DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (CENTRAL)ISBT KASHMERE GATE DELHI

COMPLAINT CASE NO. 248/2019

No. DC/ Central/

vs.

Coram:       Ms. Rekha Rani, President

                    Shri Vyas Muni Rai, Member

                   Ms. Shahina, Member (Female)

ORDER

Ms. Rekha Rani, President

1. Sh. Sourabh Sethi (in short the complainant) filed the instant complaint under section 35 of the Consumer Protection Act, 2019 against Health India Insurance TPA Services Pvt. Ltd. (in short OP1) and Oriental Insurance Company Ltd. (in short OP2) pleading therein that complainant had taken a Mediclaim Policy by the name of “happy family floater-2015 policy schedule” with the OP1 vide policy no. 211201/48/2018/2262 (renewal of previous policy no. 211201/48/2017/2275) which covered a total of 5 persons for a sum of Rs. 8,00,000/- in the name of the complainant. Mediclaim policy include services such as cashless treatment of health-related issues, reimbursement of the treatment expenses of the policy holder and his dependents which includes his parents. On 29.06.2017, father of the complainant Shri Jogesh Sethi who is dependent upon the complainant and covered under the above stated medical policy felt a little discomfort in chest, dizziness and loss of appetite. He was taken to “Saroj Super Speciality Hospital”. Upon examination, it was found that the complainant’s father was “in state of septicemia and suffering from Coronary Artery Disease (CAD), Pot PTCA and Colonic Divertculum.” Pursuant to the diagnosis, the complainant’s father had to undergo extensive medical treatment and management and, he remained admitted in “Saroj Super Speciality Hospital” for 6 days i.e. 29.06.2017 to 04.07.2017 and was discharged on 04.07.2017.

On 29.06.2019, OP1 received a cashless request from the hospital bearing claim control number- HI-OIC-000331961 for an amount of Rs. 29,800/-. On 30.06.2017, OP1 received another cashless request from the Hospital bearing claim control no. – HI-OIC-000331961(0) for an amount of Rs. 15,000/- which was subsequently approved by OP1. The information in relation to the above mentioned was communicated to the complainant vide an SMS from the OP1. However, even after approval of the request, the approved amount i.e. Rs. 15,000/- was not reimbursed to the complainant. On 01.07.2019, OP1 received a “Cash Enhancement” request from the hospital bearing claim control no: HI-OIC-000331961 for an amount of Rs. 65,943/-

On 04.07.2017, to utter shock and surprise of the complainant, a letter titled as “denial letter of additional authorization request” was received by the complainant. The abovementioned letter stated that in reference to claim control no: HIC-OIC-000331961 received by the OP1 vide fax dated 03.07.2017, the said claim amount could not be sanctioned. The remark provided along with the denial to sanction of cashless benefit stated that “as said ailment is complication of alchol, hence cashless denied.”

The treating doctor, namely, Mr. Sanjeev Aggarwal had certified that “Mr. Jogesh Sethi is a social drinker since last several years and is not habituated. He does not have any features suggestive of alcoholism and alcohol dependency. Neither does he have any liver ailment. The current episode of 071 is not related to alcoholism.”

Complainant wrote a letter to OP to reconsider their rejection in view of the certificate of Dr. Sanjeev Aggarwal. Complainant provided additional information sought by OP vide the letter dated 01.08.2017. But OP still denied the claim of the complainant by reiterating that the ailment is complication of alcohol. It is further stated that complainant’s father’s ailment was not caused due to consumption of Alcohol. Therefore, denial of the claim on that ground is unjustified. Hence, the complaint was filed seeking direction to OP to pay to the complainant, Rs. 95,743/- along with 18% p.a. interest from 05.07.2017 to the date of realization and Rs. 2,50,000/- as compensation for causing harassment and mental agony.

2. Notice of complaint was issued to OP who filed Written Statement.
3. Both sides filed evidence by way of affidavits. They also filed Written arguments. We have perused the material available on record. We have heard both sides.
4. In its Written Statement, OP2 has mentioned the exclusion clause 4.8 as under:-

“Convalescence, general debility, “run down” condition or rest cure, congenital external diseases or defects or anomalies, sterility, any fertility, sub-fertility or assisted conception procedure, venereal diseases, intentional self-Injury/ suicide, all psychiatric and psychosomatic disorders and diseases/ accident due to, and or use, misuse or abuse of drugs/ alcohol or use of intoxicating substances or such abuse or addiction etc, any disease or Injury as a result of committing or attempting to commit a breach of Law with criminal intent.”

5. Complainant has placed on record copy of the certificate issued by Dr. Sanjeev Aggarwal who is stated to be the treating doctor which certificate reads as under:-

“Mr. Jogesh Sethi is a social drinker since last several years and is not habituated. He does not have any features suggestive of alcoholism and alcohol dependency. Neither does he have any liver ailment. The current episode of 071 is not related to alcoholism.”

Complainant has also placed on record a document at page no. 26 of the case file which reads as under:-

          Medical Detail of Patient

          1. Complains-

         2. Do you have Hypertension (High B.P.) and from how many days/ months/years- No

         3. Do you have Diabetes mellitus and from how many days/ months/ years.- No

         4. Do you have Heart Problem and from how many days/ months/ years.- Yes, Stant in heart in 2013

         5. Do you have COPD/ Respiratory/ TB and from how many days/ months/ years.- No

         6. Have you under gone any operation in the past and if yes when.- Yes, heart stant in 2013

         7. Have you had similar problems in the Past?- No

         8. Do you smoke if yes since when?- Yes, 20 years

         9. Do you take alcohol if yes since when?- Yes, 20 years

         I declare that above details given by me is true.

         Signature and name of Patient/ Relatives- Sd/-

6. Referring to this document Ld. Counsel for OP submitted that complainant himself declared that he had been taking alcohol for the last 20 years.

The treating doctor, however, certified that the patient did not have features of chronic alcoholism. He did not have any liver ailment and the ailment for which he was treated was not related to alcoholism. No medical evidence to the contrary has been placed on record by OP to justify repudiation.

7. In view of the above discussion, the repudiation is held to be unjustified. Complaint is accordingly allowed. OP/insurance company is directed to pay Rs. 95,743/- to the complainant within period of 30 days from the receipt of copy of this order failing which it shall pay interest at the rate of 6% p.a. from the date of receipt of copy of this order to the date of realization/ payment of ordered amount, litigation cost of Rs.10,000/- is also allowed.

8. Copy of this order be sent to the parties as per rules. File be consigned to record room.

Announced on this 12^th September of 2022.