Chandigarh

DF-I

CC/455/2022

Vinod Kumar - Complainant(s)

Versus

HDFC ERGO Health Insurance Ltd. - Opp.Party(s)

Pavinder Singh Bedi

01 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/455/2022
Date of Institution	:	22/04/2022
Date of Decision	:	01/01/2024

 

Vinod Kumar s/o Sh. Sri Ram Naryan r/o House No.HI-445, Phase 7, Mohali

… Complainant

V E R S U S

HDFC Ergo Health Insurance Ltd., through its Manager, having its office at SCO No.50-51, Sector 34-A, Chandigarh.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                               

ARGUED BY	:	Sh. Pavinder Singh Bedi, Advocate for complainant
	:	Sh. Nitesh Singhi, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Vinod Kumar, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the month of March 2018, one Naresh Kumar, an intermediary of OP company, had approached the complainant and asked him to procure the Health Individual Standard Insurance Policy as it provides reimbursement expenses in case of hospitalisation alongwith cashless benefits. Accordingly, on 3.3.2018 complainant had purchased “Easy Health Individual Standard Insurance Policy” which was renewable on yearly basis and was accordingly renewed vide policy (Annexure A) valid w.e.f. 3.3.2020 to 2.3.2021 (hereinafter referred to as “subject policy”) on payment of premium of ₹7,585/- having sum insured of ₹6.00 lacs.  On the morning of 1.9.2020, when the complainant got up, he suffered some fits and his hands got tilted and he went unconscious.  On this, brother of the complainant immediately took him to Indus Hospital for treatment.  As there was no improvement in the health of complainant till evening, he was referred to Healing Hospital where he was admitted on 1.9.2020 and was discharged on 7.9.2020 as per discharge summary (Annexure C).  The complainant was diagnosed with Upper GI bleed chronic liver disease and the hospital has raised bill of ₹2,51,136/- on his treatment and the copy of treatment record and bills are Annexure D.  At the time of discharge of the complainant, cashless card was given to the treating hospital for payment, but, the complainant was intimated that the OP had denied the cashless benefit, as a result of which the complainant had to pay the bill amount to the said hospital.  Thereafter the complainant lodged claim with the OP company alongwith all the requisite documents, but, to the utter surprise of the complainant, the same was repudiated vide letter dated 4.12.2020 (Annexure E) on the flimsy ground that the complainant was admitted in the hospital with the diagnosis of alcoholic liver disease.  It is further alleged that there is no reference in the discharge summary that the complainant is an alcoholic or that he suffered liver disease due to consumption of alcohol, but, despite of that the OP had formed its own opinion while repudiating the claim.  In this manner, the aforesaid act of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, limitation, concealment of facts and also that the complainant has not approached the Commission with clean hands.  On merits, admitted that the subject policy was purchased by the complainant and was in force at the relevant time.  However, it is denied that the claim of the complainant was wrongly repudiated by the OP, rather the same was repudiated as the complainant was admitted in the hospital on 1.9.2020 and he was diagnosed with “alcoholic liver disease” alcohol withdrawal and he was treated for the same.  It is further alleged that the aforesaid claim of the complainant was repudiated under clause 9(C)(IV) of the subject policy which excludes any treatment from the coverage which arises due to abuse or consequence of the abuse of intoxicant etc.  It is further alleged that, in fact, the complainant himself has violated the terms and conditions of the subject policy by concealing the fact that he was having alcoholic liver disease at the time of purchasing the subject policy. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy from the OP which was valid w.e.f. 3.3.2020 to 2.3.2021 and during the currency of the same, complainant had fallen ill on the morning of 1.9.2020 and he was shifted to Indus Hospital and on finding that there was no improvement in his health, he was referred to the Healing Hospital i.e. the treating hospitals where he remained admitted w.e.f. 1.9.2020 to 7.9.2020 and the aforesaid hospitals had raised total bill of ₹2,51,736/- and thereafter firstly the cashless benefit was denied to the complainant and later on the claim of the complainant was repudiated by the OP vide repudiation letter (Annexure E), the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in repudiating the claim of the complainant on the flimsy ground in the repudiation letter that the complainant was diagnosed with alcoholic liver disease and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP has rightly repudiated the claim of the complainant by finding that the complainant himself has violated the terms and conditions of the subject policy and the consumer complaint of the complainant being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, proposal form, medical record and the repudiation letter, and the same are required to be scanned carefully to determine the real controversy between the parties.
   3. Perusal of the subject policy (Annexure A) indicates that the same was valid w.e.f. 3.3.2020 to 2.3.2021 with total sum insured of ₹6.00 lacs, having been issued by the OP. Annexure OP-1 is the proposal form and the relevant information sought from the complainant qua medical history and lifestyle is -

“Section (C) has any of the persons proposed to be insured

(i) been addicted to alcohol, narcotics, habit forming drugs or been under detoxication therapy?”

The complainant had answered the aforesaid information in negative by ticking box ‘N’.

4. Annexure OP-5 is the customer information sheet – standard plan which refers about benefits and exclusion clause etc. under the subject policy.  Annexure B and D are the medical record which shows receipt of payment and the treatment given by the treating hospital.  Annexure C is the discharge summary of the treating hospital and the relevant portion of the same is reproduced below :-

“DIAGNOSIS

Upper GI bleed..

Chronic liver disease..

Alcohol withdrawal..

Seizures..

Dyselectrolytemia.

CHIEF COMPLAINTS & REASON FOR ADMISSION

        Altered sensorium since 03 days.

HISTORY

        33 year old male patient presented with complaints of altered sensorium since 03 days.  Now he is being admitted for further evaluation and management.”

 

5. Annexure E is the repudiation letter dated 4.12.2020 which indicates the ground on which the claim of the complainant was repudiated by the OP and the relevant portion of the same is reproduced below for ready reference :-

        “1.As per the submitted documents, patient was admitted on 1/09/2020 with the diagnosis of alcoholic liver disease and was treated for same. This claim is being repudiated under section 9 c iv of policy which excludes any treatment from the coverage which arises due to abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.”

6. It has been contended with vehemence on behalf of the complainant that the medical record, having been relied upon by the parties, including the discharge (Annexure C), nowhere indicates that the complainant was diagnosed with alcoholic liver disease and the OP, by forming its own opinion that the complainant was diagnosed with alcoholic liver disease, has wrongly repudiated the genuine claim of the complainant and the consumer complain be allowed as prayed for.
7. On the other hand, it has been contended with vehemence on behalf of the OP that, in fact, the OP is resisting the claim of the complainant on two grounds i.e. firstly that he was asked about the addiction to alcohol etc. by asking him to fill up the proposal form and in answer to the same he had given answer ‘no’ and secondly in the medical record it was opined by the medical officer that the complainant was suffering from chronic liver disease and there was alcohol withdrawal making clear that the complainant was diagnosed with alcoholic liver disease and the claim of the complainant was rightly repudiated.
8. However, there is no force in the contention of the OP as the discharge summary nowhere indicates that the complainant was diagnosed with alcoholic liver disease and he was treated for the same, rather in the discharge summary the treating doctor has only mentioned that there was upper GI bleed, chronic liver disease, alcohol withdrawal, seizures and dyselectrolytemia and the chief complaint of the patient/complainant was altered sensorium since three days making further clear that even the treating doctor has nowhere mentioned that the complainant was having alcoholic liver disease, as has been mentioned by the OP in the repudiation letter (Annexure E), rather the medical officer has specifically mentioned that the patient was diagnosed with alcohol withdrawal. 
9. Even in the proposal form (Annexure OP-1) in Section C, complainant was asked if he had been addicted to alcohol, narcotics, habit forming drugs or been under detoxication therapy” and he had ticked ‘N’ i.e. no, is not going to defeat the case of the complainant as there is no material produced/ proved on the file by the OP that the complainant was addicted to alcohol at the time of filling the proposal form or he was treated on account of alcoholic liver disease, especially when it has also come on record that he was diagnosed with Upper GI bleed, chronic liver disease, alcohol withdrawal, seizures and dyselectrolytemia. Moreover, even as per the medical jurisprudence, chronic liver disease can be caused for the following reasons :-

a.     Hepatitis and other viruses

b.    Non alcoholic fatty liver disease (this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides and high blood pressure

Other less common causes of Chronic Liver Disease may include :

a.    Autoimmune disorders, where the body’s infection-fighting system (immune system) attacks healthy tissue

b.    Blocked or damaged tubes (bile ducts) that carry bile from the liver to the intestine.

c.    Use of Certain medicines.

d.    Exposure to certain toxic chemicals

e.    Repeated episodes of heart failure with blood build up in the liver.

f.     Parasite infections.

10. Since nothing has come on record that the complainant had suffered liver disease for the reason that he was addicted to alcohol and further that he was diagnosed with alcoholic liver disease, as has been opined by the OP in its repudiation letter (Annexure E), it is safe to hold that the OP has wrongly repudiated the genuine claim of complainant and the said act certainly amounts to deficiency in service and unfair trade practice on its part.
11. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.
12. Now coming to the quantum of relief, since the complainant has proved the receipts/bill (Annexure B & D) through which he paid total amount of ₹2,51,136/- to the treating hospitals, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment caused.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹2,51,136/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 4.12.2020 onwards
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/01/2024 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member