Punjab

Ludhiana

CC/18/734

Sahil Behl - Complainant(s)

Versus

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

Jaswant Singh Adv.

28 Jun 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:734 dated 19.12.2018.                                                         Date of decision: 28.06.2022.

 

Salil Behl, aged about 51 years, resident of 1693, Phase-I, Urban Estate, Dugri, Ludhiana-141013.                                                                                                                                                                                   ..…Complainant

                                                Versus

1. Star Health and Allied Insurance Company Ltd., Branch Office – Ludhiana II SCO 17, 18, 189, 2^nd Floor, Jhandu Tower, Miller Ganj, G.T. Road, Ludhiana-141003, through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., Registered & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 034, through its Director/Managing Director.                                                                                                                                                                       …..Opposite parties 

          Complaint Under Section 12 and 13 of the Consumer                                      Protection Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Jaswant Singh, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

 

PER K.K. KAREER, PRESIDENT

 

1.                Shorn of unnecessary details, the case of the complainant is that the complainant obtained a Family Health Optima Insurance Plan  for himself and his family members including his wife Anuradha Behl and dependent children Chahat Behl, Riya Behl and Pranav Behl in 2010. In the month of February 2016, the complainant unfortunately suffered from chronic liver ailment. He was got admitted in Deep Hospital, Ludhiana on 08.02.2016 where he was treated by the doctors and was discharged from the hospital on 12.02.2016. During this period, the complainant was insured vide policy No.P/161114/01/2016/009745 which was valid from 06.02.2016 to 05.02.2017. The complainant lodged claim No.0331339  with the OPs at their branch office for the reimbursement of the expenses but the claim was not reimbursed.

2.                It is further alleged in the complaint that in the month of June 2016, the complainant was again hospitalized with Deep Hospital, Ludhiana from 28.06.2016 to 01.07.2016. The complainant again lodged a medi-claim dated 01.07.2016 but the OP did not reimburse the claim and kept delaying the matter on one pretext or the other. Later on, the claim was repudiated on false and frivolous grounds that it was observed from the indoor case record dated 08.02.2016 of Deep Hospital that the treatment of the complainant was for alcohol related disease.

3.                It is further alleged that when the liver ailment of the complainant became critical in the month of September 2016, the complainant consulted Medanta Global Health Pvt. Ltd. and the concerned doctor advised immediate liver transplant. The complainant got himself admitted in Medanta, The Medicity, Gurgaon on 13.09.2016 under the observation of Dr. A.S. Soin who conducted the liver transplant on 15.09.2016. The complainant remained admitted in the said hospital till 26.09.2016. During his hospitalization, the complainant informed the OPs about his admission vide intimation memo dated 16.09.2016 However, the OPs again repudiated the claim on false and frivolous grounds. It is further alleged that the complainant got his policy renewed from 06.02.2017 to 05.02.2018. Thereafter, the complainant was again hospitalized with Medanta The Medicity, Gurgaon from 09.03.2017 till 12.03.2017 for his post surgery complications. The complainant was again hospitalized due to some complication of earlier stenting from 16.03.2017 and claim in respect of the said hospitalization was also lodged with the OPs who again adopted delayed tactics. However, the OPs approved the first medi-claim i.e. claim No.0331339 and the amount of medical expenses were transferred in the account of the complainant. However, the claim No.0102460 was repudiated on the ground that the complainant was an alcoholic. The ground of repudiating the claim No.CLI/2017/161114/0102460 dated 01.07.2016 was wrong and unjustified.

4.                It is further alleged that the complainant was again hospitalized for stent removal with Medanta The Medicity Gurgaon on 04.07.2017 regarding which the claim No.CLI/2018/211218/0254677 was lodged but the OPs continued to delay the matter. In September 2017, the complainant again fell ill and was  diagnosed with Ventral Hernia by the doctors of Medanta The Medicity. He was again hospitalized on 06.09.2017 and another claim No.CLI/2018/211218/0286079 was lodged. However, the OPs repudiated all the claims i.e. CLI/2017/161114/0102460 dated 01.07.2016, No.CLI/2017/161114/0214923 dated 16.09.2016, No.CLI/2017/211218/ 0462658, No.CLI/2017/211218/0462636, No.CLI/2018/211218/0245677 and claim No.CLI/2018/211218/0286079 on self-created and non-existing ground and on the ground that the complainant was an alcoholic whereas there is nothing on record to show that there has been any use of alcohol by the complainant and the medical ailments of the complainant were on account of use of alcohol. The claim of the OPs is falsified from the fact that the claim No.0331339 of February 2016 had already been approved and reimbursed. The repudiation of the claims amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to reimburse a sum of Rs.15,66,061/- which is the sum assured along with recharge benefits covered under the insurance policy No.P/161114/01/2015/0007988 and policy No.P/161114/01/2016/009745 and the OPs be further made to pay compensation of Rs.1,00,000/-  for causing mental harassment, pain and agony.

5.                The complaint has been resisted by the OPs. In the written statement filed by the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, the complainant had obtained Family Health Optima Insurance Policy covering himself, his wife and dependent children for a sum assured of Rs.5,00,000/-. The first policy was obtained on 01.02.2010 which was renewed from 01.02.2011 to 31.01.2012 and then from 01.02.2012 to 31.01.2013 and again from 01.02.2013 to 31.01.2014. Thereafter the complainant obtained another policy on 06.02.2015 to 05.02.2016 which was renewed from 06.02.2016 to 05.02.2017 and then from 06.02.2017 to 05.02.2018. According to the OPs, the sum assured under the policy is not Rs.15,00,000/- as alleged in the complaint. All the terms and conditions of the policy were explained to the complainant at the time of issuance of the policy. The insurance policy is based on principle of uberrimae fides. As per condition No.6 of the policy, the company is not liable to make any payment under the policy in respect of convalescence, general debility, run-down condition or rest cure, nutritional deficiency states etc.

6.                According to the OPs, in respect of his hospitalization with Deep Hospital, Ludhiana on 08.02.2016 for the treatment of hypoglycemia. The said claim was approved and an amount of Rs.63,939/- was reimbursed against a total bill of Rs.67,171/-.

7.                The OPs have further pleaded that the complainant further lodged claim No.CLI/2017/161114/ 0102460 in respect of his hospitalization with Deep Hospital, Ludhiana on 28.06.2016 for treatment of CLD (Chronic Liver Disease), PHTN (Portal hypertension, Ascites). He was discharged on 01.07.2016. In respect of this hospitalization, a claim of Rs.59,346/- was submitted.

8.                Thereafter, the complainant was admitted with Medanta The Medicity (Unit of Global Health Pvt. Ltd.) on 13.09.2016 for the treatment of Cryptogenic CLD with decompensation (jaundice, Ascites) and raised pre-authorization for cashless treatment which was rejected vide letter dated 17.09.2016 stating that as per ICP of Deep Hospital, the insured patient was alcoholic for the past 3 years and the ailment was chronic liver disease, portal hypertension, ascites  which was result of alcoholism. The amount of this claim was Rs.22,03,311/-  whereas the sum assured + bonus and recharge benefit was to the extent of Rs.7,10,000/- only.

9.                The OPs have further pleaded that the complainant was again admitted with Medanta The Medicity on 09.03.2017 for the treatment of post LDLT (15.09.2016) for cryptogenic CLD and underwent ERCP on 10.03.2017 and was discharged on 12.03.2017 and in respect of this hospitalization the claim of Rs.89,248/- was submitted.

10.              Thereafter, the patient was admitted with Medanta The Medicity on 16.03.2017 for treatment of post LDLT Status (15.09.2016) for cryptogenic chronic liver disease and was discharged on 27.03.2017 and a claim of Rs.2,68,272/- was submitted. The complainant was again hospitalized at Medanta The Medicity on 04.07.2017 for treatment of post LDLT Status (15.09.2016) for cryptogenic chronic liver disease and underwent ERCP +/- stent removal done on 05.07.2017 after which he was discharged on 07.07.2017. In respect of this hospitalization, the complainant submitted a claim of Rs.64,193/-

11.              The complainant was again admitted with Medanta The Medicity on 06.09.2017 for the treatment of Ventral Hernia, status post LDLT (15.09.2016) for cryptogenic CLD with decompensation and underwent laparoscopic mesh repair of ventral hernia on 08.09.2017 and was discharged on 10.09.2017. In this regard, a claim of Rs.1,10,000/- was submitted.

12.              It has further been submitted that on scrutiny of the claim records, it was observed that as per indoor case record (admission sheet dated 08.02.2016) submitted with claim No.CLI/2017/161114/0102460, the insured patient was an alcoholic for the past 3 years. The case sheet of Deep Hospital dated 17.02.2016 clearly mentions that CLD is alcohol related. Therefore, it can be observed tht the present ailment of chronic liver disease was due to use of alcohol and as per the exclusion clause 6 of the policy, the OP company is not liable to make any payment of expense incurred for the treatment of disease/condition due to use of alcohol. Hence the claims were rejected and the same was communicated to the complainant vide letters dated 17.09.2016, 02.06.2017, 05.09.2017, 05.09.2017, 05.09.2017 respectively.  

13.              As regards the claim No.CLI/2018/211218/0286079, it relates to the treatment of ventral hernia repair. According to the OPs, the incisional hernia (hernia defect 15+10cm) was found over the previous surgical incision as stated in the operation notes of the hospital which was due to previous surgical incision which was due to alcohol related liver disease. Therefore, this claim was also not payable and was repudiated vide letter dated 25.10.2017. The OPs have further pleaded that the reconsideration letter dated Nil and 14.12.2017 in respect of claim No.CLI/2017/161114/0102460 and claim No.CLI/2018/211218/0286079 were also considered and rejected and rejection was communicated to the insured vide letter dated 29.12.2017. Therefore, according to the OPs, all the claims have been repudiated strictly in accordance with the terms and conditions of the policy. It has also been submitted by the OPs that even if it is found that the company is liable to pay the claims, the maximum quantum of liability of the company under the terms and conditions of the policy shall be Rs.6,96,061/-  which was the balance sum insured in policy no/P/161114/2016/009745 and Rs.2,67,023/- in claim No.CLI/2018/211218/0286079, Rs.56,279/- in claim No.CLI/2018/211218/ 0254677, Rs.2,12,812/-  in claim No.CLI/2017/211218/0462636 and Rs.66,354/- in claim No.CLI/2017/211218/0462658. The other averments made in the compliant have been denied as wrong and in the end, a prayer for dismissal of the complaint has been made.

14.              In evidence, complainant his affidavit as Ex. CA along with documents Ex. C1 to Ex. C22 and closed the evidence.

15.              On the other hand, the counsel for the OPs tendered affidavit Ex. RA of Sh. Rajiv Jai, Chief Manager of the OPs along with documents Ex. R1 to Ex. R71 and closed the evidence.

16.              We have heard the counsel for the parties and have gone through the record carefully.

17.              During the course of argument, the counsel for the complainant has contended that the OPs have wrongly rejected the claims on the ground that it is mentioned in the admission history Ex. R4 of Deep Hospital, Ludhiana that the complainant has been taking alcohol for 2-3 years whereas there is no evidence on record to show that the cause of the diseases for which the complainant was hospitalized from time to time was the result of consumption of alcohol. According to the counsel for the complainant, as a matter of fact, there is no expert evidence available on the file nor in any of the discharge summaries pertaining to the hospitalization of the complainant it is mentioned that the diseases have been the outcome of consumption of alcohol. The counsel for the complainant has further contended that in the admission history Ex. R4, there is only a passing remarks that the complainant has been taking alcohol for 2/3 years without any elaboration with regard to the quantity of alcohol. Therefore, the rejection of the claims on this ground by invoking clause 6 of the policy terms and conditions Ex. R4 cannot be justified and has to be set aside.

18.              On the other hand, the counsel for the OPs has argued that in the hospitalization record of the complainant of Deep Hospital from 08.02.2016 to 12.02.2016, it is clearly mentioned that the complainant has been consuming alcohol for the last 3 years which is primarily the main cause of liver dysfunction for which the complainant was hospitalized from time to time and in these circumstances, the repudiation of the claims is as per terms and conditions of the policy. The counsel for the OPs has further contended that there is no merit in the complaint which deserves to be dismissed. In support of his arguments, the counsel for the OPs has relied upon III (2017) CPJ 7 (Del.) in Devender Kumar Vs United India Insurance Co. Ltd. whereby it has been held by the Hon’ble Delhi State Consumer Disputes Redressal Commission, New Delhi that the illness which occurs due to alcohol consumption is not payable under the policy. The claim cannot be said to have been wrongly rejected. It has further been held in this very case that chronic alcoholism of appellant is possible cause of acute pancreatitis which cannot be ruled out more particularly in view of endorsement in discharge slip and further that the failure of the complainant to produce evidence with respect to his contention that acute pancreatitis did not happen due to alcoholism has proven fatal to its case. The counsel for the OPs has further relied upon I (2013) CPJ 156 in Manohar Lal Baghla Vs National Insurance Co. Ltd. whereby it has been held by the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that if the appellant was suffering from medical problem of pancreatitis for last 3 years, the disease was pre-existing before he had purchased the policy. The repudiation of the claim was justified. The counsel for the OPs has also relied upon II (2019) CPJ 3 B (CN) (Chha.) in ICICI Prudential Life Insurance Co. Lt Vs Priya Belani whereby it has been held by the Hon’ble Chhattisgarh State Consumer Disputes Redressal Commission, Raipur that if the deceased was suffering from chronic alcoholic liver disease, but had not disclosed regarding the ailments and treatment taken, the repudiation was held to be justified. In the light of the law laid down in the above cited cases, the counsel for the OPs has urged that the claims have been rightly repudiated.

19.              We have weighed the contentions raised by the counsel for the parties and have gone through the record carefully.

20.              We proposed to deal with the claims one by one as under:

i.                 Claim No. CLI/2017/161114/0102460

                   This claim was lodged in respect of hospitalization of the complainant with Deep Hospital from 28.06.2016 to 01.07.2016. This claim has been repudiated vide letter Ex. R16 dated 27.11.2018 on the ground that as per admission record dated 08.02.2016 of Deep Hospital, the patient was alcoholic for the last 3 years. Perusal of the discharge card Ex. C8 reveals that the complainant was diagnosed to be suffering from CLD (Chronic Liver Disease) PHTN (Pulmonary hypertension) asitis, abnormal build up fluid in the abdomen.  There is no mention in the discharge card that CLD is induced by use of alcohol. Therefore, in our considered view, the repudiation of the claim on the basis of the admission record     dated 08.02.2016 of Deep Hospital whereby it has been mentioned that the patient has been taking alcohol for the last 2-3 years could not be justifiably repudiated in the absence of any concrete proof and the medical opinion that the disease was induced from the use of alcohol. Moroevr, in admission record dated 08.02.2016, there is no mention with regard to the quantity of alcohol consumed by the complainant during the period of hospitalization. Thus, the repudiation of claim No.CLI/2017/161114/0102460 is arbitrary and unjustified.

ii.                Claim No. CLI/2017/161114/0214923

                   This claim was in respect of hospitalization of the complainant at Medanta The Medicity from 13.09.2016 to 26.09.2016. As per discharge summary Ex. R24 of this period of hospitalization, the reason for admission is mentioned as procedure/surgery and against the column of diagnosis, it is mentioned that the complainant was suffering from cryptogenic CLD with decompenstion (Jaundice, ascites, HRS). Cryptogenic CLD is a condition that impairs liver function and the people with this condition develop irreversible liver disease caused by scarring of the liver (cirrhosis). As per information available on internet, the exact cause of cryptogenic CLD is unknown. Though nonalcoholic steatohepatitis is supposed to have a large role and further that the metabolic problems such as diabetes, hyperlipidemia, and obesity have all been associated with the development of this disease. Thus, the disease of cryptogenic CLD is not the direct outcome of use of liquor. Moreover, in the discharge summary Ex. R24, it is no where mentioned that the disease was due to any history of consumption of alcohol by the complainant. Therefore, the repudiation of this claim on the ground that it was induced due to history of intake of alcohol by the complainant cannot be sustained in the eyes of law.

iii.               Claim No.CLI/2017/211218/0462658

                   This claim deals with the hospitalization of the complainant with Medanta The Medicity from 09.03.2017 to 12.03.2017. The relevant discharge summary is Ex. R31. In the discharge summary, the reason for admission is mentioned as post LDLT (15.09.2016) for cryptogenic CLD anastomotic billiary stricture-post ERCP. From the discharge summary, it is evident that the patient was admitted on 09.03.2017 for post surgery care following the surgery conducted on 15.09.2016 whereby the complainant underwent liver transplant. This claim was also rejected on the same ground that in the admission record dated 08.02.2016 of Deep Hospital, the patient had a history of intake of alcohol for 2/3 years. Needless to say, as stated above, even the rejection of the claim on this ground cannot be sustained in the eyes of law and is hereby set aside.

iv.               Claim No.CLI/2017/211218/0462636

                   This claim pertains to the hospitalization of the complainant that Medanta The Medicity from 16.03.2017 to 27.03.2017. The relevant discharge summary of this claim is Ex. R37. In this claim also, the diagnosis mentioned as post LDLT status (15.09.2016) for  cryptogenic chronic liver disease which is the follow up treatment of the liver transplant undergone by the complainant on 15.09.2016. This claim was also rejected on the same ground of history of 2/3 years use of alcohol by the complainant as recorded in the admission record of Deep Hospital dated 08.02.2016 for the reasons already mentioned in respect of three previous claims. The repudiation of this claim is also not justified and is, therefore, hereby set aside.

iv.               Claim No.CLI/2018/211218/0245677

                   This claim pertains to the hospitalization of the complainant with Medanta The Medicity from 04.07.2017 to 07.07.2017. The relevant discharge summary is Ex. R43. Again diagnosis in the discharge summary is post LDLT status (15.09.2016) for cryptogenic chronic liver disease and during this period of hospitalization, the stent was removed. This claim has also been repudiated vide repudiation letter  dated 04.09.2017 Ex. R45 on the same ground and again for the sake of repetition, it has to be held that the rejection of the claim is not sustainable and is hereby set aside.

v.                Claim No.CLI/2018/211218/0286079

                   This claim pertains to the hospitalization of the complainant with Medanta The Medicity from 06.09.2017 to10.09.2017. The relevant discharge summary is Ex. R51. In the discharge summary, the diagnosis is mentioned as Ventral Hernia and during this hospitalization the laparoscopic mesh repair of ventral hernia was done on 08.09.2017. The ventral hernia refers to any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall. Again even this disease cannot be correlated to the alleged intake of alcohol by the complainant for a period of 2-3 years. Rather it appears to be a condition emanating of the liver transplant surgery undergone by the complainant on 15.09.2016. Therefore, the rejection of this claim on the ground of alcohol intake by the complainant for 2/3 years vide repudiation letter dated 24.10.2017 Ex. R55 cannot be sustainable in the eyes of law.

20.              As a result of the above discussion, it is held that the aforesaid  claims have been repudiated by the OPs in an arbitrary manner and, therefore, the repudiation of the said claims is hereby set aside. In the given circumstances, it would be just and proper if the OPs are directed to consider and reimburse the claim strictly in accordance with terms and conditions of the policy and the sum assured of the each policy.

21.              Resultantly, the complaint is allowed with a direction to the OPs to consider and reimburse the claims No.CLI/2017/161114/0102460,  No.CLI/2017/161114/0214923, No.CLI/2017/211218/0462658, No.CLI/2017/ 211218/0462636, No.CLI/2018/211218/0245677 and No.CLI/2018/211218/ 0286079  strictly in accordance with terms and conditions of the policy and the sum assured of each policy within 40 days from the date of receipt of copy of order. The OPs shall further pay composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

22               Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:28.06.2022.

Gobind Ram.

Salil Behl Vs Star Health and Allied Insurance                         CC/18/734

Present:       Sh. Jaswant Singh, Advocate for the complainant.

                   Sh. Rajeev Abhi, Advocate for the OPs.

                  

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with a direction to the OPs to consider and reimburse the claims No.CLI/2017/161114/0102460,  No.CLI/2017/161114/0214923, No.CLI/2017/211218/0462658, No.CLI/2017/211218/0462636, No.CLI/2018/ 211218/0245677 and No.CLI/2018/211218/ 0286079  strictly in accordance with terms and conditions of the policy and the sum assured of each policy within 40 days from the date of receipt of copy of order. The OPs shall further pay composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:28.06.2022.

Gobind Ram.