West Bengal

Darjeeling

cc/19/2022

Gelek Palden Bhutia - Complainant(s)

Versus

Star Health and Allied Insurance Co Ltd - Opp.Party(s)

18 Apr 2024

ORDER

F I N A L   O R D E R

       An application has been filed by the Complainant U/S-35 of the C.P. Act, 2019 against the O.P Insurance Company alleging deficiency of service due to repudiation of insurance claim of the Complainant and therefore the Complainant prays for a direction to be given upon the O.P to make payment of the claim amount of Rs. 3,80,101/( Rupees Three Lakh Eighty Thousand One hundred One only) which he has incurred as expenditure for his treatment along with  interest @15% and compensation to the tune of Rs. 50,000/( Rupees Fifty Thousand Only) and litigation cost of Rs. 30,000/( Rupees Thirty Thousand only).

       The fact of the case in a succinct way is that the family of the Complainant was duly insured with Family Health Optima Insurance Plan through Siliguri Branch Office, under Policy No. P/191124/01/220/005865. During the period of the coverage of the aforesaid Insurance Policy, the Complainant became seriously ill as he was suffering from Pancreatitis and was admitted to Adarsh Nursing Home, Kalimpong on 05.07.2021 from where he was discharged on 09.07.2021 and was again admitted in West Bengal Government Hospital, at Kalimpong. He was discharged from the West Bengal Government on 16.07.2021.  The Complainant was again admitted in Anandalok Nursing Home, Siliguri on 16.07.2021, where his treatment did not go well and was referred to Lilavati Hospital, Mumbai, where he got cured and was discharged from the hospital on 28.07.2021.

 

      It is the allegation of the Complainant that he incurred total expenses for his aforesaid medical treatment amounting to Rs. 3,80,101/- ( Rupees Three Lakh Eighty Thousand One hundred One only) and claimed such amount from the O.P Insurance Company, vide Claim Intimation Number: CIR/2022/191124/3170311 for Anandalok Multispecialty Hospital Bills and Claim Intimation Number CIR/2022/191124/2914587 for Lilavati and Research Centre Bills.

      Further, the Complainant stated that was surprised and shocked to receive the letter  dated 08.09.2021 from the O.P Insurance Company wherein absurd and non tenable objection were raised against the claim submitted by the Complainant on the ground that the Government Hospital Kalimpong had described his condition was due to Chronic Alcoholic Liver Disease (Ch. ALD) but the Anandaloke Hospital, Siliguri and Lilavati Hospital, Mumbai never mentioned that his Pancreatitis problem was due to Alcoholic Liver Disease and it was found out only in the discharge certificate of the Government Hospital, Kalimpong that described the condition was due to Alcoholic Liver Disease which was a sheer mistake on the part of the doctor of the Government Hospital Kalimpong.

       The Complainant approached the doctor of the Government Hospital Kalimpong after receiving the aforesaid letter and informed him about the mistake. The doctor realized the mistake and rectified the discharge certificate dated 20.12.2021 stating that he mistakenly wrote Chronic Alcoholic Liver Disease instead of Chronic Liver Disease, which the Complainant submitted to Star Health, Siliguri Branch.

       It is the contention of the Complainant that even after the submission of the rectified discharge certificate, both his claims got rejected vide letter of      Repudiation of Claim dated 21.10.2021 for Claim No.

      CIR/2022/191124/3170311 and dated 22.10.2021 for Claim No. CIR/2022/191124/2914587.

      The Complainant being aggrieved and dissatisfied with the Non-Settlement of claim by the O.P Insurance Company had approached to the Office of the Insurance Ombudsman for redressal of his grievance, where the complaint was dismissed without any relief to the complainant on 25.07.2022. The Complainant further stated that the O.P Insurance Company had taken false excuse to absolve the liability from paying the Mediclaim to the Complainant.

       The Complainant has alleged deficiency in service on part of the O.P Insurance Company in not attending to and making necessary payment of the Mediclaim as submitted by the Complainant despite the fact that during the relevant period the Complainant was covered by the Mediclaim Insurance and there was no reason whatsoever to deny the claim of the Complainant and thus files this case for proper redressal and prays for the reliefs as under:-

      The Complainant prays for the following reliefs :-

1. Declaration that the case of the Complainant is genuine.
2. Payment of claim amount of Rs. 3,80,101/ (Rupees Three Lakh Eighty Thousand One Hundred and One only) together with the interest at the rate of 15% on the said amount.
3. A sum of Rs. 50,000/- ( Rupees fifty Thousand only) as a compensation for harassment.

 

4. A Sum of Rs. 30,000/- (Rupees Thirty Thousand only) towards litigation expenses.

List of documents filed on behalf of the Complainant:-

 

1. Copy of Customer Identity Card issued by Star Health and Allied Insurance Company.
2. Copy of Money Receipt from Dr. G. M. Dey marked as Annexure A ( Pages 1 to 2).
3. Copy of Cash Memo of Adharsha Nursing Home marked as Annexure B ( Pages 1-2).
4. Copy of Cash Memo of Suraksha Chemist and Druggist marked as Annexure C ( Pages 1 to 4).
5. Copy of Discharge Certificate of Kalimpong District Hospital.
6. Copy of Cash receipt of Anandaloke Multi-Speciality Hospital marked as Annexure D ( Pages 1 to 4)
7. Copy of Pharmacy Clearance of Anandaloke Multi-Speciality Hospital marked as Annexure E ( Pages 1-7).
8. Copy of Discharge Certificate of Anandaloke Multi Speciality Hospital as Annexure-F( 2 pages)
9. Copy of Bill of supply of Lilavati Hospital and Research Centre as Annexure G, dated 28.07.2021( 1 page)
10. Copy of Discharge Certificate of Lilavati Hospital and Research Centre, dated 28.07.2021.( Annexure-H) Pages- 1 to 4).
11. Copy of Rejection letter from State Health Insurance Co. Ltd dated 08.09.2021 as  Annexure-I ( 1 page)

 

12. Copy of letter of reconsideration of claim along with the copy of letter of rectification of discharge certificate by Dr. G. M. Dey dated 20.12.2021 as Annexure-J.

1. Letter of Repudiation of claim bearing No. CIR/2022/191124/3170311 dated 21.10.2021 as Annexure- K( 2 pages).

The Complainant has mentioned in his annexure that he has filed the copy of letter of Repudation of claim bearing No. CIR/2022/191124/2914587 dated 22.10.2021 and the copy of the order from the Office of the Insurance Ombudsman dated 01.08.2022. But on scrutiny we do not find any such documents with the case record.

Notice has been issued to the Opposite Party from this District Commission, Darjeeling. The said notice dated 05/01/2023 was sent to the Opposite Party. It reveals from the case record that the O.P Insurance Company appeared before this Commission and filed Vakalatnama and prayed for time for filing Written Version and this Commission allowed OP’s prayer and fixed the case on 13/02/2023 for filing Written Version by the Opposite Party. On 28/02/2023 the Opposite Party filed Written Version and submitted some documents by annexure with the W/V and the Opposite Party denied all the material allegations of the Complaint Petition and stated that the case is not maintainable in the eye of law.

In the W/V the O.P with reference to the statements made in paragraph Nos. 3 to 7 of the Complaint stated that :-

(I). CIR/2022/191124/3170311.

 

1. The Complainant was admitted for treating “Haemorrhagic Pancreatitis, Acute Kidney Infection (AKI), Sepsis and Anemia” at Anadaloke Multi-speciallty Hospital from 16.07.2021 to 23.07.2021.
1. The Opposite Party Insurer Company was approached for availing reimbursement facility for an amount of Rs. 1,94,294/- vide claim form along with discharge summary of treating hospital, discharge summary of Department of Health and Family Welfare, Government of West Bengal, final bills and investigation records. (Annexure A)
2. On scrutiny of documents, it was observed from discharge summary of Department of Health and Family Welfare, Government of West Bengal (Annexure B) that the Complainant was diagnosed with Chronic Alcoholic Liver Disease (ALD) because of which, he was also diagnosed with Hepatomegaly. This was diagnosed during hospitalization from 14.07.2021 to 16.07.2021.
3. Based on this observation, the claim was repudiated vide letter dated 21.10.2021 ( Annexure C) since it is confirmed that the Complainant had undergone treatment primarily for the ailment which is due to use of alcohol as was diagnosed since hospitalization from 14.07.2021 to 16.07.2021 and the same is not payable as per Exclusion Clause 3(12) of policy terms and condition. ( Annexure D).

(II). CIR/2022/191124/2914587:-

1. The Complainant was admitted for treating “Chronic Pancreatitis with Pseudoaneurysmal Bleed Angiographic Embolization done in case of Post Cholecystectomy Status” at Lilavati Hospital and Research Centre from 23.07.2021 to 28.07.2021.

 

2. The Opposite Party Insurer Company was approached for availing reimbursement facility for an amount of Rs. 1,66,637/- vide claim form along with discharge summary, final bills, investigation records and  bills.

                ( Annexure-E).

1. On scrutiny of documents, it was observed from the discharge summary of Department of Health and Family Welfare, Government of West Bengal that the Complainant was diagnosed with Chronic Alcoholic Liver Disease (ALD) because of which, he was also diagnosed with Hepatomegaly. This was diagnosed during hospitalization for the period from 14.07.2021 to 16.07.2021. This discharge summary was derived from previous claim No. CIR/2022/191124/3170311 based on which, this claim was also repudiated.
2. Based on this observation, the claim was repudiated vide letter dated 22.10.2021 since it is confirmed that the Complainant had undergone treatment primarily for the ailment which is due to use of alcohol as was diagnosed since hospitalization from 14.07.2021 to 16.07.2021 and the same is not payable as per Exclusion Clause 3(12) of policy terms and conditions.

Thus, it is evident from the fact that the diagnosis of CLD, which is incurable led to the diagnosis of Hemorrhagic Pancreatitis, AKI, Sepsis, Anemia and Chronic Pancreatitis. Usage of alcohol on a regular basis can lead to severe damage in liver, thereby causing CLD, Hemorrhagic Pancreatitis, AKI, Sepsis , Anemia and Chronic Pancreatitis. In fact, alcohol abuse or alcoholism is one of the major contributing factors to       develop acute and chronic inflammation of both liver and pancreas. As such, treatment related to alcohol usage is not payable as per Exclusion Clause 3(12) of policy terms and conditions.

      The aforementioned facts were also observed by the Ld. Ombudsman Authority of Kolkata who concurred with the repudiations done in both the aforementioned claims due to usage of alcohol and that the same is not payable as per the terms of policy. (Annexure F).

        As per the Exclusion Clause 3(12) of the policy – Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof – Code Excl 12.

       Moreover, it is to be noted that the total amount as per claim form filled by Complainant towards claim no. CIR/2022/191124/3170311  is Rs. 1,94,291/- , as for the claim No:- CIR/2022/191124/2914587 the total amount claimed by the Complainant in the claim form is Rs. 1,66,637 /-. Hence, the total amount incurred by Complainant towards hospitalization in both these claims is Rs. 3,60,931/- and not Rs. 3,80,101/- as mentioned incorrectly by Complainant in paragraph 5 of his complaint.

        That with reference to the statements made in paragraph nos. 8 and 9, it is   submitted that the rectified discharge summary was submitted only with respect to claim no. (Annexure G) CIR/2022/191124/3170311 vide email dated 14.04.2022.

This rectified discharge summary was submitted before the grievance Department after claim was repudiated vide letter dated 21.10.2021. This action of Complainant is purely an afterthought and with a mala-fide intention to get the claim amount through illegal and unfair means. This submission is made because while submitting the original discharge summary of Department of Health and Family Welfare, Government of West Bengal under reimbursement mode in both claim nos. CIR/2022/191124/3170311 and CIR/2022/ 191124/2914587, the Complainant was completely aware of the contents of the said discharge summary. It is only after both these claims were repudiated that the Complainant, through unfair means tried to get the claim paid by submitting the “so called “ rectified discharge summary. If the Complainant truly believed that the diagnosis were wrongly mentioned in the said discharge summary, he would have provided the rectified discharge summary when he approached the Opposite Party Insurer Company under reimbursement mode. Therefore, such actions of Complainant taken by submitting the rectified discharge summary AFTER claim were repudiated constitutes “ Fraud ” as per Clause 5(9) of policy terms and conditions.

       As per Clause 5 (9) of the policy – “ Fraud : if any claim made by the insured person, is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof, or if any fraudulent means or devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit under this policy, all benefits under this policy and the premium paid shall be forfeited. Any amount already paid against claims made under this policy but which are found fraudulent later shall be repaid by all recipient (s)/ policy holder (s), who has made that particular claim, who shall be jointly and severally liable for such repayment to the insurer. 

For the purpose of this clause, the expression “ Fraud “ means any of the following acts committed by the insured person or by his agent or the hospital / doctor/ or any other party acting on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to issue an insurance policy:

1. The suggestion, as a fact of that which is not true and which the insured person does not believe to be true.
2. The active concealment of a fact by the insured person having knowledge or belief of the fact.
3. Any other act fitted to deceive; and
4. Any such act or omission as the law specially declares to be fraudulent “.

       It is further stated in the W/V by the O.P that it is incorporated in the policy as per mutual agreement, understanding, consent, knowledge and probable implications thereof and the parties have accepted the said terms and conditions as they appear in the contract itself. The terms and conditions are formulated as per policies of the insurance company, IRDA guidelines and based on available claim details/ documents. It is under such terms and conditions, upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy; its terms have to be strictly construed to determine the extent of liability of the insurer. So far as the Insured is concerned, he/she can avail the benefit under the policy with the limits fixed by the terms and conditions as well as riders appended thereto. Now, at the time of proposing the policy, the terms and conditions of the policy were explained to the Complainant and same was served to him along with Policy Schedule.

Since, the contract of insurance between the parties are governed by the terms and conditions stipulated therein, therefore the parties have to abide by the definitions given in the contract itself and all those expressions appearing the policy should be interpreted with reference to the terms of the policy. It is presumed that the parties have entered into a contract of insurance with their eyes wide open, they have to rely on the terms and conditions of the contract.  Hence, both the Insurer and Insured are required to follow those terms and conditions of the Policy correctly. Once the parties have entered into contract by setting out the clauses enumerated therein, they later on cannot turn around and allowed to travel beyond the permissible limits of the said contract. Under such circumstances, there was no deficiency in service and/or willful negligence on the part of the Insurer in the instant case. The financial and mental loss of the Complainant cannot be attributed to any fault or deficiency or negligence in service on part of the insurer. It is also denied that the Opposite Party owes any liability towards the Complainant under the policy in question or that; there is deficiency in services to Complainant.

      That moreover, it is mentioned that the Complainant was at liberty to go through the policy terms and conditions when the same was received by him at the time when the policy was issued for the first time and also when the said policy was renewed. To elaborate, a 15 days’ free look period is provided to the Proposer/ Insured to go through the policy copy from the date of receipt of the policy copy and if the said Proposer/Insured does not dispute the policy within the said 15 days period, it is presumed that the Proposer/Insured is satisfied with all the policy terms and conditions without any objection.       If at all the Complainant had objection to the said waiting period, the policy should not have been accepted by him. As such, this present complaint filed by completely turning a blind eye to the policy terms and conditions shows the ignorance of the Complainant who, despite of knowing the applicability with respect to waiting period to his diagnosis is still hell bent on walking over the said clause which is a violation of trust and good faith.

       That the benefit under the policy taken by the Complainant is conditional which are incorporated in the policy wordings. There are some restrictions such as stipulated waiting period for any type of illness which are in consonance with IRDA guidelines.

       According to the Opposite Party in its Written Version it is mentioned that per the Indian Contract Act, 1872, firstly there must be an offer, secondly the offer must be accepted by the person to whom it was intended. One of the primary requirement in the contract is Acceptance in Ad-idem i.e. through acceptance is important, there must be “Consensus ad-idem”. Consensus ad-idem means meeting of minds. It means that parties to the contract should accept the terms of the contract in the same sense.

      That according to the Opposite Party it settled law that the terms of the policy shall govern the contract between the parties they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy.

     That it is the matter of contract and in terms of the contract, the relation of the parties shall abide and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they have to rely on the terms of the Contract. Hence, the Insurance Company and the Insured are to follow all terms and conditions of the Policy correctly.

      It is submitted by the Opposite Party in the Written Version that the terms and Conditions of the Policy were explained to the Complainant at the time of proposing policy and the same was served to the Complainant along with the Policy Schedule.

      That it is further stated that upon insurance policy, the Complainant undertakes to indemnify the loss suffered by the Complainant on account of risks covered by the Policy; its terms have to be strictly construed to determine the extent of liability of the Opposite Party.

      The Opposite Party submits that the Policy issued by the Complainant under which the dispute has been raised is governed by limits of Liability as per various clauses. That without any prejudice to whatever has been stated in the foregoing paragraphs of the Written Version filed by the Opposite Part and even assuming but not admitting that the insurer is liable to pay the claim in terms of the contract of insurance issued to the Complainant it is respectfully submitted by the Opposite Party that the maximum quantum of liability will be as per the terms of the Policy and not beyond the same.

      That it is further submitted by the Opposite Party that the Claim of the Complainant was rightly repudiated by the Opposite Party Insurance Company and hence there is no deficiency in service from their part. On this ground the Opposite Party moves before this Ld. Commission that the instant Complaint Petition is liable to be dismissed in-limine against the Opposite Party with an exemplary cost. The Opposite Party denies all the allegations made by the Complainant as false and unbelievable. The Opposite Party denies the allegations holding it requiring strict proof to substantiate the allegation as labeled against the Opposite Party. The Opposite Party further submits that it is the Complainant who has committed fraud and as such he is not entitled to relief claimed by him and hence the case filed by the Complainant is liable to be dismissed.  Further. The Opposite Party stated in its Written Version that the case if the Complainant is not maintainable in the back drop of the settled principles of law and there is no deficiency of service caused by the Opposite Party in anyway. The Opposite Party therefore, prayed for dismissal of the case.

      During hearing of the case, the Complainant adduced evidence and filed Written Evidence-in-Chief on 25/05/2023 supported by an affidavit and further submitted documents by making Annexure. The Opposite Party was to file questionnaire on 12/06/2023 but O.P did not appear before this Commission on that day and hence next date was fixed on 22/06/2023 for the same, but on that day the O.P filed time petition and sought time for filing questionnaire. The Petition was heard and allowed and the next date was fixed on 07/07/2023. The Opposite Party since 25/05/2023 till 18/07/2023 did not file the Questionnaire.  The O.P did not appear before this Commission even on 18/07/2023 where in the date was fixed for Show Cause by the Opposite Party as per Order no.16 dated 12/07/2023.   

Hence, the Commission seemed that the O.P was least interested to proceed on with the case causing unlimited delay in following the procedure or law as mentioned in C.P Act 2019. Hence the Evidence of the Complainant was closed and the case was fixed on 02/08/2023 for filing Evidence by the O.P with an affidavit.

        The O.P has filed Evidence-in Chief with an Affidavit on 29/08/2023 and the next date was fixed on 13/09/2023 for filing Questionnaire by the Complainant. But still on the date fixed by this Commission for filing Questionnaire by the Complainant, the Complainant remained absent without taking any steps. Hence the order was passed by this Commission to file Show Cause by the Complainant on the next date i.e. 20/09/2023. However the Complainant did not appear before this Commission on the said date and again next date was fixed on 13/10/2023 for filing Show cause by the Complainant. However, on the said date the Complainant again failed to appear before this Commission however this Commission granted another  date fixing on 07/11/2023 for filing Show Cause and a cost of Rs.500/-was imposed upon the Complainant.

 

       On the said date i.e. 07/11/2023, the Ld Advocate on behalf of the Complainant appeared before this Commission, however the Advocate on behalf of the Complainant filed a Time Petition on the ground of devastating calamity affecting the life and property caused by Teesta River. Considering the prayer of the Complainant on the ground mentioned therein last chance was allowed or else the opportunity to file questionnaire by the Complainant was to be closed.

The Complainant paid the cost of Rs.500/- Hence, next date was given to the Complainant as a last chance to file Show cause. Accordingly, next date was fixed on 24/11/2023 for the same.

      But on the date fixed i.e. 24/11/2023, the Complainant remained absent without any steps while the Ld. Advocate on behalf of the O.P was present. This Commission upon going through this case record could see that the Complainant and the O.P both have filed Evidence and the instant case was pending since long for filing questionnaire by the Complainant against the Evidence of the O.P but the Complainant remained absent on several dates and that is why an order for Show Cause has been passed by this Commission and it is further seen from the case record that on last occasion i.e. on 07/11/2023the Complainant had appeared and paid the cost of rs.500/- but he did not file the Show cause and this Commission extended further time for filing Show Cause but the Complainant still on 24/11/2023 did not avail the opportunity as passed by this Commission on earlier occasion. Hence, the chance of filing questionnaire by the Complainant remained closed and the matter was fixed for argument. Next date was fixed on 11/12/2023 for argument of the case and filing BNA by both parties i.d the case was to be decided on merit in terms of Section 38(3)(C) of the C.P Act.2019.

 

      On the date fixed for argument i.e. on 11/12/2023, the Complainant remained absent without taking any steps and also did not file BNA. While the Advocate on behalf of the Opposite Party did file written BNA.

      Therefore, due to absence of the Complainant, this Commission constrained to invoke the provisions as laid down under section 38(3)(c) of the C.P Act 2019 and accordingly after hearing the argument pass the final order.

       From the Complainant Petition, W/V of the O.P and Evidence of both the parties and other materials on record, the following points have been framed:-

1. Is the Complainant a Consumer?
2. Is the case filed within the period of limitation as provided U/S-69 of the C.P Act?
3. Has this Commission pecuniary and territorial jurisdiction to entertain, try or adjudicate the case?
4. Is the O.P deficient in providing service towards the Complainant?
5. Is the Complainant entitled to get any relief as prayed for?

 

                                DECISION WITH REASONS:

 

      All the points are taken for the sake of brevity, avoidance of repetition of facts, convenience for discussion and arriving at a just decision of the case.

      In order to unearth the point whether the present complainant is a consumer or not, we have to scan the evidence of the complainant and other documents filed by him and it is seen that the Complainant had obtained an Insurance Policy  from the O.P being a family Health Optima Insurance Plan through Siliguri Branch Office under Policy No. P/191124/01/220/005865. The Complainant has filed a copy of the Customer Identity card issued by the O.P. The Complainant has neither submitted any Policy details in respect of P/191124/01/220/005865 nor any details about premium amount deposited by the Complainant with the O.P during his evidence. The O.P Insurance Company has not denied the fact that the Complainant has not purchased the above noted policy, rather it is an admitted position that the Complainant has obtained the above noted policy from the O.P Insurance Company. However taking the identity card filed by the Complainant we are of considered view the Complainant is a Consumer within the meaning and definition given U/S 2(7) of the C.P Act 2019.

      Now in order to ascertain the point of limitation of time we have scrutinize the evidence of the Complainant and other materials on record. Here the instant case was filed on 05/01/2023, The cause of action arose on 21.10.2021 & 22.10.2021 when the O.P Insurance Company repudiated the claims of the Complainant.

      Therefore, we are of the view that the instant case was filed within the limitation period as provided U/S- 69 of the C.P. Act, 2019.

      Now in order to ascertain whether this District Commission has ample power and jurisdiction to entertain, adjudicate and decide the case or not we have to look at the evidence of the Complainant and other materials on record.

      It is seen from the cause title of the case that the Complainant is a resident of P.O and District-Kalimpong and O.P is carrying its business at Chennai. It is relevant to be mentioned that though Darjeeling District has been bifurcated and       a new District has been emerged as Kalimpong out of the territory of Darjeeling but till date no separate District Commission has been set up at Kalimpong and the area of Kalimpong District is still within the territorial limit of this District Commission, Darjeeling in view of section 34(2) (b) of the C.P Act 2019 this    Commission has territorial jurisdiction to entertain and adjudicate the instant case.

      Further, it is seen from the case record that the Complainant has initiated the case against O.P and prayed for directions to be given upon the O.P to pay the claim amount of Rs. 3,80,101/-(Rupees Three Lakh Eighty Thousand One Hundred and One only )together with an interest at the rate of 15% on the said amount.

       No document has been filed by the Complainant from which we could deduce how much amount he had paid as premium for the aforesaid policy.

       It is the settled principle of law that in order to ascertain the pecuniary limit, the amount paid as premium together with the claim amount constitute the pecuniary limit of the Commission.  Here, in this case in hand the Complainant has not filed any document relating to his policy document or premium receipt, from which we could ascertain the amount. However, from the nature of policy purchased by the Complainant and considering the claim amount it is well presumed that this Commission has ample pecuniary limit or jurisdiction to entertain and try the case.

       Now, in order to ascertain whether the O.P Insurance Company was negligent or deficient in service or not we have to gauge the evidence of the parties once again. 

It is seen from the evidence of the Complainant and the O.P and other materials on record that the family of the Complainant was duly insured with Family Health Optima Insurance Plan through Siliguri Branch Office, under Policy No. P/191124/01/220/005865. During the period of the coverage of the aforesaid Insurance Policy, the Complainant became seriously ill as he was suffering from Pancreatitis and was admitted to Adarsh Nursing Home, Kalimpong on 05.07.2021 from where he was discharged on 09.07.2021 and was again admitted in West Bengal Government Hospital, at Kalimpong. He was discharged from the West Bengal Government on 16.07.2021.  The Complainant was again admitted in Anandalok Nursing Home, Siliguri on 16.07.2021, where his treatment did not go well and was referred to Lilavati Hospital, Mumbai, where he got cured and was discharged from the hospital on 28.07.2021.

     It is stated by the Complainant that he incurred total expenses for his aforesaid medical treatment amounting to Rs. 3,80,101/- ( Rupees Three Lakh Eighty Thousand One hundred One only) and claimed such amount from the O.P Insurance Company, vide Claim Intimation Number: CIR/2022/191124/3170311 for Anandalok Multispecialty Hospital Bills and Claim Intimation Number CIR/2022/191124/2914587 for Lilavati and Research Centre Bills.

      Further, the Complainant stated that was surprised and shocked to receive the letter dated 08.09.2021 from the O.P Insurance Company wherein absurd and non tenable objection were raised against the claim submitted by the Complainant on the ground that the Government Hospital Kalimpong had       described his condition was due to Chronic Alcoholic Liver Disease (Ch. ALD) but the Anandaloke Hospital, Siliguri and Lilavati Hospital, Mumbai never mentioned that his Pancreatitis problem was due to Alcoholic Liver Disease and it was found out only in the discharge certificate of the Government Hospital, Kalimpong that described the condition was due to Alcoholic Liver Disease which was a sheer mistake on the part of the doctor of the Government Hospital Kalimpong.

       The Complainant approached the doctor of the Government Hospital Kalimpong after receiving the aforesaid letter and informed him about the mistake. The doctor realized the mistake and rectified the discharge certificate dated 20.12.2021 stating that he mistakenly wrote Chronic Alcoholic Liver Disease instead of Chronic Liver Disease, which the Complainant submitted to Star Health, Siliguri Branch.

       It is the contention of the Complainant that even after the submission of the rectified discharge certificate, both his claims got rejected vide letter of      Repudiation of Claim dated 21.10.2021 for Claim No.CIR/2022/191124/3170311 and dated 22.10.2021 for Claim No. CIR/2022/191124/2914587.

      The Complainant being aggrieved and dissatisfied with the Non-Settlement of claim by the O.P Insurance Company had approached to the Office of the Insurance Ombudsman for redressal of his grievance, where the complaint was dismissed without any relief to the complainant on 25.07.2022. The Complainant further stated that the O.P Insurance Company had taken false excuse to absolve the liability from paying the Mediclaim to the Complainant.         From the Evidence of the O.P Insurance Company and other materials on record it is evident that the O.P stated that in respect of the claim No:-  CIR/2022/191124/3170311 the Complainant was admitted for treating “Haemorrhagic Pancreatitis, Acute Kidney Infection (AKI), Sepsis and Anemia” at Anadaloke Multi-speciallty Hospital from 16.07.2021 to 23.07.2021.

      The Opposite Party Insurance Company was approached for availing reimbursement facility for an amount of Rs. 1,94,294/- vide claim form along with discharge summary of treating hospital, discharge summary of Department of Health and Family Welfare, Government of West Bengal, final bills and investigation records. On scrutiny of documents, it was observed from discharge summary of Department of Health and Family Welfare, Government of West Bengal  that the Complainant was diagnosed with Chronic Alcoholic Liver Disease (ALD) because of which, he was also diagnosed with Hepatomegaly. This was diagnosed during hospitalization from 14.07.2021 to 16.07.2021. Based on this observation, the claim was repudiated vide letter dated 21.10.2021 since it is confirmed that the Complainant had undergone treatment primarily for the ailment which is due to use of alcohol as was diagnosed since hospitalization from 14.07.2021 to 16.07.2021 and the same is not payable as per Exclusion Clause 3(12) of policy terms and condition.

       Again, in view of the claim No:- (II). CIR/2022/191124/2914587 the Complainant was admitted for treating “Chronic Pancreatitis with Pseudoaneurysmal Bleed Angiographic Embolization done in case of Post Cholecystectomy Status” at Lilavati Hospital and Research Centre from 23.07.2021 to 28.07.2021.

      The Opposite Party Insurance Company was approached for availing reimbursement facility for an amount of Rs. 1,66,637/- vide claim form along with discharge summary, final bills, investigation records and  bills.

       On scrutiny of documents, it was observed from the discharge summary of Department of Health and Family Welfare, Government of West Bengal that the Complainant was diagnosed with Chronic Alcoholic Liver Disease (ALD) because of which, he was also diagnosed with Hepatomegaly. This was diagnosed during hospitalization for the period from 14.07.2021 to 16.07.2021. This discharge summary was derived from previous claim No. CIR/2022/191124/3170311 based on which, this claim was also repudiated.

      Based on this observation, the claim was repudiated vide letter dated 22.10.2021 since it is confirmed that the Complainant had undergone treatment primarily for the ailment which is due to use of alcohol as was diagnosed since hospitalization from 14.07.2021 to 16.07.2021 and the same is not payable as per Exclusion Clause 3(12) of policy terms and conditions.

      Thus, it is evident from the fact that the diagnosis of CLD, which is incurable led to the diagnosis of Hemorrhagic Pancreatitis, AKI, Sepsis, Anemia and Chronic Pancreatitis. Usage of alcohol on a regular basis can lead to severe damage in liver, thereby causing CLD, Hemorrhagic Pancreatitis, AKI, Sepsis , Anemia and Chronic Pancreatitis. In fact, alcohol abuse or alcoholism is one of the major contributing factors to       develop acute and chronic inflammation of both liver and pancreas. As such, treatment related to alcohol usage is not payable as per Exclusion Clause 3(12) of policy terms and conditions.

      The aforementioned facts were also observed by the Ld. Ombudsman Authority of Kolkata who concurred with the repudiations done in both the aforementioned claims due to usage of alcohol and that the same is not payable as per the terms of policy.

        As per the Exclusion Clause 3(12) of the policy – Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof – Code Excl 12.             

      This is to be mentioned that the Complainant had submitted rectified discharge summary before the grievance Department after claim was repudiated vide letter dated 21.10.2021.  In this connection we would like to observe that the Complainant was treated at the Govt. Hospital, Kalimpong and original discharge summary of Department of Health and Family Welfare, Government of West Bengal had been submitted while making the claim. But, subsequently the Complainant submitted rectified discharge certificate from one doctor G.M. Dey dated 20.12.2021.Said rectified discharge certificate was given not on a Government Hospital Paper, but on the writing pad of the concerned doctor. It is not confirmed that the doctor who had treated the patient and issued discharge certificate in the Government hospital was the same person who has issued the rectified discharge certificate afterwards. The Concerned Hospitals or the Doctors who had issued the Discharge Certificate in the Government Hospital or the       Doctor who has later on issued rectified discharge Certificate have not been made as party to the case.  Not even the concern doctor, who later on issued rectified discharge certificate, was examined as witness before this Commission in order to test the veracity of the concerned doctor.  There may be of chances of threat, undue influence upon the concerned doctor who has issued the said certificate or it might be the afterthought of the Complainant. Therefore, the document produced by the Complainant i.e the rectified discharge certificate is not a reliable document and we are not convinced with the said document.

       The Complainant has not filed the policy document before this Commission. No premium receipt has been filed.

       In absence of such documents we are unable to look into the policy documents and the terms and conditions as laid down in the said policy. However, from the documents annexed by the O.P Insurance Company and other materials on record it is detected that the Complainant had a health Insurance Policy. It is admitted by the O.P Insurance Company. But the crux of the matter is that whether the disease of the Complainant would come under the exclusion clause of the Insurance Policy and the terms and Conditions as laid down thereon or not.

       From the copy documents of the Ombudsman it is clearly manifested that the repudiation was rightly done by the Insurance Company as the doctor concerned of the Govt. Hospital diagnosed the Complainant with A.L.D which falls under the exclusion clause of the Insurance Policy.  The version of the O.P Insurance  Company in repudiating the claims of the Complainant has more weightage   in comparison to the evidence led by the Complainant. Though the subsequent hospitals did not mention the disease as ALD but the Complainant was treated in Mumbai and diagnosed as Chronic Pancreatitis with Pseudoaneurysmal bleed with Angiographic Embolization, which may be the consequence of his earlier disease. No reliable or fruitful expert opinion has come from the side of the Complainant. The doctors of the Lialvati Hospital was also not examined in the case.  

      Considering the preponderance of the evidence of both sides we are of the view that the evidence led by the O.P Insurance Company is more convincing, reliable and therefore we are of the view that the repudiation done by the O.P Insurance Company in respect of the claim of the Complainant was justified.

 The Complainant has not come with clean hands. Therefore we are of the view that the Complainant has miserably failed to prove its case.                    

       Since, the contract of insurance between the parties are governed by the terms and conditions stipulated therein, therefore the parties have to abide by the definitions given in the contract itself and all those expressions appearing the policy should be interpreted with reference to the terms of the policy. It is presumed that the parties have entered into a contract of insurance with their eyes wide open, they have to rely on the terms and conditions of the contract. 

Hence, both the Insurer and Insured are required to follow those terms and conditions of the Policy correctly. Once the parties have entered into contract by setting out the clauses enumerated therein, they later on cannot turn around and allowed to travel beyond the permissible limits of the said contract.

      Under such circumstances, we find that there was no deficiency in service and/or willful negligence on the part of the O.P Insurance Company in the instant case and the Complainant is not entitled to get any kind of relief from this Commission.

Accordingly,

 It is ordered that the Consumer Complaint, being No:- C.C-19 of 2022 is dismissed on contest but without any cost.

 Let free Copies be given to the parties Concerned as per the C.P. Rules & Regulations,2020.