FINAL ORDER/JUDGEMENT
SHRI ASHOKE KUMAR GANGULY, MEMBER
This is a complaint case filed u/s.35 of the C.P. Act, 2019.
The complainant was having a Group Mediclaim Policy bearing No. 101101501810002283 (renumbered) from the OP effective from 28.08.2014 for Sum assured of Rs.1,25,000/-. The policy was continuing upto 27.08.2019. Because of health problem the complainant started taking treatment w.e.f 18.01.2019 under the advice of Dr. Pradeep Kumar Sharma and underwent so many tests and finally for better treatment he consulted Dr.Vijay Kumar Rai who after examining advised him to be admitted in a Hospital. Accordingly he took admission in Parkview Super Specialty Hospital, Bidhannagar, Kolkata – 700106 on 24.01.2019. After so many tests and treatment the complainant got discharged on 29.01.2019 from the said Hospital. The expenses incurred for the treatment stands Rs.50,000/- and afterwards he placed the claim to the OP which was repudiated by the OP by citing the Clause No. 4.21 of the said Mediclaim Policy vide letter dated 28.03.2019. The complainant sent protest letter dated 10.04.2019 wherein he categorically pointed out that the disease is Acute Pancreatitis and not ethanol related disease. In this regard the complainant enclosed one certificate from the treating doctor substantiating the contents of the said letter dated 10.04.2019. No reply was received by the complainant. Finally a legal notice dated 02.07.2019 was sent to the OP for redressal of the complaint. Thereafter another legal notice dated 12.11.2019 was sent because of some factual mistake being there in the earlier notice. Still no reply was received from the OP. Finding no alternative the complainant has approached the Commission seeking justice with relief as detailed in the complaint petition.
The OP has contested the case by filing W/V contending inter alia that the present complaint is misconceived and is a flagrant abuse of law and is not maintainable. It is admitted by the OP that the subject Insurance Policy has been continuing since August 2014 to 3rd September 2019. It is also admitted that the complainant consulted Dr. Pradeep Kumar Sharma first on 18.01.2019 and thereafter consulted Dr. B.R. Roy Choudhury on 23.01.2019 and finally took admission in Park View Super Specialty Hospital, Bidhannagar, Kolkata – 700106 on 24.01.2019 under the advice of Dr. Vijay Kumar Rai for the treatment of Acute Pancreatirtis and was discharged on 29.01.2019 from the said Hospital. The claim of Rs.50,000/- was lodged with the OP which was however repudiated by the OP vide letter dated 28.03.2019 on the ground of the clause No.4.21 of the said policy. The said clause No. 4.21 is read as under : - “ Treatment arising out of illness / disease / injury due to misuse or abuse of drugs/alcohol or use of intoxicating substances”.
In the said repudiation Letter dated 28.03.2019 it is clearly stated that the claim file has been studied in detail and as per documents submitted it is clearly mentioned that the said ailment is ethanol related. Hence, it is reasonably concluded that the underlying cause of presenting ailment in this case is alcohol intake . The OP further cited the prescription dated 24.01.2019 issued to the complainant where it is clearly stated that the disease is ‘Acute Pancreatitis’- ethanol related. The same is legible and clearly decipherable from the same. It is further stated that the Pancreatitis was a result of ethanol intake which in common terminology is alcohol intake. Hence the OP is completely justified in repudiating the claim in question.
Points for Determination
In the light of the above pleadings, the following points necessarily have come up for determination.
1) Whether the OP is deficient in rendering proper service to the Complainant?
2) Whether the OP has indulged in unfair trade practice?
3) Whether the complainant is entitled to get relief or reliefs as prayed for?
Decision with Reasons
Point Nos. 1 to 3 :-
The above mentioned points are taken up together for the sake of convenience and brevity in discussion.
We have travelled over the documents placed on record. The complainant and the OP have filed their Evidences supported by affidavit.. Both parties have submitted their BNAs.
The fact of the case in brief is that the complainant is one of the beneficiaries of the subject Group Mediclaim Policy No. 101101/48/14/8500002657 of the OP Insurance Company which was however renumbered to 101101501810002283 for a sum assured of Rs. 1,25,000/- . The policy has been continuing since August 2014 and was in force during the period from 04.09.2018 to 03.09.2019. The complainant had to take admission in Park View Super Specialty Hospital, Bidhannagar, Kolkata – 700106 on 24.01.2019 in connection with his abdominal problem after due consultation with different doctors. The complainant was discharged on 29.01.2019 from the said Hospital. On perusal of the Discharge Summary issued to the complainant it is observed the disease diagnosed was ACUTE PANCREATITIS. In the said Discharge Summary we do not find any other observation of the Hospital in the matter of intake of alcohol. The OP Insurance Company has relied upon the prescription dated 24.01.2019 of the Hospital where the provisional Diagnosis on the day of admission was Acute Pancreatitis – ethanol related. The said observation of the Hospital has been found mentioned in the repudiation letter dated 25.02.2019 issued by the Insurer. The language mentioned in the repudiation letter is as follows.
“ As per documents submitted it is clearly mentioned that the said ailment is ethanol related. Hence it is reasonably concluded that the underlying cause of presenting ailment in this case is alcohol intake.
Exclusion clause 4.21 states that : The Company shall not be liable to make any payment under this Policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of Treatment arising out of disease/injury due to misuse or abuse of drug/alcohol or use of intoxicating substances.
Hence the claim is recommended for repudiation as per exclusion clause 4.21.”
The complainant moreover sent one clarification letter from the treating doctor namely Dr. Vijay Kumar Rai who has certified that Mr. Vipul Gupta was admitted with pain abdomen and found to have acute pancreatitis. The cause of which is not known.
The OP has neither submitted any document/evidence in support of their conclusion nor they have conducted any independent assessment that the illness/disease/injury which was caused to the complainant was due to misuse or abuse of drugs/alcohol or use of intoxicating substances. No material has been collected by the OP as to whether the complainant had earlier suffered any illness on account of alcohol or any treatment taken. Simply recording of history of taking alcohol per se would not be sufficient to come to the conclusion the Acute Pancreatitis was caused due to alcohol abuse/ consumption. The prima facie suspicions of the treating doctor at the time of admission is not found in the discharge summary of the Hospital. The judgment cited in the matter “LIC vs Sukhwant Kaur 1999(1CPC 99.; decided by the Punjab SCDRC is absolutely relevant.
Ld Advocate of the complainant has also cited the judgment of the Hon’ble NCDRC vide R.P. No. 2856 of 2009 decided on 17.11.2017 in the matter of New India Assurance Co.Ltd. Vs Surendra Kumar Nanda where the Hon’ble Court has observed that Acute Pancreatitis may develop due to many reasons and use of Alcohol is one of them. It is not the only cause for the same. Nothing is mentioned in clause 4.21 relating to exclusion that treatment expenditure of any disease caused by use of alcohol or arising out of the use of alcohol shall not be admissible. Common interpretation could only mean that any expenditure incurred in respect of or in connection with use of alcohol shall not be admissible. The expenditure in respect of or in connection with use of alcohol in normal parlance would mean the expenses incurred on actual use of alcohol or in treatment on drug addiction in respect of alcohol. It is not possible to extend the meaning of this clause to cover all cases of diseases, which may have something to do with the use of alcohol particularly if that disease can be caused due to many other reasons including use of alcohol.
Therefore it is settled law that the terms of the contract has to be strictly read and natural meaning be given to it. No outside aid should be sought unless the meaning is ambiguous.
Ld. Advocate for the OP has referred certain headlines of two judgments without enclosing the full judgment for which full facts of the cases are not known. Apparently the referred judgments do not appear to have the similarities with the present case.
In nutshell, in the present case neither the discharge summary does reflect in any way that the Acute Pancreatitis is due to consumption of Alcohol or abuse nor the certificate of the treating doctor Dr. Vijay Kumar Rai has any reflection of that. Moreover, the OP could not produce finally a single document to invalidate the said fact as already discussed.
Under the above facts and circumstances we are of the view that the complainant has established the case against the OP. Accordingly, the hospitalization expenses to the tune of Rs.38,635/- along with expenses for relevant medical tests done in different Diagnostics within 30 days prior to the admission as per clause No. 3.24 of the terms and conditions of the subject policy against Pre hospitalization expenses to the tune of Rs.2750/-,Rs.1620/- & Rs.700/- are payable. As such,the total expenses in this regard stands Rs.43,705/-.
All the points under determination are thus answered accordingly.
In the result, the Consumer Complaint succeeds.
Hence,
Ordered
That the complaint case be and the same is allowed on contest against the OP with the following directions.
- The OP is directed to reimburse Rs.43,705/- to the complainant against the medical expenses..
- The OP is directed to pay a sum of Rs.10,000/- as compensation for causing harassment and also a sum of Rs.5,000/- as litigation cost to the complainant.
The above order is to be complied by the OP within a period of 45 days from the date of this order. In default, the complainant will be at liberty to putthe order into execution.
Copy of the judgment be delivered to the parties free of cost as per the C.P. Act and Judgment be uploaded in the website of the Commission for perusal of the parties
