State Consumer Disputes Redressal Commission
Deepali Aggarwal vs Apollo Munich Health Insurance on 28 February, 2022
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH Appeal No. : 60 of 2020 Date of Institution : 02.03.2020 Date of Decision : 28.02.2022 Deepali Aggarwal wd/o Sh. Vineet Aggarwal r/o House No.1611, Sector 18-D, Chandigarh. ...Appellant/Complainant V e r s u s Apollo Munich Health Insurance, 4th Floor, SCO No.50-51, Sector 34-A, Chandigarh 160022, through its Authorised representative .....Respondent/opposite party BEFORE: JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT. MRS.PADMA PANDEY, MEMBER.
MR.RAJESH K. ARYA, MEMBER.
Present through Video Conferencing :-
Sh.Devinder Kumar, Advocate for the appellant.
Sh.Vishal Sharma, Advocate proxy for Sh.Sachin Ohri, Advocate for the respondent.
PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT This appeal has been filed by the complainant- Deepali Aggarwal (in short the appellant), feeling aggrieved by the order dated 24.01.2020 passed by the District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short the District Commission), whereby the consumer complaint bearing no.464 of 2018 filed by her was dismissed.
The District Commission noted down the following facts of the consumer complaint:-
".......complainant happens to be widow of deceased, Sh. Vineet Aggarwal who had taken health insurance plan of the OP in the year 2010. The same was continued on payment of the premium and the health insurance coverage was in respect of deceased, his wife (complainant) and two children to the tune of Rs.5,00,000/- per person. Her case is, the last time the policy was renewed on 12.5.2017 for a period of one year which had expired on 11.5.2018. Per policy, complainant being nominee is entitled to the amount of Rs.8,50,000/- i.e. Rs.5,00,000/- being sum assured and Rs.3,50,000/- being cumulative bonus earned over the past years. The short facts are deceased was admitted in Max Healthcare on 31.3.2017 and discharged on 1.4.2017 and thereafter remained admitted from 1.4.2017 and expired on 20.5.2017. The complainant being nominee filed claim amounting to Rs.28,96,382/- to the OP. Certain queries were raised and documents asked for. However, despite having been supplied the documents, her claim was repudiated per clause VI C v of the policy as treatment related to alcohol abuse which was excluded in the policy while the claim of the complainant is the deceased had renal failure due to sepsis incited as a result of bronchopneumonia and thus pleaded claim was wrongly repudiated....".
Reply was filed by the respondent, which was noted down by the District Commission in the impugned order as under:-
"...OP contested the consumer complaint, filed its reply and, inter alia, raised preliminary objections of consumer complaint being not maintainable and the claim is deceased, Sh. Vineet Aggarwal was admitted on 25.5.2018 and discharged on 26.5.2018 and as per Section 6 clause ii the claim was repudiated as deceased had chronic liver disease due to alcohol. Before repudiating the claim, certificates were obtained from the doctors of Max Hospital which certified deceased died due to use of ethanol. Besides the complainant had also preferred claim to ICICI Lombard, but, the result was not intimated.....".
In the rejoinder filed, the complainant reiterated all the averments contained in her complaint and controverted those contained in written version of the opposite party.
The contesting parties led evidence by way of affidavits and numerous documents before the District Commission.
The District Commission after hearing the contesting parties and on going through the material available on record, dismissed the consumer complaint, as stated above. Hence this appeal.
We have heard Counsel for the parties and gone through the material available on the record; including the written arguments/short synopsis.
The short question which needs consideration in this case is, as to whether, the disease for which treatment was taken by the insured-Sh.Vineet Aggarwal, now deceased, was covered under the insurance policy in question or not. For coming to any conclusion, we need to refer relevant condition contained in the policy document, Annexure C-22, which shows the major exclusions, as under:-
"Following is a partial list of the policy exclusions. Please refer to the policy wording for the complete list of exclusions.
War or any act of war, nuclear, chemical and biological weapons, radiation of any kind, breach of law with criminal intent, intentional or attempted suicide, participation or involvement in naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing, abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, treatment of obesity and any weight control program, Psychiatric, mental disorders, congenital Internal or external diseases, defects or anomalies, genetic disorders; sleep apnoea, expenses arising from HIV or AIDs and related diseases, sterility, treatment to effect or to treat infertility, any fertility, sub-fertility, surrogate or vicarious pregnancy, birth control, circumcisions, treatment for correction of eye due to refractive error, plastic surgery or cosmetic surgery unless required due to an Accident, Cancer or Burns, any non-allopathic treatment."
It is significant to mention here that the document Annexure C-22 has been placed on record by the appellant only. Perusal of the aforesaid condition makes it very clear that if any treatment is taken by the insured, which is related to abuse of alcohol, it is not covered under the policy in question.
Now we will like to refer to the etiology of illness dated 08.02.2018, Annexure R-5, of the deceased Sh.Vineet Aggarwal and the opinion of Dr. Nikhil Nadkarni, which is reproduced below:-
"1. Acute on chronic liver failure : Acute insult due to severe bronchopneumonia superimposed on chronic liver disease due to ethanol use.
2. Renal failure due to sepsis incited as a result of bronchopneumonia
3. Shock due to sepsis i.e. Septic Shock
4. GI bleed due to sepsis induced thrombocytopenia and coagulopathy."
From the afore-extracted etiology of illness, it is clearly established that the deceased Sh.Vineet Aggarwal had acute chronic liver failure and acute insult due to severe bronchopneumonia superimposed on chronic liver disease due to ethanol use. This itself shows that ethanol misuse had led to bronchopneumonia superimposed on chronic liver disease, which was one of the causes of death. Report further provides that the insured also suffered renal failure due to sepsis incited because of bronchopneumonia. The treating doctor has clearly opined that bronchopneumonia was the result of ethanol use and there was shock due to sepsis and GI bleed due to sepsis induced thrombocytopenia and coagulopathy. In these circumstances, we are of the considered opinion that the District Commission was right in holding that all these diseases were the outcome of ethanol use, which clearly falls in the exclusion clause. The District Commission was also right in holding that mere mentioning of some wrong section in the repudiation letter cannot be taken as a ground to say that the claim was wrongly repudiated, especially in the face of the major exclusions, Annexure C-22, extracted above, which was part of the policy in question, and was placed on record by the appellant herself.
As far as case bearing no.579, 580 of 2019 decided by the Permanent Lok Adalat (Public Utility Services), U.T., Chandigarh on 03.12.2021, is concerned, it may be stated here that the dispute therein was, as to whether, the deceased-Vineet Aggarwal had declared pre-existing disease in the proposal form, before obtaining the insurance policy from ICICI Lombard General Insurance Company Limited or not. As such, no help therefore can be drawn by the appellant from the said case filed against ICICI Lombard General Insurance Company Limited.
In view of the above discussion, it is held that the impugned order passed by the District Commission, dismissing the consumer complaint, being based on the correct appreciation of evidence and law on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission and the same stands upheld.
For the reasons recorded above, this appeal being devoid of merit must fail and the same stands dismissed with no order as to costs.
Certified copies of this order be sent to the parties, free of charge.
The concerned file be consigned to Record Room, after completion.
Pronounced 28.02.2022 _ Sd/-
[JUSTICE RAJ SHEKHAR ATTRI] PRESIDENT Sd/-
(PADMA PANDEY) MEMBER Sd/-
(RAJESH K. ARYA) MEMBER Rg