the insurer is clause 2.1.4 of the Exclusion Clause, attached to the policy which, inter-alia, provides that the insurer shall not be liable to make any payment under the policy in connection with or in respect of any insured event occurred or suffered before the commencement of the period of insurance or arising within the first 90 days of the commencement of the period of insurance. Admittedly, the deceased died within 90 days of the commencement of the policy and, therefore, if the aforesaid Exclusion Clause is applied, insurer is not liable to pay any amount to the complainant.
9. The contention of the learned counsel for the petitioner/complainant is that since the terms and conditions relied upon by the insurer were never supplied to the insured, the insurer cannot be permitted to rely upon such a condition. Reliance in this regard is placed upon the decision of this Commission in National Insurance Company vs. D. P. Jain, 2007 (2) CLT 468. In our opinion, the complainant can have no personal knowledge as to whether the terms and conditions applicable to the policy taken by the deceased were supplied to him or not, such an evidence being only in the knowledge of the insured. Therefore, any averment to this effect by the complainant cannot be accepted. Moreover, admittedly the deceased was an educated person. It is clearly stated in the cover note issued to the deceased that policy was covered by and was subject to the terms, conditions and exclusions therein contained or otherwise expressed in the said policy. Had the terms and conditions applicable to the policy not been supplied to him, the deceased, he being an educated person, would atleast have written a letter to the insurer, claiming that the said terms, conditions and exclusions had not been supplied to him. Since no such letter was written by him, the inference would be that the terms and conditions applicable to the policy were either supplied to him or were brought to his notice and that is why he did not write any such letter to the insurer. We, therefore, are not inclined to accept the plea that the terms and conditions attached to the insurance policy were neither made available nor made known to the deceased.
10. For the reasons stated hereinabove, we find no merit in the appeal and the same is accordingly dismissed. No order as to costs.
......................J V.K. JAIN PRESIDING MEMBER ...................... DR. B.C. GUPTA MEMBER