Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed a health insurance policy for himself and his wife from Opposite Parties since, 30.11.2017, which was timely renewed and lastly the said policy was renewed vide policy bearing no.P/211222/01/2023/008838 and the said policy is valid upto 29.11.2023. Unfortunately on dated 16.03.2023, the complainant fell ill and got admitted in Dayanand Medical College and Hospital, Ludhiana and after treatment got discharged from the hospital on 24.03.2023. At the time of treatment of the complainant and after discharging from the hospital, the complainant requested the Opposite Parties to pay all the medical expenses including Pre and Post to the complainant, but the Opposite Parties lingered on the matter on one pretext or the other and did not pay the expenses of treatment. After discharge from the hospital, the complainant also submitted all the medical record to Opposite Parties as per their demand, but inspite of that the Opposite Parties had not paid any amount in lieu of medical expenses to the complainant. Alleged that the complainant has made the payment of Rs.36,664/- to the said hospital from his own pocket. The complainant requested many times to make the payment of claim, but the Opposite Parties refused to make the payment to the complainant. However, vide letter dated 14.08.2023, the Opposite Parties repudiated the claim of the complainant on the basis of false and baseless reason. Due to such act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.36,664/- alongwith interest @ 24% p.a. till its realization.  

b)      To pay a sum of Rs.30,000/- as compensation on account of mental tension, and harassment.

c)       To pay Rs.22,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination, which is not possible in the summary procedure under C.P. Act; the complainant has concealed material facts and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that he has violated the terms and filed the present complaint only to harass the Opposite Parties. The real facts are that the complainant availed the ‘Family Health Optima Insurance Plan Policy’ bearing No.P/211222/01/2023/008838 renewed for the period 30.11.2022 to 29.11.2023 and in this policy complainant self, his wife Kamal and Children Divjot & Ruhani were insured for an amount of Rs.5 lakh. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the Opposite Parties have already given claim to the insured/complainant for TIBIA for an amount of Rs.61,667/-. Averred further that the insured has submitted the claim vide claim no.CIR/2023/211222/1683198 regarding the cashless and medical reimbursement expenses towards treatment taken by him at DMC & Hospital, Ludhiana on 16.03.2023 towards the treatment of Bipolar Disorder with Alcohol dependence. Averred further that on perusal of cashless and after seeing record, medical team of the Opposite Parties observed that the treatment taken by him on 16.03.2023 is not admissible in accordance with exclusion clause 12 of the policy and cashless denied. Thereafter, the insured applied for medical reimbursement from 16.03.2023 to 24.03.2023 and it is observed from the claim documents that the above said treatment taken by him on 16.03.2023 are not admissible in accordance with exclusion clause 12 of the policy and reimbursement was denied because the disease regarding which he had taken treatment was occurred due to use of Alcohol. Hence the claim was rejected vide repudiation letter dated 14.08.2023. As per Exclusion No.12-Code Excl 12 of the above policy, the Company is not liable to make any payment in respect of expenses incurred at hospital for treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.

4.       On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP1/A and copies of documents Ex.OP1 to Ex.OP10.

 5.        We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is admitted and proved on record that the complainant has been availing the health insurance policy namely ‘Family Health Optima Insurance Plan’ since 2017, which regularly got renewed from time to time and lastly, the complainant purchased the policy bearing no.P/211222/01/2023/008838 for the period 30.11.2022 to 29.11.2023 for fifth time, covering self, his wife and two dependent children for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant got admitted in Dayanand Medical College and Hospital, Ludhiana with chief complaints of “Overtalkativeness, irritability, Self Muttering, Suspiciousness, Sleep Disturbance”, where he remained admitted for the period 16.03.2023 to 24.03.2023. It  is not disputed that during hospitalization, the complainant applied with Opposite Parties for cashless treatment, but the request of the complainant was denied by Opposite Parties, vide letter dated 24.03.2023 (Ex.OP5). Thereafter, the complainant lodged the claim with Opposite Parties for the reimbursement of the said hospitalization period, which was repudiated by the Opposite Parties, vide letter dated 14.08.2023 (Ex.OP10). The contents of repudiation letter are reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Bipolar Disorder with Alcohol Dependence.

It is observed from the submitted medical records that the insured patient has undergone treatment for disease due to use of alcohol.

As per Exclusion No.12-Code Excl 12 of the above policy, the Company is not liable to make any payment in respect of expenses incurred at hospital for treatment for alcoholism, drug or substance abuse of any addictive condition and consequences thereof.

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.

7.       We have considered the rival contentions of the ld. Counsels for both the parties and have gone through the record. The only ground taken by the Opposite Parties for the repudiation of the claim of the complainant is that the complainant undergone the treatment for the disease due to consumption of alcohol. Now, we have to find that whether repudiation of the claim of the complainant on the aforesaid ground is genuine or not?  

8.       The perusal of discharge summary of Dayanand Medical College and Hospital, Ludhiana placed on record by both the parties (Ex.C3 and Ex.OP7) shows that the complainant admitted in the hospital with chief complaints of “Overtalkativeness, irritability, Self Muttering, Suspiciousness, Sleep Disturbance” and he was diagnosed as “Bipolar Type I Disorder Current Episode Manic with Psychotic symptoms with Alcohol dependence currently in sustained partial remission and In the Column “Clinical Findings” at the end of the para, it has been mentioned that H/O consumption of alcohol in the form of whiskey upto ½ bottle/day since 15 years, currently abstinent since 4 months. We have perused the terms and conditions of the policy placed on record by the Opposite Parties (Ex.OP3) and perusal of Exclusion Clause No.12 reveals that treatment of Alcoholism, drug or substance abuse or any addictive condition and consequences thereof is excluded. For the sake of convenience, the contents of exclusion clause are reproduced as under:-

“12. Treatment of Alcoholism, drug or substance abuse or any addictive condition and consequences thereof- Code Excl 12.”

The above facts and circumstances gives a hint that the complainant suffered from the ailment in question due to his excessive intake of alcohol and his claim fall under the ‘exclusion clause 12’ of the policy’s terms and conditions. Moreover, perusal of the proposal form placed on record by Opposite Parties as Ex.OP1 shows that in the said proposal form, the complainant/insured nowhere disclosed about his use of alcohol. Although the complainant availed this policy since, 2017 and the same is renewed for the fifth time, but in all these years, he never ever disclosed this fact that he is consuming alcohol from the last 15 years. The reason for non disclosure of this fact is best known to the complainant. As such, we are of the concerted view that Opposite Parties rightly repudiated the claim of the complainant as per the terms and conditions of the policy.

9.       Sequel to the above discussion, the present complaint is hereby dismissed. Keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. The pending application(s), if any also stands disposed of. Copy of the order be supplied to the parties free of costs. File be consigned to record room.

Announced in Open Commission