Haryana

Karnal

CC/132/2020

Jyoti Kumari - Complainant(s)

Versus

Reliance General Insurance Company Limited - Opp.Party(s)

M.S Sandhu

14 Mar 2022

ORDER

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                       Complaint No. 132 of 2020

                                                        Date of instt.02.03.2020

                                                        Date of Decision:14.03.2022

 

Jyoti Kumari @ Jyoti Rani widow of Amit Khokhar, resident of house no.41, New Wazir Chand Colony, near Sector 12, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Reliance General Insurance company Ltd. registered office, Reliance Center, South Wing, 4^th floor office Western Express highway Shantacruz East Mumbai 400055 through its Manager.

2.     Reliance General Insurance Company Ltd., corporate office, Reliance Center South Wing, 4^th floor office Westren Express Highway Shantacruz East Mumbai 400055 through its Manager.

3.     Reliance General Insurance Company Ltd., RCare health, 1-89/3/B/40 to 42/CS/301, 3^rd floor Krishe block, Krishe Sapphire Madhapur Hydrabad, 500081, Telengana through its Manager.

                                                                      …..Opposite Parties.

 

Complaint under Section 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

           

 Argued by: Shri M.S. Sandhu, counsel for complainant.

                    Shri Ashok Vohra, counsel for opposite parties.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that husband of complainant obtained the family health insurance policy from the OPs through their agent at Karnal under the plan of “Reliance Health Gain Policy” bearing no.606821928280000036, valid from 08.03.2019 to 07.03.2020. Complainant was insured for Rs.6,00,000/- and also paid the installment of Rs.12692/- annual. The said insurance plan covered the complainant herself, her husband Amit Khokhar and her son. At the time of taking the policy, the husband of complainant, as well as her family members were examined by the doctor of OPs. On 18.09.2019, husband of complainant fell ill and admitted in Virk Hospital, Karnal, where he was treated and remained admitted from 18.09.2019 to 24.09.2019 but his health did not improve and when on 24.09.2019 he became serious, the doctor of Virk hospital, Karnal, discharged the husband of complainant. Then he was shifted to Alchemist Hospital, Sector-21, Panchkula, Haryana and same was intimated to the OPs and the officials of OPs visited and verified, the complainant spent Rs.1,29,128/- on the treatment of her husband and the same was approved by the OPs and paid the same to Virk Hospital, Karnal.

2.             It is further averred, that the husband of complainant was admitted in Alchemist Hospital, Panchkula, on 24.09.2019 in serious condition where he remained admitted from 24.09.2019 to 30.09.2019 and where a sum of Rs.4,06,187/- was spent by the complainant. All the bills were submitted by the complainant to the OPs but OPs has refused to pay the said amount to the concerned hospital with remarks that, as per the received documents as member is a alcoholic liver disease and same is not disclosed during policy inception, vide report dated 25.09.2019. However, the doctor of Alchemist Hospital gave his opinion dated 26.09.2019 as “it is to state that patient Amit Khokhar admitted in medical ICU currently is not a known case of alcoholic liver disease as is mentioned in your rejection mail. Patient used to consume occasional alcohol and so is mentioned in the history noted previously. No mention is made of alcoholic liver disease at any point in the file of patient. Patient ultra sound report is attached along to second the fact that patient is presently not suffering from liver disease, secondary to alcohol or any other reason. Present condition/diagnosis confirms extensive bilateral lung consolidation, ground glassing ARDS, secondary origin. Kindly approved the claim of patient as current medical condition is totally unrelated to alcohol related”. Thereafter, complainant submitted all documents alongwith opinion of doctor on 29.10.2019, but OPs rejected claim and refused to pay said amount to the concern hospital without any reason. But no improvement done in the health of the husband of the complainant and he was discharged from there on 30.09.2019. On 30.09.2019 again due to serious condition he was taken to PGI Chandigarh in emergency, where he died on 03.10.2019. Complainant again spent a sum of Rs.82365/- on the treatment of her husband in PGI and same was informed to the OPs but OPs did not pay the said amount also. Due to non-payment of amount for treatment by the OPs, the complainant could not get treatment of her husband properly in time. The complainant has spent total amount of Rs.617680/- on the treatment of husband of complainant and complainant submitted all the original bills and documents of treatment to the OPs with a request to pay the remaining amount as per policy, but OPs paid only Rs.129128/-  and failed to pay the remaining amount i.e. Rs.470872/- to the complainant. Thereafter, complainant requested several times to OPs to pay the remaining amount but OPs has refused to pay the same. In this way there was deficiency in service on the part of the OPs. Hence this complaint.

3.             On notice, OPs appeared and filed their written version raising preliminary objections with regard to maintainability; locus standi; cause of action; jurisdiction and concealment of true and material facts. On merits, it is pleaded that after receipt of the intimation from the insured/complainant regarding the medi claim, the OPs have registered the claim of the insured/complainant, vide claim no.10119002944. The complainant/insured had requested for the cashless approval for the “Acute Febrile Illness” which get rejected by the company. Further, complainant also requested for the reimbursement claim which is also get repudiated on the basis of Permanent exclusion criteria of insurance policy as etiology of current ailments specified by Doctor is due to alcoholic habits. It is further pleaded that husband of complainant namely Amit Khokhar is suffering with Acute Febrile Illness, SEPSIS, ARDS, AKI, Acute liver failure with Hepatic Encephalopathy grade 4, Coagulopathy with Alcoholic Liver Disease. Patient was admitted in Alchemist Hospital Ltd. with DOA-24.09.20-19 and DOD 03.10.2019 during the admission has undergone medically managed. Upon verification and on going through the claim documents it was found that patient is known Alcoholic. Received justification from Treating Doctor as the present diagnosis is a Direct Complication of Alcoholism. The line of treatment is directed primary to treat the complication of Alcoholism. As per Group Policy Permanent Exclusion-under clause:3 and Subclause:3.3.27 which reads-Expenses incurred for treatment of complication of Alcoholism due to use of intoxicating drugs/Alcohol is not covered. Hence, the claim of the complainant is not admissible as per the terms and conditions of the policy. The insurance company is unable to reimbursed/admit any amount under the captioned claim. OPs have rightly repudiated the claim of the complainant and intimation in this regard was also sent to the complainant, hence OPs are not liable to pay any claim amount to the complainant. There is no deficiency in service on the part of the OPs. The other allegations made in complaint have been denied by the OPs and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Complainant has tendered into evidence her affidavit Ex.CW1/A, copy of health policy Ex.C1, copy of premium certificate Ex.C2, copy of customer information sheet Ex.C3, copy of discharge/refer summary Ex.C4, case summary of Alchemist Hospital Ex.C5, opinion letter of Dr. Vishal Sharma Alchemist Hospital Ex.C6, copy of application of complainant to OP Ex.C7, copy of application dated 17.12.2019 Ex.C8, postal receipts Ex.C9 and Ex.C10, copy of claim repudiation letter Ex.C11, bill of Virk Hospital Ex.C12, copy of approval of amount Ex.C13, bill of Alchemist Hospital Ex.C14, bill of PGI Chandigarh Ex.C15, Medical Certificate of PGI and death certificate Ex.C16 and closed the evidence on 16.04.2021 by suffering separate statement.

6.             On the other hand, OPs have tendered into evidence affidavit of Suryadeep Thakur, Area Manager Ex.OP1/A, insurance policy Ex.P1, Renewal Intimation Ex.P2, discharge summary Ex.P3, letter of complainant to OPs regarding request for reimbursement of the mediclaim Ex.P4 and Ex.P5, postal receipt Ex.P6, repudiation letter dated 25.09.2019 Ex.P7, Certificate of Doctor Ex.P8, request letter for documents Ex.P9, claim repudiation letter dated 22.01.2020 Ex.P10 and closed the evidence on 03.02.2022 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             Learned counsel for complainant while reiterating the contents of complaint, has vehemently argued that husband of complainant obtained the family health insurance policy from the OPs. On 18.09.2019 the husband of complainant fell ill and admitted in Virk Hospital Karnal where she spent Rs.1,29,128/- on the treatment of her husband. The said amount paid by the OPs to the Virk Hospital, Karnal. Thereafter, the husband of complainant remained admitted in Alchemist Hospital from 24.09.2019 to 30.09.2019 due to serious condition where she spent Rs.4,06,187/- on the treatment of her husband and thereafter, husband of complainant shifted to PGI, Chandigarh in emergency where he remained admitted from 30.09.2019 to 03.10.2019 where complainant had spent Rs.82365/- on the treatment of her husband but no improvement done in the health of her husband and ultimately he died on 03.10.2019.  Complainant submitted the claim with the OPs for reimbursement of the remaining amount but OP did not pay the claim and lingered the matter on one pretext or the other and lastly repudiated the claim of complainant on the false and frivolous ground. Hence prayed for allowing the complaint.

9.             Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that the patient is known case of Alcoholic. As per Group Policy Permanent Exclusion-under clause:3 and Subclause:3.3.27 expenses incurred for treatment of complication of Alcoholism due to use of intoxicating drugs/Alcohol is not covered. Hence, the claim of the complainant is not admissible as per the terms and conditions of the policy and rightly repudiated by the OPs. Hence, prayed for dismissal of the complaint.

10.           Admittedly, the husband of complainant during his life time had purchased the Mediclaim policy from OPs. It is also admitted that husband of complainant had taken treatment from Virk Hospital, Alchemist Hospital, Panchkula and PGI Chandigarh during the subsistence of the insurance policy.  It is also admitted that the sum insured of the policy in question is of Rs.six lakhs only.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.P10/Ex.C11 dated 22.01.2020 on the following ground:-

“Member Reimbursement cannot be considered as per received documents Patient. Patient name-Amit Khokhar is suffering with Acute Febrile illness. SEPSIS, ARDS, AKI, Acute liver failure with Hepatic Encephalopathy grade 4, Coagulopathy with Alcoholic Liver Disease. Patient was admitted in Alchemist Hospital Ltd. with DOA-24.09.20-19 and DOD 03.10.2019 during the admission has undergone medically managed. Upon verification and on going through the claim documents it was found that patient is known Alcoholic. Received justification from Treating Doctor as the present diagnosis is a Direct Complication of Alcoholism. The line of treatment is directed primary to treat the complication of Alcoholism. As per Group Policy Permanent Exclusion-under clause:3 and Subclause:3.3.27 which reads-Expenses incurred for treatment of complication of Alcoholism due to use of intoxicating drugs/Alcohol is not covered. We regret to inform you that the claim is repudiated”.

 

11.           The claim of the complainant has been repudiated by the OPs only on the ground that husband of complainant was habitual of alcohol and due to use of alcohol he was suffering from liver disease. The onus to prove its version lies upon the OPs but OPs have miserably failed to prove its version by leading cogent and convincing evidence. Rather, complainant and OPs themselves have placed on file certificate Ex.C6/Ex.P8 issued by Dr. Vishal Sharma, Consultant, Pulmonology wherein concerned doctor has specifically mentioned that “patient Amit Khokhar, admitted in Medical ICU currently is not a known case of Alcoholic Liver Disease, as is mentioned in rejection letter. Patient used to consume occasional alcohol and so is mentioned in the history noted previous. No mention is made of alcoholic liver disease at any point in the file of patient. Patient’s ultrasound report is attached along to second the fact that patient is presently not suffering from liver disease, secondary to alcohol or any other reason. Present condition/diagnosis confirms extensive bilateral lung consolidation, ground glassing? ARDS, secondary to infective origin”. Thus, the plea taken by the OPs that husband of complainant is suffering from liver disease due to alcohol has no force.

12.            Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

13.           Keeping in view that the ratio of the law laid down in the aforesaid judgment and the facts and circumstances of the present complaint, we are of the considered view that the insurance company has failed to prove the allegations, on the basis of they have repudiated the claim of the complainant. In the present case OPs had already paid Rs.1,29,128/- to the Virk hospital, Karnal. Meaning, thereby, OPs did not reimburse the further claim to the complainant intentionally and deliberately.Thus, the act of the OPs while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine one.

14.           As per version of the complainant, she spent Rs.6,17,680/- on the treatment of her husband but as per insurance policy Ex.C1/Ex.P1, the insured amount is only Rs.6,00,000/-(Rs.six lakhs only). Complainant has already received Rs.1,29,128/- from the OPs. Hence, complainant is entitled for Rs.4,70,872/-(6,00,000-1,29,128= 4,70,872/-) the remaining insured amount.

15.  

Announced

Dated: 14.03.2022

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

                  (Vineet Kaushik)      

                      Member