Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 128/15.12.2021
Satender Sing Badhautiya through his
legal heir/ representative Shri Guru Ashish
s/o Late Satender Singh Badhautiya
R/o House No. 3/46, 4th Floor, Old Rajinder Nagar,
New Delhi-110060 …Complainant
Versus
OP1-Star Health and Allied Insurance Co. Ltd.
First Floor, Kasturba Gandhi Marg, Atul Grove Road,
Connaught Place, New Delhi-110001 ...Opposite Party
OP2- Sir Ganga Ram Hospital,
Rajinder Nagar, New Delhi-110060 …Pro-forma Party
Date of filing: 15.12.2021
Coram: Date of Order: 18.01.2024
Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
ORDER
Inder Jeet Singh , President
1.1. (Introduction to case of parties) – At the outset this complaint is filed in the name of insured/Sh. Satender Singh Badhautiya (since dead) by his son/legal heir that insured had taken insurance policy from OP1. What is appearing, since Sh. Satender Singh Badhautiya was insured and he died during his treatment that too during period of insurance policy, the complaint has been filed in his name through his legal representative.
The complaint is authored by Guru Ashish for himself and for his mother Ms. Adesh, brother Vikas Kumar and sister Ms. Anjali Chaudhary, since they authorized Shri Guru Ashish by power of attorney to file, institute and prosecute the complaint for all of them. That is why the complaint is under the signature of Sh. Guru Ashish.
1.2. There are allegations of deficiency of services since the insured had taken insurance policy for period from 21.01.2019 to 20.01.2020 and it was got renewed from 21.01.2020 to 20.01.2021 but he had suffered illness and got treatment firstly at Synergy Plus Hospital Agra on 06.03.2020 and then at Sir Ganga Ram Hospital (pro-forma party/ OP2 herein), where he died on 13.03.2020. The valid medical claim preferred was not reimbursed by OP1/Insurer on the frivolous grounds of exclusion clause that he had undergone treatment for alcoholism, which was not covered under the policy.
1.3. The OP1 opposes the complaint that there is no deficiency of services but the parties to insurance contract are bound by its terms and conditions. Since the insured-complainant was known case of treatment for alcoholism, the claim was rightly repudiated by invoking the exclusion clause no. 12 of policy, which reads “the company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof.” The insured had also suppressed fact in the proposal form of his using alcohol. The OP1 is not liable for any claim.
1.4 While reading the case of parties for reimbursement of medical claim against medical health insurance or its opposition, there are many medical terms appearing in the pleading, documents and evidences on the basis of medical treatment record (but without mentioning their meanings), therefore, the relevant terms are being reproduced with its ordinary meanings, so that they may be apprehended with the case of parties :-
(i) CLD - chronic liver disease is a progressive deterioration of liver function for more than six months, which includes synthesis of clotting factors, other proteins, detoxification of harmful products of metabolism.
(ii) decompensate CLD - decompensate cirrhosis is defined as an acute deterioration of liver function in patient with cirrhosis and is characterised by jaundice, ascites, hepatic, encephalopathy, hepatorenal syndrome or variceal hemorrhage.
(iii) decompensate portal hypertension- one of the serious complication of advanced liver disease. Scar tissue in the liver (cirrhosis) comprises the blood vessels running through it and reduces their blood flow. This affects many other organs throughout body.
(iv) sepsis - sepsis is a body's extreme response to an infection. It is life threatening medical emergency. Sepsis happens when an infection have already triggers a chain reaction throughout the body.
(v) occasional alcoholic - Those people who drink occasionally drink alcohol. They are also called casual or social drinker, they do not get drunk or black out regularly.
(vi) alcohol abuse - It is a pattern of drinking too much alcohol too often. A person will be called suffering from alcohol abuse if such person drinks too much alcohol at one time or too often throughout the week.
(vii) ascites - ascites means when one has too much fluids in the belly, often due to severe liver disease. The extra fluids collect in the space abdomen and layers of tissues surrounding the belly.
(ix) jaundice - jaundice occurs when liver cannot efficiently process red blood cell as they break down. It signals infection or liver disease in adults. Skin and white eyes turn into yellowish because of build-up of billirubin in the blood.
2.1. (Case of complainant) –The insured-complainant took health insurance policy no. P/231115/01/2020/014859 from OP1 valid from 21.01.2019 to 20.01.2020 and it was also got renewed from 21.01.2020 to 20.01.2021. The complainant was admitted in Senergy Plus Hospital, Agra on 06.03.2020 due to ill health and his condition was deteriorated, he was referred to Sir Ganga Ram Hospital on 11.03.2020. The complainant was diagnosed and treated for cirrhosis of liver, cause child-C, decompensate portal hypertension, acute kidney Injury, hepatic encephalopathy, sepsis with shock. The insured died on 13.03.2020 during his treatment in the hospital of OP2, the immediate cause of death as per report of doctor is septic shock, acute kidney injury and multi-organ dysfunction syndrome. Thence, the legal heir of deceased furnished all original documents, hospitalization bills, medicine bill to the OP1 for reimbursement of claim, the bills were of more than Rs. 4 lakhs.
2.2. However, it shocked on receipt of repudiation letter dated 05.11.2020 from the OP1, while declining the claim by invoking exclusion clause no. 12 of the policy and OP1 declined to reimburse the expenses on the ground that the treatment was for alcoholism, drug or other substance abuse. Whereas, the OP1 has wrongly jumped to that conclusion, since the insured used to consume alcohol occasionally, which find mentioned in the reports of doctors. The insured was suffering from cirrhosis of liver, which may occur for various reasons but OP1 concluded wrongly that cirrhosis of liver was caused due to alcohol but there is no iota of evidence of it. The valid and proper claim was lodged of hospitalization and medical expenses by the legal heirs of deceased-insured. That is why the complaint for reimbursement of medical expense of Rs. 4 lakhs along with interest at the rate of 18% from the date of filing of the claim to OP1 till realization of the amount, besides compensation of Rs.1 lakh for suffering harassment and mental agony from OP1, cost of the litigation and other appropriate relief.
2.3. The complaint is accompanied with copy of insurance certificate, critical and care emergency record issued by Sir Ganga Ram Hospital, repudiation letter, death summary by Sir Ganga Ram Hospital, bills issued by Synergy Plus Hospital and Sir Ganga Ram Hospital, power of attorney in favour of author of the complaint by the legal heirs of deceased-insured. The complaint also refers case law, however, it will be dealt appropriately in the paragraph no. 6 (ibid).
3.1 (Case of OP1)-The OP1/insurer does not dispute issue of health insurance policy in favour of insured and its renewal from 21.01.2020 to 20.01.2021. However, the parties to the insurance contract are bound by terms and conditions of the policy. The insured Sh. Satender Singh Badhautiya had furnished proposal form for availing Family Health Optima Insurance Policy no. P/23115/2019/011532 for sum insured of Rs. 10 lakh covering Sh. Satender Singh Badhauditya and his spouse Ms. Adesh.
3.2. The insured was under treatment at Synergy Plus Hospital Agra and later at Sir Ganga Ram Hospital, where he died on 13.03.2020. However, as per clinical report and casualty card dated 11.03.2020, the insured-patient was an occasional alcoholic. Further, as per ICU Evaluation sheet dated 12.03.2020, he was an occasional alcoholic. Thus, it is evident that insured was an alcoholic. Therefore, OP1 is not liable to pay any expenses incurred at hospital towards the treatment of alcoholism, drug or substance abuse or any addictive condition and consequence thereof (which is explicitly mentioned in the policy schedule alongwith terms and conditions thereof). The paragraph-4 of the reply reproduces the contents of discharge summary dated 11.03.2020, death summary dated 13.03.2020, ICP dated 12.03.2020, ICP dated 22.07.2020 and casualty card dated 11.03.2020 to highlight that insured was alcoholic and he died due to liver disease.
The most common causes for cirrhosis are hepatitis and other viruses, alcohol abuse, non-alcoholic fatty liver disease-this happens from metabolic syndrome and is caused by conditions such as obesity, high cholesterol and triglycerides, and high blood pressure. Thus, the expenses incurred towards the treatment of cirrhosis of liver of disease is due to alcohol consumption, which is not payable as per the terms and conditions of policy. The exclusion clause-12 is also referred in support thereof [which has already been reproduced in paragraph-1.3 above).
3.3. The complaint has been filed to mislead the Commission by misrepresenting the facts as well as the proposal form was executed, wherein certain information were withheld vis-à-vis the policy was issued on the basis of material information provided in the proposal form, the terms and conditions of the policy were also explained before accepting the proposal form. The complaint has been filed to take undue advantage in the form of relief being claimed. The complaint is liable to be dismissed being mala-fide, since the insured was an alcoholic, he was aware of his habits but the same were purposely concealed, while applying for claim of his insurance policy.
3.4. There were two claims of Rs.1,64,921/- and of Rs. 1,98,415/- submitted in respect of hospitalization and other claims, however, they are not entitled for any such relief or for claim of Rs.4 lakhs in respect of reimbursement of the amount or claim of Rs.1 lakh as compensation or cost or other relief claimed.
The OP1 also contends (being without conceding to complaint or claim) that in other eventuality the Commission considers the claims of complainant to be allowed, the liability of OP would be to the extent of Rs.1,85,621/- in respect of claim no. CLI/2021/231115/0290285 and to the extent of Rs. 1,27,025/- in respect of claim no. CLI/2021/231115/02900264, which have been explained in the billing sheets filed [Annexure-R12 and R18 to the reply]. The complaint is liable to be dismissed.
3.5. The reply is accompanied with record of terms and conditions of policy, policy schedule, proposal form, copy of claim form, casualty card, ICU initial consultation record dated 12.03.2020, clinical record dated 02.03.2020, death summary dated 13.03.2020 & medical certificate of cause of death dated 13.03.2020, copy of final bill, repudiation letter dated 05.11.2023, billing assessment sheet (R12), copy of claim form, progress sheet, discharge summary, final bill, repudiation letter dated 04.11.2020 and billing assessment sheet (R18). The OP1 also cites case law in its reply, however, the same will be referred in the paragraph no.6 (Ibid.).
4. (Replication of complainant) –The complainant filed detailed replication to deny the allegations of reply of OP1 as well as to reaffirm the contents of complaint. It is explained that nothing was concealed by the insured-complainant at any point of time or about his health. However, it is also stated that both the claims of Rs. 1,85,621/- and of Rs.1,64,921/-, which are actual expenses incurred as medical expenditure on the hospitalization and treatment of insured are to be reimbursed, besides compensation and other relief claimed.
5.1. (Evidence)- In order to establish the complaint, Sh. Guru Ashish led evidence (author of the complaint and son of insured Sh. Satender Singh Badhautiya). On the other side OP1 led evidence by filing affidavit of Sh. Sumit Sharma, Senior Manager of OP1. They have led evidence on the pattern of their respective pleadings and documents.
5.2. The OP2/Sir Ganga Ram Hospital was impleaded as a pro-forma party, it had not appeared and that is why for want of pleading/reply, there is no evidence by OP2.
6.1 (Final hearing)- The complainant and the OP1 have filed their respective written arguments along-with case laws. They were given opportunity to make oral submission, therefore, Shri Sachin Miglani, Advocate for complainant and Ms. Sukriti Khokhar, Advocate for OP1 presented their oral submission. It does not require to repeat their contentions, since the same will be dealt appropriately.
6.2. The complainant relies upon the reasoning of following cases:-
(a) 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 OP1 was held unjustified.
(b) National Insurance Co. Ltd. Vs. Preeti Sharma appeal No. 07499 (dod 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.
6.3. The OP1 also derives reasons from the following cases :-
(i) Star Health Allied Insurance Co. Ltd. Vs. Sanjay Goyal 2019 (3) CPJ3, held that undisputedly the ailment was caused due to use of alcohol thereby cirrhosis of liver developed and the complainant failed to demonstrate that the cirrhosis of liver caused on account of any infection of virus or otherwise. Hence complaint was quashed.
(ii) Pradeep Kriplani Vs. New India Assurance Co. Ltd. & 2 Ors. R.P. No. 2617/2016 by NCDRC dod 07.09.2017 in the discharge summary of petitioner, it was held that he was suffering from ALD, CLD with Ascities k/c HTN disease. He was also known case of hypertension. Further Alcoholic liver disease is a term that encompasses the liver manifestations of alcohol over consumption including fatty liver, alcoholic hepatitis and chronic hepatitis with liver fibrosis or cirrhosis. Chronic liver disease in the clinical context is a disease process of the liver that involves a process of progressive destruction and regeneration of the liver parenchyma leading to fibrosis and cirrhosis. Chronic liver disease, refers to disease of the liver which lasts over a period of six months. While the list of conditions associated with chronic liver disease is extensive one of many categorizations is alcoholic liver disease.
(iii) United India Insurance Company Ltd. Vs. Harchand Rai Chandan Lal (2004) 8 SCC 644, wherein it was held that the parties are governed by terms and conditions of the insurance policy contract and they are bound to abide it, it is not open to them to take shelter of definition of other enactments.
7.1 (Findings)- The rival contentions are considered keeping in view the material on record. It is apparent that there are many undisputed facts and other are disputed facts.
It is not disputed that first insurance policy was valid from 21.01.2019 to 20.01.2020 and it was renewed from 21.01.2020 to 20.01.2021 by appropriate endorsement issued by OP1. The insured had suffered sickness and got treatment firstly at Synergy Plus Hospital Agra, where he had undergone treatment from 6.3.2020 to 11.3.2020 and then at Sir Ganga Ram Hospital, Delhi from 11.03.2020 to 13.03.2020. The Hospitals have issued their respectively discharge summary and death summary, which are matter of record and evidence of parties besides other medical record.
7.2. However dispute rests upon other facts and features about information/details with-held or furnished in the proposal form, whether or not there was pre-existing CLD? whether or not exclusion clause no. 12 of policy would be applicable?.
7.3. By taking into account stock of all material, the following conclusions with reasons are drawn:-
(i) The OP1 has proved the proposal form, it is dated 21.01.2019 and first insurance policy was effective from 21.01.2019 to 20.01.2020. It was renewed from 21.01.2020 to 20.01.2021. The tenure of treatment is from 6.3.2020 to 13.3.2020. The OP1 has objections on point of the suppression of material facts by insured about previous ailment/habits, which is opposed by the LR of insured. It needs to look into the proposal form.
The OP has proved proposal form (Annexure-R3/page-35 to 42) and in questionnaire (at page-38, health history/sub-column-1) it is responded “Yes” that the insured and his wife have been keeping good health. On page-39, about previous ailments, the insured has declared in column-(h) that his wife’s ovary was removed in 2017. Further, on page-40/column-6 sub-clause (D)(c) the query was whether the insured or his wife consume alcohol, if yes, since when?, however, the insured answered it “No” for him and for his wife. This is being read by OP1 with the casualty card (Annexure R5 to R8, pages-48 to 51) to highlight that the insured was diagnosed of occasional alcoholic and CLD, consequently the insured had suppressed his habit of alcoholic and claim is not made out because of abuse of alcoholic and his false statement in proposal form. Whereas, according to insured LR, he was not habitual alcoholic but occasional alcoholic, which is also mentioned so in medical papers; there was no concealment of any fact vis-à-vis what was there, it was disclosed in the proposal form. The contentions of OP1 are not tenable.
The answer of this issue is in the record itself. Firstly, in all the medical documents, there is observation that the insured was occasional alcoholic and there is no observation in any of the medical record that he was habitual alcoholic or there was abuse of alcohol. It is already mentioned that occasional alcoholic means those people who drink occasionally drink alcohol; they are also called casual or social drinker, they do not get drunk or black out regularly. Further, habitual alcoholic or alcohol abuse means it is a pattern of drinking too much alcohol too often. A person will be called suffering from alcohol abuse, if such person drinks too much alcohol at one time or too often throughout the week. Secondly, chronic liver disease is that disease, which is a progressive deterioration of liver function for more than six months
By reading them together, on the face of it, it may appear that the insured had suppressed about his alcohol consumption at the time of furnishing proposal form of 21.01.2019, but simultaneously the chronic disease could be more than six months but there is no medical record or proof of fact by the OP1 that while furnishing the proposal form on 21.01.2019, the insured was known case of CLD or he was habitual or occasional drunker or using the alcohol. The treatment tenure is from 6.3.2020 to 13.3.2020 (during span of renewed insurance policy). Therefore, for want of proof of these facts, it cannot be construed that insured had suppressed those facts in the proposal form vis a vis he had disclosed about other surgery in 2017 of his wife. Accordingly, this contention is disposed off.
(ii) The other issue is in respect of case of ALD & CLD. Alcohol related liver disease (ALD) is a result of drinking more alcohol than the liver can process, which damages the organs. It is matter of record of clinical record, causality card, discharge summary and death summary that the insured was occasional user of alcohol. There is no record or diagnosis that it was known case of ALD prior to treatment or during treatment of insured or at the time of taking the policy. The insured had suffered jaundice, which is also related with the liver and in document of medical certificate of cause of death (Annexure-R-9) proved by OP1, the manner of death is stated ‘natural’, antecedent cause as decompensate chronic liver disease (CLD) and immediate cause septic shock, acute kidney injury, multi-organ dysfunction syndrome. There is no such medical finding that death was due to alcohol abuse or ALD. There is also no other medical evidence by OP1 contrary to the medical record proved. Thus, case laws present by insured’s LR apply to the situation of this case but case law presented on behalf of OP1 is distinguishable from the features of case of insured.
(iii) The insured was not treated for alcohol liver disease but for jaundice as per medical record proved, however, he expired and cause of death has been certified by the Hospital.
(iv) The exclusion clause no.12 was invoked in the repudiation letter 5.11.2020 on the basis of alcoholism or alcohol abuse but this clause no.12 does not apply to the facts and features of the present case.
(v) Since, valid claim was lodged but it was repudiated, it amounts to deficiency of services.
7.2.1. There is no dispute with regard to medical expenses incurred during hospitalization of the insured. The complaint filed is for claim of Rs.4,00,000/-, for which bills have also been proved. However, OP1 contends that all bills cannot be reimbursed but admissible amount. During the oral submission, ld. Counsel for OP1 has been to documents (Annextures-R-12 and R-18 in respect of each claim lodged) to demonstrate that two claims were lodged but admissible amount are Rs.1,64,921/- and of Rs. 1,98,415/- were calculated item-wise under policy (but they were subject to other terms and condition of policy).
7.2.2. On perusal of this plea of the parties, two aspects are emerging viz (a) the contention of OP1 is based on record of Annexture-R-12 and R-18 (but subject to other terms and conditions of policy) showing the amount of each bill claimed and assessed as per policy with specific remarks/reasons for disallowance in reference to policy and (b) in paragraph no. 18 of replication of insured to written statement, it is asserted that insured-LR is entitled for such amount on actual expenses basis.
Since, exclusion clause no. 12 is already held to be not applicable. There is also no evidence by insured’s LR to be contrary to the calculations and admissible amount stated in documents (Annextures-R-12 and R-18 respectively at pages 57 & 70 of the paper book of OP1) that too by reading them with the insurance policy, its terms and conditions. Thus, the complainant is held entitled for reimbursement of admissible medical bills amount of Rs.3,63,336/-[i.e.Rs.1,64,921+ Rs. 1,98,415].
7.3. The insured-complainant's LR claims interest at the rate of 18% pa from the date of claim, however, there is no provision of interest component in the insurance policy, nor there is proof of circumstances which may entitle him for such interest. Simultaneously, the Insured-complainant/LR has parted with money, while spending the amount on treatment despite insurance cover. Therefore, simple interest at the rate of 5%pa from the date of complaint till realisation of amount in favour of insured-complainant/LR and against OP1 will meet both ends of justice, it is determined so.
7.4. The Insured/LR claims compensation of Rs.1 lakh in lieu of sufferings, harassment and mental agony from OP1 besides cost of the litigation and other appropriate relief because of denial of claim. Since, it is already held, after disposing off their serious disputes, that the insured/LR is entitled for reimbursement of Rs.3,63,336/- and by considering the inconvenience, difficulties, trauma faced by them, they also deserve reasonable compensation to be consonance to the situation involved. Thus, compensation of Rs. 15,000/- is determined in favour of insured/LRs and against the OP1 besides costs of Rs.10,000/- is also allowed in favour of insured/LRs and against OP1.
7.5. Accordingly, the complaint is allowed in favour of the insured-complainant/LR and against the OP1 to reimburse medical bills of Rs.3,63,336/- [i.e.Rs.1,64,921 + Rs. 1,98,415] along-with interest at the rate of 5%pa from the date of complaint till realization of the amount, apart from compensation of Rs.15,000/- and cost of Rs. 10,000/-. The OP1 will pay the amount within 45 days from date of this order, failing which the OP1 will be liable to pay enhanced interest at the rate of 7% on the amount Rs. Rs.3,63,336/-.
The OP1 may deposit the amount within time in the Registry of this Commission by way of demand draft/pay order in the name of Shri Guru Ashish. However, it will be responsibility of Shri Guru Asish/LR (author of complainant) to look into the interest of other LRs (whom he is representing) for amount to be received.
7.6. Since OP2 is a pro-forma party, no relief was claimed against it, therefore, no order against OP2.
8. Announced on this 18th January 2024 [पौष 28, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules, besides to upload on the website of this Commission.
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