BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

1.       Ms. Geetu Jain w/o Late Sh. Anish Jain S/o Sh. Ramesh Jain, aged 50     years,

2.       Ms. Divya Jain D/o Late Shri Anish Jain, aged about 25 years,

3.       Shri Aryan Jain S/o Late Shri Anish Jain, aged about 21 years,

All R/o: 2586, Subhash Park Road, behind S.D.Vidya School, Ambala Cantt.

          ……. Complainants.

Vs.

1. Star Health and Allied Insurance Company Ltd., Branch office, through its Branch Manager, # 1^st Floor, 5, Prem Nagar, Near Post Office, Prem Nagar, Ambala City- 134 003
2. Star Health and Allied Insurance Company Ltd., Regd. & Corporate office, through its Managing Director: # 1, New Tanks Street, Valluvar Kottam High Road, Nungambakkam, Chennai -600 034

                                                                                   ….….  Opposite parties

Before:       Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

Present:       Shri Rohit Mittal, Advocate, counsel for the complainants.

                      Defence of OPs already struck off.

                   (Shri Mohinder Bindal, Advocate, counsel for the OPs.)

Order:        Smt. Neena Sandhu, President.

                   Complainants have filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay claim amount of Rs.12,07,815/- alongwith interest @ 18% per annum, from 08.01.2022, till its realization.
2. To pay a sum of Rs.1,00,000/- as compensation for mental agony & sufferings and cost of travelling etc,
3. To pay cost of litigation to the tune of Rs.55,000/-.
4. OR

Grant any other relief which this Hon’ble Commission may deems fit.

2.             Brief facts of the case are that the complainant No.1 is the wife of Sh. Anish Jain and the complainants No.2 and 3 are the daughter and son of Shri Anish Jain and unfortunately Shri Anish Jain expired on 08.06.2022. The husband of the complainant No.1 purchased medi-claim policy i.e. Family Health Optima Insurance Plan from OP No.1 which was effective from 08.07.2015, which was obtained on making payment of premium alongwith service tax. Under the said policy, the whole family including complainants were covered for medical benefits. The complainant No.1 alongwith her husband had been getting the said policy renewed from the  OP No.1 regularly time to time from the last 7 years and the same was renewed on 08.07.2016, 08.07.2017, 08.07.2018, 08.07.2019, 08.07.2020 and on 08.07.2021. Lastly the policy was renewed on 08.07.2021 under policy no.: P/211117/01/2021/001739 bearing customer Code: AA0002777559 after payment of Rs.24,378/- as premium and the period of Insurance was 08.07.2021 to 07.07.2022 for a total limit of coverage of Rs.8,25,000/-. In the month of January, 2022 the husband of the complainant No.1 started feeling some urinary problem, abdomen pain, fever and on 06.01.2022, the husband of the complainant No.1 for the first time went to the Alchemist Hospital, Panchkula where he was admitted by the doctors concerned and various tests were conducted upon him. He was diagnosed as "HEPATIC ENCEPHALOPATHY" which is medically a problem generally occurs in people with chronic liver disease, such as cirrhosis or hepatitis. It is generally caused when toxins that are normally cleared from the body by the liver accumulate in the blood, eventually travelling to the brain. Many of the symptoms of "HEPATIC ENCEPHALOPATHY" are reversible when promptly detected and treated. The complainants showed the Insurance policy issued by the  OPs  to the Incharge of the Hospital and they registered the claim of the husband of the complainant No.1 under claim intimation No.: CIR/2022/211117/3703541 dated 06th January, 2022 for cashless facility but to the utter surprise of the complainant, instead of approval of the cashless treatment, the  OPs  started putting off the claim on one pretext or the other and on 08.01.2022 rejected the request of the complainants for approval of cashless treatment on false grounds i.e. "We noted that the insured patient has been admitted for treatment of "Cirrhosis of liver" expenses for this treatment are not admissible in accordance with exclusion no. 12 of the policy" and as such denied the cashless treatment to the husband of the complainant No.1. The complainant No.1 again on 10th of January 2022 sent letter dated 10.01.2022 to the OPs to reconsider the Insurance claim but again on the same day i.e. 10.01.2022 at about 05:59 P.M. the  OPs  issued a letter for Rejection of Authorization for cashless Treatment vide E-mail on the ground that "We have scrutinized your request for approval for cashless treatment of the above insured patient for the diagnosed disease of "Cirrhosis of Liver". We note that the insured patient has been admitted for treatment of Ethanol related cirrhosis of liver- expenses for this treatment are not admissible in accordance with exclusion no. 12 of the policy" We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease. Condition of the husband of the complainant No.1 was critical and immediate treatment was required to be taken and as such the complainant  No.1 just to save the life of her husband borrowed huge amount from the friends and relatives to pay the heavy medical bills. During the course of treatment and stay in Alchemist Hospital the husband of the complainant No.1 was also found Covid-19 Pneumonia positive and he was shifted to Covid Ward on 12th January, 2022 and he remained admitted in Corona Ward till 16.01.2022 and an amount of Rs.1,17,477.98 was spent for the treatment of Covid-19 Pneumonia during the above period. After denying the cashless treatment, the complainant No.1 whose husband remained admitted in Alchemist, Panchkula from 06.01.2022 to 17.01.2022 had to spent a huge amount of Rs.3,63,577/- including the abovesaid amount of Rs.1,17,477.98 which was spent for the treatment of Covid-19 Pneumonia. The  husband of the complainant No.1 was discharged from the Alchemist Hospital on 17.01.2022 and a detailed discharge summary was prepared by the Doctors concerned. Again on 25.01.2022, the husband of the complainant No.1 was taken to Alchemist Hospital. Panchkula as he was feeling drowsiness, decreased appetite and also his stool was not passing and feeling some problem in "Urinary Tract",. The complainants again showed the Insurance policy issued by the  OPs  to the Incharge of the Hospital and they registered the claim of the husband of the complainant No.1 under claim intimation No.: CIR/2022/211117/3915457 dated 25.01.22 for cashless facility but again the  OPs  recklessly denied the cashless facility whereby the doctors again on 25.01.2022 admitted him for further treatment. Various tests were again conducted and treatment was given to him accordingly and he was discharged on 31.01.2022 and the complainants again under the compelling circumstances had to arrange and pay an amount of Rs.1,61,082/- for the treatment conducted during the above period of treatment i.e. from 25.01.2022 to 31.01.2022 and as such had spent an amount of Rs. 5,24,659/- during the abovestated time period for taking treatment in the hospital. The husband of the complainant No.1 being not recovered fully, had been taking treatment/follow ups for which an amount of Rs. 17,000/- was spent till May, 2022 for follow up treatment. After denying the cashless facility for the treatment of the husband of the complainant No.1 against the claim registered by her through Alchemist Hospital on 06.01.2022 and 25.01.2022, the  OPs  demanded various documents from time to time, which were provided by the complainant.  The OPs  even after receiving the original documents alongwith claim form again demanded the documents for claim intimation No.: CIR/2022/211117/3703541 dated 06.01.2022 vide letter dated 13.03.2022. To the utter surprise of the complainants the  OPs  after receiving all the documents in original had issued a rejection letter dated 28.03.2022 for claim intimation No.: CIR/2022/211117/3703541 stating reason that "Even after reminders, you have not sent us the above documents. We therefore presume that you are not interested in preferring claim and therefore the same is rejected." Similarly the  OPs  after receiving the Original Documents alongwith claim form again demanded the documents for claim intimation No.: CIR/2022/211117/3915457 dated 25.01.2022 vide letter dated 15.03.2022 and 30.03.2022 and again the  OPs  keep continued their malafide conduct and after receiving all the documents in original had issued a rejection letter dated 14.04.2022 for claim intimation No.: CIR/2022/211117/3915457 stating reason that "Even after reminders, you have not sent us the above documents. We therefore presume that you are not interested in preferring claim and therefore the same is rejected." After receiving the above said e-mail dated 13.03.2022, 15.03.2022 and 30.03.2022 and also the rejection letters dated 28.03.2022 and 14.04.2022 the complainants contacted the  OPs  in the matter but to no avail. The  OPs  have repudiated the claim by giving the following observation:-

"We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of "CHRONIC LIVER DISEASE"

It is observed from the submitted records that the insured patient has undergone treatment for the above disease which is due to use of Alcohol.

As per exclusion Code Excl. 12 of the above policy, the company is not liable to make any payment in respect of expense incurred at hospital for treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.

Similarly, the OPs repudiated the claim for claim intimation CIR/2022/211117/3915457 dated 25.01.2022 in the same cyclostyled manner vide e-mail dated 24.04.2022 received by the complainants. The OPs  have repudiated the claim by giving the exactly same remarks which were given at the time of repudiation of  claim. However, there is no such report or diagnosis done by the doctors concerned who has given treatment to the husband of the complainant that the disease i.e. "Cirrhosis of liver" has developed due to the use of alcohol by him. As per the Medical Science and The Mayo Clinic which is a non-profit American academic medical centre focused on integrated health care, education and research the disease "Cirrhosis of liver" is caused by many forms of liver disease and conditions. It is not known from where the OPs have developed the idea of alcoholism and drugs while rejecting the claim. In the entire discharge summary, the doctors concerned have no where reported that the disease for which the treatment was given to the husband of the complainant No.1 occurs due to the use of alcohol. Moreover the OPs have failed to consider the genuine request of the complainants and also failed to give the amount of Rs.1,17,477/- spent for the treatment of Covid-19 pneumonia without assigning any reason. The husband of the complainant No.1 again suffered some complications and was again got admitted in Alchemist Hospital, Panchkula on 29.05.2022 for treatment of Chronic liver Failure and lodged claim for cashless treatment on 29.05.2022 under the Claim Intimation No.:- CIR/2023/211117/0243936 dated 29.05.2022 but the approval was again denied to the husband of the complainant No.1 by the OPs on 29.05.2022 itself. That the  OPs have recklessly with bent up mind denied the approval for cashless treatment to the husband of the complainant No.1 illegally arbitrarily and with malafide intention just to escape their liability in the matter and to harass the complainant No.1 and her husband who was under treatment and was in dire need of cashless facility on the following concocted ground “We have noted that the insured patient has been admitted for the treatment of CLD. Expenses for this treatment are not admissible in accordance with exclusion no.12 of the policy”. However the condition of the husband of the complainant No.1 was critical and immediate treatment was required to be taken and as such the complainant No.1 just to save the life of her husband again borrowed huge amount from the friends and relatives to pay the heavy medical bills. The husband of the complainant No.1 took the treatment in the abovesaid hospital from 29.05.2022 till 08.06.2022 when the husband of the complainant No.1 finally expired. During this period of 29.05.2022 to 08.06.2022 a medical Bill for a total sum of Rs.6,66,156/- was paid by the complainant. The OPs  are bound to allow the claim of the complainant as per the terms and conditions of the policy. The husband of the complainant No.1 has not taken any treatment for Alcoholism, drug or substance abuse or any addictive condition. Hence this complaint.

3.           The defence of the OPs was struck off, by this Commission vide order dated 27.03.2023 which stood upheld by the Hon’ble State Commission, Haryana, vide  order dated 25.05.2023 in Revision Petition No.48 of 2023 filed by the OPs.
4.           Learned counsel for the complainants tendered affidavit of complainant No.1 as Annexure CW1/A alongwith documents as Annexure C-1 to C-28 and closed the evidence on behalf of the complainantd.
5.            We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainants submitted that by repudiating the genuine claim of the insured on bald grounds, referred to above, despite the fact that the insured took treatment in the hospital, referred to above, during subsistence of the policy in question, the OPs have indulged into unfair trade practice and are also deficient in providing service.
7.           On the other hand, though the defence of the OPs was struck of, as stated above, yet, learned counsel for OPs submitted that on receipt of medical documents qua the insured patient seeking reimbursement of hospitalization expenses for treatment of "CHRONIC LIVER DISEASE", it was observed that he has undergone treatment for the above disease which is due to use of Alcohol, as such, his claim was rightly repudiated under the provisions of condition no.12 of the policy in question.
8.           The moot question which falls for consideration is whether the OPs were justifying in repudiating the claim of the insured or not. It may be stated here that a bare perusal of rejection letter reveals that the claim of the insured was rejected by the OPs, vide letter dated  10.01.2022, Annexure C-6, 28.03.2022, Annexure C-8 and  09.04.2022, Annexure C-9 on the following ground:-

“……We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of CHRONIC LIVER DISEASE.

It is observed from the submitted records that the insured-patient has undergone treatment for the above disease which is due to use of alcohol.

As per Exclusion-Code Excl 12 of the above policy, the Company is not liable to make any payment in respect of expense incurred at hospital for treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim……….”

9.           It is not in dispute that the insured obtained the policy in question from the OPs covering him and his family member, the complainants. It is also not in dispute that the said policy was renewed from time to time i.e. 08.07.2016, 08.07.2017, 08.07.2018, 08.07.2019, 08.07.2020 and on 08.07.2021 and lastly, it was got renewed for the period from 08.07.2021 to 07.07.2022 for a total limit of coverage of Rs.8,25,000/-. It is also an admitted fact that the insured was diagnosed with Chronic Liver Disease; Ethanol related, Decompenated: Ascites/Jaundice and also during his treatment in the Alchemist Hospital for the period from 06.01.2022 to 17.01.2022, he was also detected as COVID positive and took treatment for the same. This fact is evident from the Discharge summary, Annexure C-10 issued by the Alchemist Hospital. It is further coming out from the record i.e. Discharge Summary, Annexure C-16,  that the insured was again admitted in the Alchemist Hospital and was diagnosed with Chronic Liver Disease; Ethanol related, Decompenated:No Ascites/ Jaundice and  chief complaints made were drowsiness x 2 days; decreased appetite x 2 days, nausea + and stool not passed.  He again remained admitted in the said hospital for the period from 25.01.2022 to 31.01.2022 and was discharged with prescriptions of various medicines and advice.  It is further coming out from the record i.e. Discharge Summary, Annexure C-19, that the insured was again admitted in the Alchemist Hospital and was diagnosed with Acute on Chronic Liver failure. However, it is coming from this discharge summary that though the insured was admitted on 29.05.2022, yet, he died in the said hospital on 08.06.2022. 
10.           It is significant to mention here that we have gone through all these discharge summaries issued by the Alchemist Hospital and found that though it has been mentioned therein that the  insured was suffering from Chronic Liver Disease and died on 08.06.2022 due to Acute on Chronic Liver failure, yet there is nothing on record that the cause of death of the insured has been  mentioned as Alcoholism, drug or substance abuse or any addictive condition and consequence thereof.  Under these circumstances, no justifiable reasons are reflected the repudiation letters dated 10.01.2022, Annexure C-6, 28.03.2022, Annexure C-8 and  09.04.2022, Annexure C-9 for applying the provisions of condition no.12 in the present case, for rejecting the claim in question. In our considered view, unless and until the cause of death has been specifically assessed as alcoholic lever cirrhosis, the claim of insured cannot be repudiated. Thus, the OPs have miserably failed to justify the reasons mentioned in the claim rejection letters dated 10.01.2022, Annexure C-6, 28.03.2022, Annexure C-8 and  09.04.2022, Annexure C-9.
11.           The Hon’ble National Commission in  Ranvir Singh Alias Ranbir Kaur Vs. LIC & 2 Ors (R. P. NO. 1571/2013) held when there is no conclusive evidence to show that DLA was suffering from chronic liver disease due to long alcohol consumption and PGI Chandigarh have not given definite diagnosis of alcoholic lever cirrhosis, that is why repudiation done by the insurance company is unjustified.  In National Insurance Co. Ltd. Vs. Preeti Sharma appeal No. 07499, decided on 08.10.2007 by Hon’ble State Commission, Delhi held that unless and until the cause of death has been specifically assessed as alcoholic lever cirrhosis, the claim of insured cannot be repudiated. 
12.           The plea of the complainant is that the total amount of Rs.12,07,815/- stood incurred on the treatment of the DLA including expenses for medicines, reports, COVID-19 etc., yet, in our considered opinion because the policy in question was obtained for the sum insured i.e. Limit of Coverage of Rs.8,25,000/- as such the  complainant is not entitled to get anything more than the insured amount. 
13.           In view of the aforesaid discussion, we hereby partly allow the present complaint and direct the OPs, in the following manner:-
    1. To pay the insured amount of Rs.8,25,000/-, to the complainants alongwith interest @6% p.a. from the date of filing of this complaint i.e 29.07.2022, till its realization.
    2. To pay Rs.5,000/- as compensation for the mental agony and physical harassment suffered by the complainant.
    3. To pay Rs.3,000/- as litigation expenses.

                    The OPs are further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OPs shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

 Announced:- 20.03.2024