Vishavjot Singh, complainant has filed the present complaint against The Bajaj Allianz Insurance Company Limited (hereinafter called, the OPs)  U/S 12 of the Consumer Protection Act, 1986 (hereinafter for short, the C.P.Act.) in which he has prayed that the opposite party be directed to pay claim amount of Rs.4,96,121/- being the principle amount which was incurred by the complainant from his own pocket during his treatment/hospitalization  alongwith interest @ 18% per annum from the date of spending of principle amount till its realization. Opposite parties be further directed to pay Rs.20,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he alongwith his family members i.e. Mrs. Manpreet Kaur (wife) and Miss Vishanpreet Kaur (daughter) was insured with the opposite parties under the scheme namely “Bajaj Allianz family care first scheme” from the period of 12.4.2012 to 12.4.2015 as a matter of health insurance for all the members of the family after paying the annual premium of Rs.11,857/- alongwith other cesses for Rs.5,00,000/-. He was issued policy No.0260158836 dated 13.4.2012 under the said scheme after the considerable laps of about five to six months and no terms and conditions of the abovesaid policy was ever explained to him or his family members. Suddenly, on 18.6.2014, he felt uneasiness and developed certain physical complications by way of vomiting etc. with the result he reported himself to Civil Hospital, Batala immediately and Dr. referred him to Guru Nanak Dev Hospital, Amritsar for further treatment as the same was not within the competence of the doctor of the Civil Hospital, Batala but his family members got admitted him in Fortis Escort Hospital at Amrisar with the better understanding that he shall get proper and required treatment from Fortis Escort Hospital, Amritsar rather than from Guru Nanak Hospital, Amritsar. He remained admitted there from 19.6.2014 to 27.6.2014 and during his treatment he incurred the expenses amounting to Rs.65,700/- as hospitalization charges which was duly paid by him. Hence, he was discharged by the abovesaid hospital after getting the requisite treatment. He has further pleaded that again unfortunately on 2.8.2014 he developed complications regarding his health and on consultation and advice of Fortis Escort Hospital, Amritsar he remained admitted there for the period of 2.8.2014 to 7.8.2014 for further treatment of his health and incurred the expenses of his hospitalization charges amounting to Rs.29,578/. He has next pleaded that again unfortunately on 6.10.2014, he developed the same complications suddenly regarding his health and he approached the doctor on that day of the Fortis Escort Hospital Amritsar and on the advice of the doctors he was got admitted in the said hospital from the period of 6.10.2014 to 10.10.2014 and again incurred the expenses of his hospitalization charges amounting to Rs.26,894/- but he did not cure. Since he developed further complications regarding his health and was unable to improve to his fittest condition, his state of health further deteriorated on 20.10.2014 with the result he consulted the doctors of Dayanand Medical College and Hospital, Ludhiana for further treatment of the disease. The doctors attending on him at D.M.C. & H advised him that he must admit himself in the hospital for further treatment as the disease occurring to him requires immediate surgery. Consequently, he remained admitted in the abovesaid hospital from the period 21.10.2014 to 19.11.2014 for the treatment as well as surgery by the hospital doctors and spent the expenditure of Rs.3,63,021/- for the cure of the disease.  He again developed the same complications regarding his health and on consulting the doctors of D.M.C. & H at Ludhiana advised him to get himself admitted in the hospital with the result he remained admitted in the said hospital from 10.7.2015 to 11.7.2015 and incurred the expenses amounting to Rs.10,928/- as his hospitalization charges including the drugs charges as well as MRCP charges dated 9.7.2015 and in this way he spent total Rs.4,96,121/- on his treatment by way of his hospitalization charges etc. The opposite party was periodically informed about his hospitalization telephonically and otherwise also. He also requested them that his treatment in the hospitals be declared as Cashless facility in view of the abovesaid insurance but they refused the hospital authorities of cashless  treatment vide its letters dated 3.8.2014 and 7.10.2014. He submitted all the bills/invoices, cash memos of the expenditure incurred by him at various episodes but the opposite parties have refused to make the payment of the abovesaid treatment without following any lawful and legal procedure and verification of his claim. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.       On notice, the OPs filed its written reply taking preliminary objections that no cause of action has arisen in favour of the complainant against the opposite parties as claim for reimbursement of medical expenses by the complainant for treatment of Acute Pancreatitis in Fortis Hospital, Amritsar from 19.6.2014 to 27.06.2014 was legally and rightly repudiated by the opposite parties vide letter dated 21.08.2014 strictly in accordance with the terms and conditions of the contract of insurance. Similarly, the subsequent request for pre-authorization of Cashless facility were also legally and rightly denied by the opposite parties vide letters dated 3.08.2014 and 7.10.2014 respectively as per the terms and conditions of the insurance. The various investigations, hospital treatment records, doctors certificates and reports of Fortis Hospital Limited, Amritsar confirmed that Mr.Vishavjot Singh was diagnosed as a case of Acute Pancreatitis and the said disease was caused due to the Alcohol Consumption but the hospitalization or medical expenses attributed to or based on or arising out of Alcoholism are standard exclusion under the policy. Thus, the illness suffered by the complainant due to Alcoholism was neither covered nor admissible under the policy bearing number 0260158836. Hence, the claim for reimbursement of medical expenses as well as requests for pre-authorization of cashless facility were legally and rightly repudiated or denied by the opposite parties; the complaint is pre-mature and is liable to be dismissed at the outset; the complainant has no locus standi to file the instant complaint as the complainant has withheld the true and correct facts from this Hon’ble Forum just to derive illegal financial gains contrary to the contract of insurance. The complainant admittedly was diagnosed as a case of Acute Pancreatitis and a certificate dated 02.08.2014 issued by Dr.Amitabh Mohan Jerath, MD, Consultant, Gastroenterology, Fortis Hospital, Amritsar confirmed that the complainant Vishavjot Singh was diagnosed as a case of Actue Pancreatitis (CTSI 10/10) and was having history of Alcoholic intake for 9 years, History of RTA in March, 2003, Post Op. Craniotomy in 2006.The said doctor clearly confirmed that the disease suffered by the complainant  was due to Alcohol Consumption whereas the policy in question does not extend any coverage for the expenses incurred on the treatment of any disease occurred due to intake of Alcohol. Thus, the complainant has lodged a false claim. The complainant has not approached this Hon’ble Forum with clean hands as he deliberately, dishonestly and with a malafide intention concealed the material facts relating to health & habits and knowingly & fraudulently gave wrong and false information/answers at the time of proposal for insurance dated 17.03.2012 in order to induce the opposite parties to accept risk on his life. The hospital treatment records, investigations and other medical reports of Fortis Hopital, Amritsar submitted by the complainant himself confirmed that Fortis Hospital, Amritsar confirmed that Mr.Vishavjot Singh was diagnosed as a case of Actue Pancreatitis (CTSI 10/10) and was having history of Alcoholic intake for 9 years, History of RTA in March, 2003, Post Op. Craniotomy in 2006 and the contract of Insurance is a contract of UTMOST GOOD FAITH technically known as “Uberrima Fides” and the complainant is estopped to file the instant complaint due to his own act and conduct as he was offered 15 days Free Look Cancellation period to review the terms and conditions of the policy as per the provisions of the Protection of Policy Holders’ Interest Regulation, 2002 but he did not make any such request for cancellation of the policy with in the permissible period of 15 days. On merits, it was submitted that the complainant being a prudent and educated person himself out of his free will opted for Regular Premium Bajaj Allianz “Family Care First” policy after fully understanding the Benefits Exclusions, Features and Terms and Conditions thereof and submitted a proposal form dated 17.03.2012 duly signed in English Language. The proposal of the complainant was accepted by the opposite parties believing the information, answers and statements made by the proposer in the said proposal form and a policy bearing no.0260158836 was issued to him with date of commencement as 12.04.2012 in normal course of insurance business for maximum risk cover of Rs.5,00,000/- under the said policy. The original policy bond containing express terms and conditions of the contract of insurance dispatched to him vide speed post No.EH457530770IN dated 13.04.2012 which was admittedly received by him and the receipt thereof has never been disputed by the complainant. All other averments made in the complaint have been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Complainant has tendered into evidence his own affidavit Ex.C1 alongwith other documents Ex.C2 to Ex.C150 and closed the evidence. 

5.       Sh.Fakhrul Hasan posted as Regional Head of opposite parties tendered into evidence his own affidavit Ex.OP1 alongwith other documents Ex.OP2 to Ex.OP16 and closed the evidence.

6.       We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants in the wake up of the arguments as duly put forth by the respective learned counsels of the present contestants. We find that the present dispute has arisen on account of the OP insurers’ denials/ refusals Ex.C3 & Ex.C4/Ex.OP5 to cash-less hospitalization requests by the Hospitals in which the complainant was admitted for medical treatment and having further aggravated at the repudiations Ex.OP11 (pages 19 & 20) and Ex.OP12 of the medical claims Ex.OP6 on account of the detected ailment of ‘Chronic Pancreatitis’ as suffered by the complainant alleged to have caused by an excessive and long-time alcohol intake. The OP insurers have allegedly presumed the detection of ‘pancreatitis’ as violation of policy term since the same falls under the exclusion clause 6(r) being presumably caused by alcoholism.

7.       However, we are not convinced with the OP insurers’ logic since the medical science does not admit ‘alcoholism’ as the exclusively one and only reason to cause ‘chronic pancreatitis’ and explains it as hereunder:

Chronic Pancreatitis

The term “chronic pancreatitis” refers to inflammation of the pancreas that lasts more than 6 months, and is associated with scarring and other permanent complications.  There are many causes of chronic pancreatitis, but all of the major causes seem to converge on the immune system, which is responsible for most of the organ damage.  Many lines of evidence suggest that premature activation of trypsinogen to become the active digestive enzyme trypsin, while it is still inside of the pancreas, is responsible for repeated injury and inflammation.   See “What is the Pancreas>Pathology-nonmalignant for micrographic pictures of chronic pancreatitis.

Causes of chronic pancreatitis:                                                                          

• Hereditary pancreatitis – caused by mutations in the trypsino gen gene (PRSS1)
• Cystic fibrosis (CF) – caused by mutations in the cystic fibrosis trans membrane conductance regulator (CFTR).
• Atypical CF – caused my mild mutations in CFTR that may only affect the pancreas
• Autoimmune pancreatitis – caused by the immune system attacking the pancreas
• Severe acute pancreatitis – caused by destruction of the pancreas in a severe attack with pancreatic necrosis.
• Alcohol and smoking.  These behaviors appear to be risk factors and usually do not cause chronic pancreatitis. However, if there is injury to the pancreas from another cause, alcohol consumption and smoking may cause rapid destruction of the pancreas – with the combined effect being much more potent than either one alone.

Thus, alcoholism can surely be a cause of pancreatitis but it shall not be the ‘only’ cause to the exclusion of all others. And, we find here that the OP insurers have failed to prove rather not even attempted to prove that ‘alcoholism’ has been the sole cause of chronic pancreatitis in the present case.

8.       However, it is not understood as to why the OP insurers did not further investigated the matter in question to know the truth and rather rejected the impugned claim on the presumption of alcoholism and it certainly amounts to unfair trade practice coupled with deficiency in service and that rakes them up for an adverse statutory award under the Consumer Protection Act’ 1986. 

9.       In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to settle and pay the impugned claim but strictly in terms of the related health policy in accordance with the IRDA guidelines on ‘settlement of claims’ besides to pay him Rs.5,000/- as cost and compensation within 30 days of receipt of the copy of these orders otherwise the aggregate awarded amount shall carry interest @ 9% PA from the date of the orders till actual payment. 

10.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                  (Naveen Puri)

                                                                                     President

ANNOUNCED:                                                            (Jagdeep Kaur)

July 28,2016.                                                                Member             

*MK*