Punjab

Ludhiana

CC/19/284

Bindesh Kumar - Complainant(s)

Versus

Reliance General Ins.Co.Ltd - Opp.Party(s)

Alok Mohindra Adv.

11 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 284 dated 11.06.2019.                                                        Date of decision: 11.01.2023.

 

Bindesh Kumar @ Bindesh Kumar Aggarwal, R/o.609/22-A, Street No.5, Gurudwara Street, Sham Nagar, Ludhiana-141001.                                                                                                                                     ..…Complainant

                                                Versus

1. Reliance General Insurance Co. Ltd., 7^th Floor, Surya Tower, The Mall, Ludhiana0141001 through its Branch Manager/Authorized Signatory.
2. Reliance General Insurance Co. Ltd., Reliance Centre, South Wing, 4^th Floor, Off Western Express Highway, Santacruz (West), Mumbai-400055 through its Manager/Authorized Signatory.  
3. Reliance General Insurance Co. Ltd., R Care Health, No.1-8/89/3/B/40 to 42/KS/301, 3^rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad, Telangana-500081 through its Manager/Authorized Signatory.                                                                                                                                                                       …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Alok Mohindra, Advocate.

For OPs                          :         Sh. Sunil Goel, Advocate.

 

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant got an insurance policy for himself, his wife Smt. Anu
Aggarwal, sons Nandan Aggarwal and Raghav Aggarwal vide policy No.2001272828000051 valid from 22.10.2017 to 21.01.2019 for a tenure of two years having sum assured of Rs.3,00,000/-. The said policy was further renewed vide policy No.200121928280000044 w.e.f. 20.01.2019 to 21.01.2020. There was in continuity of the original insurance policy of  22.01.2014. During the subsistence of the earlier policy, on 19.02.2018 the complainant had pain in his abdomen and vomiting so he consulted the doctors in the DMC & Hospital and on seeing his condition, the doctor concerned opined that the complainant needs to be got admitted in the hospital for further treatment. As such, he was admitted in DMC & Hospital, Ludhiana under hospital CR No.442036 dated 19.02.2018. At the time of admission, the complainant explained the symptoms and problems faced by him and told the staff that he is having pain in his abdomen and vomiting for the last about one hour and the same was recorded by the staff of the hospital. On the basis of his checkup and symptoms disclosed by the complainant he was diagnosed to be suffering from Pain Abdomen-Acute Infective Gastritis, Fatty Liver and BPH (Grade-I) and was given treatment for the said ailments and administered medicines and his diagnostics investigations were done. The complainant remained admitted in the hospital from 19.02.2018 to 22.02.2018 and was discharged on 22.02.2018 in improved condition. As per discharge summary dated 22.02.2018 issued by DMC & Hospital, Ludhiana the details regarding diagnosed illness and investigations carried out during the course of hospitalization and recommended medicines were mentioned in the same. The complainant submitted that he has taken a cashless policy and during his stay in the hospital, he lodged the pre-authorization request and when the said pre-authorization request was not accepted, the original documents were submitted with the opposite parties to reimburse the amount spent on his treatment but the opposite parties did not approve the pre-authorization request and repudiated the same vide letter dated 22.02.2018. However, the complainant submitted documents after the hospitalization and the claim was also repudiation vide letter dated 18.04.2018 on the ground that “During investigation by our authorized person & on going through the claim documents it was found that patient is known alcoholic. The present diagnosis is a direct complication of prolong alcoholism. The line of treatment is directed primary to treat the complication of alcoholism. As per Group Policy Exclusin-Clause-3.10 & 3.18-Expenses incurred for treatment of complication of alcoholism due to use of intoxicating drugs/alcohol is not covered.”  The complainant further alleged that the repudiation of the claim is totally wrong, against the facts and record of the hospital and the said repudiation letter is liable to be set aside and the complainant is liable to be paid the expenses incurred by him during hospitalization of his wife and other benefits, if any, as per term of the policy in view of the following reasons:-

a. That it has nowhere been mentioned in the discharge summary that the ailments of pain in abdomen and vomiting have taken place due to intake of alcohol, excessive or otherwise.

b. That even in the follow-up treatment, it has not been advised that the complainant should not consume alcohol. Had the complications arisen due to intake of alcohol by the complainant then the doctors would definitely have advised the complainant not to take alcohol.

c. That the problems of pain in abdomen or acute infective gastritis or fatty liver can occur due to many reasons and it cannot be ascribed without any basis that intake of alcohol is the reason for the said ailments.

d. That in the entire medical record of the hospital, it has nowhere been mentioned that the complainant is an excessive alcoholic or that he had taken huge quantity of alcohol immediate prior to developments pain in abdomen and vomiting. Therefore there is no material on record from which the respondents have drawn the said wrong inference.

e. That the representative of the respondents had come to the complainant to enquire the matter and to record his statement and he was specifically told that the complainant is not an alcoholic and as per the understanding of the complainant, the said statement of the complainant was correctly recorded.

f. That although the complainant is not an alcoholic yet these days occasional consumption of alcohol in small quantities is more of a life style and as per the understanding of the complainant, majority of people do take alcoholic drinks once a while and no ailments can be ascribed to intake of such occasional alcohol in small quantities.

g. That the letters dated 22.02.2018 and 18.04.2018 issued by the respondents are totally non-speaking one and do not divulge that what is the internal verification that has been conducted by the respondents and which documents have been referred to by them while conducting the said verification. It also does not mention that on basis of what evidence, it has been concluded by the respondents that the complainant was admitted in the hospital for treatment of ailments caused by excessive alcoholism. Therefore, it is evident that the said conclusion has been arrived at while sitting in the office by the respondents without going through the facts or the medical record or the history narrated by the complainant to the medical staff of DMC & Hospital, Ludhiana. Therefore, the respondents have acted on a pre-conceived notion and with pre-determined mind that the claim of the complainant has to be repudiated without having any valid reasons for the same.    

h. That the complainant had incurred Rs.37,267/- approximately during the course of the hospitalization in the DMC & Hospital, Ludhiana. Even at the time of his discharge, he was advised to remain under regular medication as mentioned in the discharge summary. The complainant had to incur a lot of expenses on the purchase of medicines and visiting the OPD clinic and even now the complainant has to purchase the said medicines by way of follow up treatment.

The complainant further submitted that the opposite parties did not enquiry before issuing the repudiation letters dated 22.02.2018 and 18.04.2018 and have repudiated the claim without application of mind in order to deny the genuine claim of the complainant. The opposite parties have provided deficient services and are liable to pay the amount incurred by the complainant on the hospitalization along with compensation. In the end, the complainant made a prayer for directing opposite parties to pay the amount of Rs.37,267/- incurred on the treatment and purchase of medicine for his son and investigations in DMC & Hospital, Ludhiana along with interest @12% per annum and also to pay compensation of Rs.50,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable and the complainant has not come to the court with clean hands and has suppressed the material facts. The complainant is estopped by his own act and conduct and has no locus-standi to file the present complaint. The opposite parties alleged that from the documents submitted by the complainant, his claim was not found good for payment since as the complainant was suffering from Acute Infective Gastritis, Fatty Liver and BPH (Grade-I) and therefore the hospitalization is not justified as admission is only for observation. The complainant was admitted in Dayanand Medical College & Hospital on 19.02.2018 and discharged on 22.02.2018 and during the admission has undergone medically managed. During investigation by the authorized person of the opposite parties and on going through the claim documents, it was found that patient is known alcoholic. The present diagnosis is a direct complication of prolong alcoholism. And line of treatment is directed primary to treat the complication of alcoholism. As per Group Policy Exclusion- Clause-3.10 & 3.18- Expenses incurred for treatment of complication of Alcoholic due to use of intoxicating drugs/Alcohol is not covered. Thus, the claim of the complainant was rightly repudiated as per terms and conditions. 

                   On merits, opposite parties reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CW1/A in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C4 are the copies of policy schedule, Ex. C5 to Ex. C7 are the copies of discharge summary dated 22.02.2018, Ex. C8 to Ex. C21 are the copies of receipts/bills, Ex. C22 to Ex. C27 are the copies of investigation/test reports of the complainant, Ex. C28 is the copy of health claim form, Ex. C29 is the copy of letter dated 30.04.2018 written by the complainant, Ex. C30 is the claim repudiation letter dated 14.05.2018 and closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Sh. Suryadeep Thakur, Area Manager (Legal Claims) of the opposite parties along with documents Ex. R1 is the copy of policy schedule valid from 22.01.2017 to 21.01.2018, Ex. R2 is the copy of indoor patient admission record of the complainant, Ex. R3 is the copy of claim repudiation letter dated 27.08.2019 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.      

6.                The claim of the complainant has been repudiated by the opposite parties by invoking exclusion clause No.3.10 and 3.18 of the insurance policy Ex. C1 = Ex. R1 which reads as under:-

Policy Exclusion

Clause-3.10 & 3.18- Expenses incurred for treatment of complication of Alcoholic due to use of intoxicating drugs/Alcohol is not covered. Thus, the claim of the complainant was rightly repudiated as per terms and conditions. 

The claim has been repudiated on the premise during investigation by the  authorized person of the opposite parties & on going through the claim documents it was found that patient is known alcoholic. The present diagnosis is a direct complication of prolong alcoholism. The line of treatment is directed primary to treat the complication of alcoholism.

7.                Now the point for consideration arises how it is required to be assessed whether the admission of the complainant is primarily to treat the complication of alcoholism?

8.                The counsel for the complainant has referred to the extract of the discharge summary Ex. C6 which is reproduced as under:-

‘Patient presented with above mentioned complications to DMC & H. In view of pain abdomen USG was done which was S/O FLC (Grade-I) & BPH (Grade-I).Patient was managed conservatively and is now being discharged in a stable condition.’

The counsel for the complainant has further contended that Fatty liver disease (steatosis) is a common condition caused by having too much fat build up in the liver and it interferes with the normal functioning of the liver. Intake of alcohol could be one of the reasons but it cannot be the only reason for such fatty liver disease.

                   It can be seen that at the time of admission or at the time of discharge, the treating doctor(s) have not specified that the ailment has occurred due to excessive intake of alcohol by the complainant. No caution has been given against the consumption of alcohol at the time of discharge of the patient. The claim was repudiated on the ground that the expenses incurred by the complainant for the treatment during the hospitalization are because of complication of alcoholism. Moreover, except the affidavit Ex. RA of one Suryadeep Thakur, Area Manager (Legal Claims) of the opposite parties, no medical evidence has been adduced by the opposite parties to substantiate their version.  The opposite parties have also not relied upon in medical literature  or authority to support their claim. The affidavit Ex. RA is also verbatim reproduction of the averments of written reply only. In the given facts and circumstances, it cannot be said that the repudiation of the claim is justified and as such, it would be just and appropriate if the opposite parties are directed to pay the medical expenses of Rs.37,267/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.02.2018 till date of actual payment along with composite costs of Rs.10,000/-.

9.                As a result of above discussion, the complaint is allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.37,267/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.02.2018 till date of actual payment . The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

 

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:11.01.2023.

Gobind Ram.

 

 

Bindesh Kumar Vs Reliance General Insurance Co. Ltd.                    CC/19/284

Present:       Sh. Alok Mohindra, Advocate for complainant.

                   Sh. Sunil Goel, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with an order that the opposite parties shall pay the claim of medical expenses of Rs.37,267/- spent on treatment of the complainant along with interest @8% per annum from the date of admission i.e. 19.02.2018 till date of actual payment . The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

                

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:11.01.2023.

Gobind Ram.