BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.255 of 2022

      Date of Instt. 01.08.2022

      Date of Decision: 05.02.2024

Ashwani Malhotra aged about 62 years S/o Sh. S. L. Malhotra R/o H. No.27, Kasturba Nagar, Jalandhar Cantt.

..........Complainant

Versus

1.       Star Health & Allies Insurance Co. Ltd., No.15, Shri Bala Ji    Complex, First Floor, Whites Lane, Royapettah, Chennai-   600014, Through its Chairman/Mg. Director.

2.       Star Health & Allies Insurance Co. Ltd., EH-198, Second Floor,       Nirmal complex, G. T. Road, Jalandhar-144001, Through its     Senior Divisional Manager/Branch Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)                                          Sh. Jaswant Singh Dhillon       (Member)   

Present:       Sh. R. K. Bhalla, Adv. Counsel for Complainant.

                    Sh. Nitish Arora, Adv. Counsel for OPs No.1 and 2.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant purchased one Cashless Mediclaim Policy namely Family Health Optima Insurance Plan bearing Policy note no.P/161125/01/2019/002668 dated 28.09.2018 valid from 28.09.2018 to 27.09.2019 from the OP No.2. The said policy include the coverage of all kinds of risks of medical expenses of medical treatment including major surgeries of the complainant and his wife namely Madhu Malhotra as mentioned in the policy. The yearly premium of policy was Rs.20,460/- and the complainant has paid the said premium to the OPs and the said policy is to cover the risk of medical treatment upto the tune of Rs.5,00,000/- of each insured member plus recharge benefit of Rs.1,50,000/-. At the time of purchase of the policy, the concerned agent assured the complainant that during the validity of the policy, if the complainant will suffer any kind of medical problem including any kind of surgery, the entire treatment will be cashless and the complainant has not to pay even a single penny at the time of hospitalization or otherwise and the OPs is liable to pay all the hospital expenses, medicine expenses as well as other connected expenses to the concerned hospital. Moreover, at the time of purchase of policy the entire formalities as required by the OPs done and only thereafter, after due satisfaction the policy in question is issued to the complainant. The said policy was renewed from time to time for the year 2019-20, 2020-21 and then for the 2021-22 and present policy is valid from 28.09.2021 to 27.09.2022. During the validity of said policy, in the last week of March, 2022, the complainant suffered medical problem of severe Vertigo, Tremor, vomiting, blurred vision and unable to stand and walk. Due to that reason on 25.03.2022, the complainant visited Apex Hospital & Maternity Home, New Jawahar Nagar, Jalandhar where he remained admitted from 25.03.2022 to 31.03.2022. The complainant submitted the insurance policy to the insurance branch of hospital authorities for cashless treatment and the said officials further take up the matter with the OP No.1 for approval of cashless treatment, but the OPs declined the cashless treatment of the complainant without any rhyme or reason vide letter dated 25.03.2022. However, the OPs assured the complainant that after the complete treatment, the complainant should give total detail expenses of medical treatment and OP will reimburse the total expenses incurred by the complainant on his medical treatment. However, under compelling circumstances the complainant has to continue with the medical treatment. The complainant has paid a sum of Rs.91,138/- to the Apex Hospital, Jalandhar. Even thereafter the complainant has spent thousand of rupees on further treatment. Thereafter the complainant submitted the claim by completing the formalities on 18.04.2022 and also submitted the entire medical record, discharge summary as well as receipts of payment to the hospital, pharmacy and other. In spite of completion of all the necessary formalities, OPs repudiated the claim of the complainant vide letter dated 07.06.2022 on the ground that ‘As per Exclusion No.12-Code Exclusion 12 of above policy, the complainant is not liable to make any payment in respect of expenses incurred at hospital for treatment for alcoholism, drug or substance, abuse or any addictive condition and consequences thereof’. In fact the complainant has not treatment for alcoholism, drug or substance, abuse or any addictive condition and consequences thereof as alleged by the opposite parties and the doctor diagnosed the problem of complainant as "Wernicke's Encephalopathy". This problem is having no connection with alcoholism and the complainant is not addicted of alcohol at any point of time in his life. The doctor also holds that this problem is having no significance with the drugs and the entire medical treatment which was provided to the complainant was not of alcoholism or its abuse. So, the reason for the repudiation of claim by the OPs is totally baseless and OPs have wrongly repudiated the claim of the complainant on false and frivolous grounds. The complainant is suffering from mental tension, harassment and agony due to rejection of cashless treatment and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay the amount of claim i.e. premium of policy Rs.20,460/- + Rs.91,138/-. Further, OPs be directed to pay a compensation of Rs.3,00,000/- for causing mental tension and harassment to the complainant and Rs.55,000/- as litigation expenses.

2.                Notice of the complaint was sent to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complaint filed by the complainant is false, frivolous, vague, baselss and misconceived because there was no deficiency in service on the part of the OPs. It is further averred that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further averred that no cause of action  has arisen in favour of the complainant to file the present case. the complaint has been filed by the complainant with the malafide intention, and further to grab the public money. Hence the present complaint is liable to be dismissed. It is further averred that the complainant has not approached this Forum with clean hands by not disclosing and misrepresenting material facts. It is further averred that the complainant has no locus-standi and cause of action to file the present complaint. On merits, it is admitted that the complainant purchased mediclaim policy covering himself and his wife for a sum insured of Rs.5,00,000/- earlier in the year 2018 which was renewed from time to time and lastly it was renewed from 28.09.2021 to 27.09.20223. It is also admitted that the claim for reimbursement was declined by the OP, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                It is admitted fact that the complainant purchased mediclaim policy covering himself and his wife for a sum insured of Rs.5,00,000/- earlier in the year 2018 which was renewed from time to time and lastly it was renewed from 28.09.2021 to 27.09.2022. The insurance policies have been proved by the complainant as Ex.C-1 to Ex.C-4. The complainant has alleged that he suffered medical problem of severe Vertigo, Tremor, Vomiting, blurred vision and unable to stand and walk. Due to this reason, he visited Apex Hospital on 25.03.2022 and remained admitted there till 31.03.2022. The claim for cashless treatment was furnished, which was declined by the OP vide letter Ex.C-5. The complainant has got the treatment and made the entire payment of Rs.91,138/- to the Apex Hospital, Jalandhar. The claim for reimbursement was filed, which was declined vide Ex.C-7.

6.                This fact has also been admitted that the claim for reimbursement was declined by the OP, but the OP has alleged that the claim was rightly declined as the complainant has concealed the factum of alcohol consumption and as per the terms and conditions , this is an exclusion clause. He has further submitted that the complainant was diagnosed of ‘Wernicke’s Encephalopathy’and that is due to history of alcohol consumption. Therefore, it was rightly rejected.

7.                All the facts of insurance policy, admission of the complainant in the hospital have been admitted and proved. Now the point in controversy is as to whether the assessment of the OP that the insured has withdrawn alcohol and due to that he suffered the problem of severe Vertigo, Tremor, Vomiting, blurred vision and unable to stand and walk was correctly assessed and the claim of the complainant was repudiated rightly or not. The validity of the insurance policy during the period 2021-22 is not disputed. Perusal of Ex.C-7 i.e. the repudiation letter shows that the claim of the complainant was rejected on the ground that ‘It is observed from the indoor case records of the aforesaid treatment that the insured-patient is diagnosed as alcohol withdrawal and the insured patient has undergone treatment for the same.

                   As per Exclusions No.12- Code Exel 12 of the above policy as referred by the OP, 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.’

8.                Perusal of the discharge summary Ex.OP-9 and Ex.C-6 claim form, which is accompanied by the discharge summary at Page No.38, shows that the complainant was diagnosed with ‘Wernicke’s Encephalopathy’. There was history of Alcoholism, Tobacco or Substance Abuse, if any and there was a history of alcohol use. Course of treatment was that the complainant was given the medicine Thiamine, Antibiotic, Antacids and other medical management. The OP has laid stress on the word history of alcohol use and he was advised to have the Tablet Thiamine. As per Ex.OP-11, the complainant was having history of using Amlong since 10 years. The complainant was checked-up on 24.03.2012. Ex.OP-12 also shows that he used to have advised injection Thiamine and Ex.OP-13 shows that liver was normal and it showed enhanced echopattern. The OP has also produced on record the detail of Thiamine administration used in Alcohol. It is well settled law that there should be a nexus between the disease and the cause of the disease. The Commission is to see as to whether the complainant suffered the disease of ‘Wernicke’s Encephalopathy’ due to consumption of alcohol and as to whether the medicines provided to him earlier and relied upon by the OP were only for the alcoholist or he was having some other problem. So for as the problem of ‘Wernicke’s Encephalopathy’ is concerned, it is an acute neurological condition and this disease is caused by thiamine deficiency, which affects the peripheral and central nervous systems. This is degenerated brain disorder and caused by the lack of Vitamin B-1.

9.                Thiamine Injection is a supplement of Vitamin B-1. It is being given in the treatment of Vitamin B-1 deficiency. It is also used in Digestive problems and Ulcerative colitis.

10.              The medicine Amlong is used to treat heart related conditions like Angina (chest pain) and high blood pressure i.e. hypertension. In the entire medical term, it has nowhere been mentioned that the medicines relied upon by the OP are used exclusively for the patient, who have withdrawn alcohol. Even the Literature relied upon by the OPs, nowhere shows that Thiamine Injection are given only to the alcoholic patients. The onus was upon the OPs to prove that there is a nexus between the disease and the cause of the disease. To prove this fact, it was incumbent upon the OP to prove that due to consumption of alcohol, the complainant suffered ‘Wernicke’s Encephalopathy’ and he was having brain disorder or neurological problem due to the consumption of alcohol. In the entire medical record relied upon by the complainant alongwith the claim form Ex.C-5 that the complainant suffered the disease of ‘Wernicke’s Encephalopathy’ because of Alcohol nothing has been mentioned. Though, in the discharge summary, it has been mentioned that history of use of alcohol, but it nowhere shows that the complainant was having problem because of use of alcohol. Even otherwise, as per Medical Jurisprudence, Alcohol per schedule is not the only cause of the disease or the neurological disease or brain disorder. Apart from other factors, the alcohol may be one of the contributory factor. There are number of factors which lead to the disease of ‘Wernicke’s Encephalopathy’. The OPs have failed to prove that the complainant suffered this problem due to alcohol nor it has been proved that the complainant is a habitual drunker nor the OPs have proved the extent of alcohol being consumed by the complainant, which has caused effect on the nerves of the complainant or the brain of the complainant. The amount of consumption of the liquor as alleged has not been proved. It has been held by the Hon’ble Punjab State Consumer Disputes Redressal Commission, in Vol.III (2008) CPJ 279, titled as “Life Insurance Corporation of India Vs. Satinder Kaur”, that where the cause of death due to alcohol is not proved, the claim cannot be repudiated. In the case decided by the Hon’ble State Commission, the person died and it was held by the Hon’ble State Commission that where the cause of death of alcohol is not proved, the claim cannot be repudiated, but in the present case, it has not been proved by the OPs that the disease suffered by the complainant was due to alcohol, therefore, it is not covered under the Exclusions No.12- Code Exel 12 as alleged by the OPs as the complainant was never admitted nor took the treatment of alcoholism nor this fact has been proved. So, there is a clear cut deficiency in service and unfair trade practice on the part of the OPs. The repudiation letter Ex.C-5 is wrong and illegal. Thus, the repudiation letter is hereby set-aside and further, finds that the complainant is entitled for the relief.

11.              In the light of above detailed discussion, the complaint of the complainant is partly allowed. The OPs are directed to pay the amount of claim Rs.91,138/- to the complainant. Further, OPs are directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

12.              Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

05.02.2024         Member                    Member               President