CONSUMER DISPUTES REDRESSAL COMMISSION-VII
DISTRICT: SOUTH-WEST
GOVERNMENT OF NCT OF DELHI
FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN
SECTOR-20, DWARKA, NEW DELHI-110077
CASE NO.CC/323/15
Date of Institution:- 02.06.2015
Order Reserved on:- 24.10.2024
Date of Decision:- 19.11.2024
IN THE MATTER OF:
Sh. Rahul Tanwar,
S/o Sh. Rajbir Singh Tanwar
R/o WZ-508, BasaiDarapur,
New Delhi - 110035
.….. Complainant
VERSUS
- M/s National Insurance Company Ltd.
(A Government of India undertaking)
New Delhi DO-18-1st Floor,
Sector-12, R.K. Puram, New Delhi – 110066
- M/s East Wes Assist Pvt. Ltd.
TPA of National Insurance Company Ltd.
97, Manekshaw Road, Sainik Farms,
New Delhi - 110068
.…..Opposite Parties
Suresh Kumar Gupta, President
- The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that the complainant has obtained health/mediclaim policy no.351800/46/14/8500001578 for himself as well as for his family for OP-1 as OP-2 is TPA of OP-1. His father Rajbir Singh Tanwar was suffering from decompensated chronic liver disease (hereinafter referred to as DCLD) with ascites esophageal varices (Non-bleeding) and taken treatment from PSRI and Kalra Hospital. His father was admitted in ILBS for above said disease. The OPs have refused to give cashless facility so he had to pay a sum of Rs.3,50,000/-. His father was again admitted to PSRI for the said disease and again cashless facility was denied and he had to pay a sum of Rs.82000/- to the hospital. His claim was rejected vide letter dated 17.03.2015 by the OP with the reason that ethanol related CLD is not admissible under the policy. The case of his father was never ethanol related and doctor in the discharge summary of ILBS has inadvertently recorded the same. His father has remained admitted to various hospitals but he was never diagnosed with ethanol related disease. The legal notice dated 25.04.2015 was served upon the OPs but in vain. There is deficiency in service in rejecting the claim. Hence, this complaint.
- OP-1 has filed WS with the averments that policy in question was issued to the complainant and his family members. The claim was repudiated vide letter dated 24.04.2015 because the discharge summary dated 15.01.2015 of the patient issued by ILBS shows that patient has been suffering from ethanol related CLD for the last five years which is a violation of clause 4.21 of Tailor Made with Floater Policy. The disease is related to the ethanol so the claim was rightly rejected. There is no deficiency in service in rejecting the claim.
- Ld. Counsel for OP-1 submitted that OP-2 is TPA of OP-1 so OP-1 is liable for OP-2 and this is apparent from order sheet dated 16.10.2015.
- The complainant has filed the rejoinder wherein he has reiterated the stand taken in the complaint and denied the averments made in the written statements.
- The parties were directed to lead the evidence.
- The complainant has filed his own affidavit in evidence wherein he has corroborated the version of complaint and placed reliance on the documents Annexure-A to H.
- The OP-1 has filed the affidavit of Sh. Alexander, Assistant Manager, in evidence wherein he has corroborated the version of written statement and placed reliance on the documents Ex.OP-1W1/1 to 4.
- We have heard the complainant as no one has turned up from the side of OP to address the arguments and perused the entire material on record.
- The issuance of policy in question is not in dispute. The perusal of the Annexure-B shows that Sh. Rajbir Singh, Father of the complainant, has remained admitted to Kalra hospital from 02.11.2011 – 07.11.2011 wherein he has diagnosed with Hematemesis grade-III/esophageal varices and HTN. The discharge summary nowhere shows that the disease was related to the alcohol or ethanol. He was again admitted to PSRI on 19.04.2013 and discharged on 01.05.2013 wherein he was diagnosed with DLCD-Ascites and esophageal varices (non-bleeding). The discharge summary nowhere shows that it was related to ethanol/alcohol. He was repeatedly admitted to PSRI Hospitalon 02.05.2014, 27.05.2014 and 27.06.2014 wherein he was diagnosed with DLCD-Ascites and esophageal varices (non-bleeding). He was also diagnosed with diabetes mellitus type-II. The discharge summary nowhere shows that it was related to ethanol/alcohol.
- He was admitted to ILBS on 11.01.2015 wherein he was diagnosed with CLD-ethanol related (LI-5 years back) and discharged on 15.01.2015 as apparent from Annexure-C which is also being relied by the OP-1 as Ex.OP1W1/4 and on this basis, the claim of the complainant was rejected on the premise that it is covered under clause 4.21 of the insurance policy vide letter Ex.OP1W1/3.
- The question that needs consideration is whether patient was suffering from DLCD from alcohol/ethanol which isa pre-existing disease.
- The patient has been under treatment for the said disease since 2011. He has taken treatment from Kalra Hospital. The discharge summary issued by Kalra hospital does not show that patient was having alcohol related disease qua liver. The patient has also remained under treatment from PSRI from 29.04.2013 onwards but the discharge summary nowhere shows that DLCD is alcohol related. The discharge summary Annexure-C issued by ILBS on 15.01.2015 shows for the first time that CLD is alcohol related (LI-5 years back). This is the only document available with the OP to reject the claim. The claim of the complainant is that the disease was not related to alcohol so that is why this fact was never reflected in the discharge summary issued by PSRI and Kalra Hospitals. The OP-1 should have filed the treatment related documents from ILBS to show that CLD is alcohol related. The OP should have filed the documents in order to further corroborate the fact that DLCD was alcohol related. The OP has not come with any evidence that alcohol is the sole cause of DLCD. There is no record or diagnosis from OP that it is a known case of DLCD prior to the taking of policy in question. There is no evidence on record that DLCD has occurred only due to alcohol though complainant has filed the discharge summary issued by other hospitals which nowhere show that disease is alcohol. There is no document that patient was suffering from said disease from alcohol at the time of taking the policy. To our mind, suppression of any
pre-existing disease, if it has not resulted into death then it would not disentitle the claimant for the claim.
- The aforesaid discussion shows that OP-1 has not considered the entire medical documents in totality and rejected the claim merely on the basis of one line written in the discharge summary Annexure-C in a mechanical manner. The repudiation of claim in such a manner is without any basis thus leads to deficiency of service.
- In view of our aforesaid discussion, the complaint of the complainant is allowed to the effect that OP shall pay a sum of Rs.3,50,000/-& Rs.82,000/- along with an interest @6% p.a. from the date of repudiation of the claim i.e. 17.03.2015 till its realization to the complainant. The complainant is also entitled for compensation on account of mental harassment and litigation expenses to the tune of Rs.50,000/-. The OP is directed to comply with the order within 45 days from the receipt of the order failing which complainant will be entitled for interest @6% p.a. on the amount of mental harassment and litigation charges i.e. from the date of order till its realization.
- A copy of this order is to be sent to all the parties as per rule.
- File be consigned to record room.
- Announced in the open court on 19.11.2024.
