FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is an application U/s.12 of the C.P. Act, 1986.
The petitioner had a mediclaim policy bearing no.104500/50/18/10011054 with the OP 1. The petitioner was admitted to Divine Nursing Home, Beliaghata on 25.03.2019 for treatment of high fever and stomach pain. He was treated over there and was discharged on or about 31.03.2019. The expenditure for the treatment was Rs.50,000/- . The petitioner lodged claim to the OP 2 which was rejected by the OP 2 on frivolous ground of chronic alcoholism without acknowledging the certificate of Dr.Oindrila Mandol on behalf of Dr. Sourabh Dutta dated 30.03.2019. On 16.4.2019 the petitioner again admitted to Divine Nursing Home for treatment of Pancreatitis with Sepsis and was discharged after treatment on 25.04.2019. This time the total expenditure was Rs. 73,000/- . Mails dated 17.04.2019 and 22.04.2019 were sent to the TPA for processing the claim which was also rejected by the OP2. The petitioner went to Hyderabad for second opinion and the second opinion did not indicate chronic alcoholism. Legal notice were served upon the OPs on 24.06.2019 to pay the amount spent for treatment. The OPs did not pay the claim amount inspite of repeated appeal for which the petitioner has approached the Commission for justice with the prayers as mentioned in the complaint.
The OP No. 1 has contested the case by fling their W/V contending inter alia that the case has been filed for disallowance of claim of the petitioner against his National Mediclaim Policy being No. 104500/50/18/10011054 with the OP1. The complainant was admitted to Divine Nursing Home on 25.03.2019 for treatment of Acute Pancreatitis, Calculous Cholecystitis, hepatic dysfunction and hypokalemia and was discharged on 31.03.2019. The complainant applied for a cashless claim to the OP no.2 which was rejected on 30.03.2019. Thereafter he was again admitted to the said Nursing Home on 16.04.2019 for treatment of Gallstone Pancreatitis with obstructive Jaundice with Sepsis and was discharged on 25.04.2019.
The cashless claim preferred by the complainant while admitted in the Divine Nursing Home on 25.03.2019 was a follow up case of Alcoholic Pancreatitis with Jaundice having Amylase 3048 & Lipase 39299 WI, as revealed from submitted medical documents. As per treatment sheet available with the TPA, the complainant is chronic Alcoholic and alcohol is pre disposing factor of Pancreatitis & Jaundice. Accordingly, the cashless claim was rejected as per policy terms and conditions
The complainant was further admitted to the said Nursing Home on 16.04.2019 and it is learnt from pre authorization request of hospital that the patient is suffering from Billiary Pancreatitis. The suffering as stated by hospital and USG report was conflicting as USG report was showing Acalculous Pancreatitis. The TPA enquired from the hospital about such difference of diagnosis. In reply the hospital provided CT abdomen report which shows Cholelithiasis without specifying the size and number of stone. In the wake of such situation, TPA’s doctor went to the Nursing Home to check the CT scan Plate in reference to the original report for a fact finding and the hospital authority was unable to provide both medical documents. The TPA called for a meeting with Divine Nursing Home to sort out the issue. But Mr. Dutta of Divine Nursing Home could not throw any light in the issue and sought for some time but till date TPA has not heard anything from them. In view of the above, medically Biliary Pancreatitis is possible if common bile duct is obstructed and size of stone in large according to the hospital report submitted by them, it may reasonably be concluded that there was no obstruction which could cause Pancreatitis & Jaundice which is excluded peril in terms of policy condition 4.21 of National Mediclaim policy which read as follows. “ Drug / alcohol abuse – Treatment arising out of illness/disease/injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances”
OP2 has also filed their WV and submits that there is no agreement in between the complainant and the OP2 and no consideration is also paid by the complainant and there is no claim against the OP2. More over the claim is rightly repudiated as per clause 4.21 of the terms and conditions of the policy. As per treatment sheet patient is chronic alcoholic and alcohol is pre disposing factor of Pancreatitis and Jaundice. Accordingly the claim was repudiated as per the terms and conditions of the policy.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OPs are deficient in rendering proper service to the Complainant?
2) Whether the OPs have indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. Both parties have submitted their evidence on affidavit and also their BNA The complainant and the OP1 have filed replies to the questionnaire set forth by their adversaries.
While perusing the records it is observed that the complainant Mr. Sankhanad Mukherjee was refused the expenses of hospitalization during the in force period of his Mediclaim Policy No.104500/50/18/10011054 with the OP1. The complainant was admitted to Divine Nursing Home, Beliaghata, Kolkata on 25.03.2019 for treatment of abdominal pain and other related problems and was discharged on 31.03.2019. The cashless claim was rejected on 30.03.2019 by the OP2 on the ground that the complainant is chronic Alcoholic and alcohol is pre-disposing factor of Pancreatitis & Jaundice. Accordingly, the cashless claim was rejected as per terms & conditions of the said policy under clause no. 4.21 which read as follows. “ Drug / alcohol abuse – Treatment arising out of illness / disease / injury/ due to misuse or abuse of drugs / alcohol or use of intoxicating substances. The claim related to the above treatment is not payable.
The OP1 has rejected the claim of expenses of first hospitalization on the ground that the patient was chronic alcoholic. Alcohol is predisposing factor for Pancreatitis and Jaundice. Moreover, from the pre authorization request of the hospital it appears that the patient is suffering from Billiary Pancreatitis whereas from the USG Report it shows that the patient is suffering from Acalculous Cholecystitis. The OP2 did not get clarification from the hospital for which they have not settled the claim. The repudiation letter of the OP1 dated 29.05.2019 also shows that they are also agreed with the OP2 being the TPA that the claim does not seem to fall within the purview of consideration for settlement of claim National Mediclaim policy condtion.
These are the reasons cited by OP1 and OP2 against repudiation of the claim of Rs.46,221/- & Rs.8779/- submitted by the complainant. The OPs have put stress on the remark “Pt. is chronic alcoholic” written on the case sheet of Divine Nursing Home dated nil which appears to have been issued at the time of admission of the patient. But scrutiny we do not find the name of the patient in the said case sheet issued by the Nursing Home. As such the document does not confirm that it was issued in favour of the patient complainant Sri Sankhanand Mukherjee. Moreover, declaration of the patient party at the time of admission is not a cognizable document in the eye of law unless it is authenticated by proper legal document. Moreover, Unusual reading of Amylase & Lipase in blood caused only by excessive intake of alcohol is also not affirmed by appropriate medical expert. The observation of the nursing home in the matter of the detection of disease whether it is billiary pancreatitis or Acalculus cholecystitis does not lead to the conclusion of nullifying the claim. Moreover we don’t find any observation of the appropriate authority/ authorities in the entire submitted documents that the disease is due to intake of excessive alcohol only. As such the OPs stand in the matter of repudiation does not justify. The wordings in the repudiation letter dated 29.05.2019 issued by the OP1 that “We are also agreed with the TPA’s opinion that the claim does not seem to fall within the purview of consideration for settlement of claim National Mediclaim policy condition “ give rise to doubts in the minds of the OP1 whether the claim is payable or not payable which is not expected of from them. This signifies some hesitations to repudiate the claim on the part of the OP1. Ld. Advocate for the complainant has cited one Judgment of Hon’ble SCDRC, Delhi in the matter of Surendra Kumar Nanda vs New India Assurance Co. Ltd., decided on 19.03.2009 vide First Appeal No. 413/2006 where in point no.08 & 09, the Hon’ble Commission have observed that
“ The intention of the policy was that any expenses incurred by a person in connection with or in respect of use of intoxicating drug/alcohol are not reimbursable. In other words it means that if a person lands in a hospital for treatment for disease which is direct result of use of intoxicating drug/alcohol, he shall not be entitled for the reimbursement of the expenses.
If the interpretation provided by the learned counsel for the appellant is accepted then more than 50% of the insured people obtaining the policy would be out of its net, if they just provide information that they take drink or drug in moderation.”
In the light of the above observation we are of the view that the OPs were not justified in raising the inference and rejecting the claim on surmises & conjectures. However the final bills dated 31.03.2019 of the Divine Nursing Home amounting to Rs.8779/- and Rs.46221/- have been scrutinized at our end where the Night Service Charges and Service amounting to Rs.300/- & Rs.50/- respectively are not reimbursable since they are not related to treatment of the disease. As such, the amount reimbursable stands Rs 8779/- plus 46,221/- minus Rs.350/- i.e. Rs.54,650/- . The reimbursement of other payment of Rs.73,000/- has not been considered since no break up of expenses related to the treatment has been furnished by the complainant.
All the points under determination are answered affirmative. No order is passed against OP2 since they are the processing authority.
In the result, the Consumer Complaint succeeds .
Hence,
Ordered
That the complaint case is allowed on contest against the OP 1 & dismissed against OP2 with the following directions:-
- The OP 1 is directed to reimburse the claim of Rs.54,650/- to the complainant with interest @ 4% from the date of filing the case till realization
- The OP1 is also directed to pay a sum of Rs. 5,000/- to the complainant as litigation costs.
The above orders are to be complied within a period of 30 days from the date of the order.
In the event of non compliance of the order, liberty be given to the complainant to put the order into execution U/ss 71 & 72 of the C.P. Act,2019.
The judgment be uploaded to the website of the Commission forthwith for perusal of the parties.
