Delhi

East Delhi

CC/251/2019

SHAKUNTALA AGG. - Complainant(s)

Versus

RELIGARE HEALTH INS. - Opp.Party(s)

31 Jul 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO. 251/2019

 

	SMT. SHAKUNTALA AGGARWAL Wd/o. LATE MAHESH KUMAR AGGARWAL R/O: A-31, GURU NANAK PURA, LAXMI NAGAR, DELHI - 110092	….Complainant
Versus
	CARE HEALTH INSURANCE LTD. (Previously known as Religare Health Insurance Co. Ltd) THROUGHT ITS BRANCH MANAGER, OFFICE NO.206, SECOND FLOOR, ROOTS TOWER, PLOT NO.7, DISTRICT CENTRE LAXMI NAGAR, DELHI – 110092	……OP

 

                                                         

Date of Institution: 09.08.2019

Judgment Reserved on: 28.07.2023

Judgment Passed on: 31.07.2023

                  

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Rashmi Bansal (Member)

 

 

Order By: Sh. Ravi Kumar (Member)

 

 

 

JUDGEMENT

 

The Complainant has alleged deficiency in service on the part of OP in not settling the Mediclaim in respect of her husband late Sh. Mahesh Kumar Aggarwal despite of having valid Insurance Policy. 

1. The case of the Complainant is that initially her husband late Sh. Mahesh Kumar Aggarwal had taken ‘Easy Health Floater Standard Policy’ of Apollo Munich Health Insurance Co. Ltd. in the year 2009 covering himself, his wife and minor son and minor daughter and the same was regularly renewed without any break.  In the year 2012 he opted for ‘Floater Health Insurance Policy’ from the OP by way of porting and Policy bearing number 10008367 was issued by OP which was last renewed and was valid from 28.01.2018 to 27.01.2019 and the sum insured was Rs.5,00,000/- along with ‘No claim bonus’ of Rs.2,10,000/- and also ‘No claim bonus SUPER’ of Rs.5,00,000/-. The Complainant contends that   no policy document was delivered by the OP and only Cover Note was issued. 
2. On 29.10.2018 the Complainant’s husband was admitted in Sir Ganga Ram Hospital New Delhi on account of Progressive Jaundice, Hypertension and it was recorded by the Hospital that there was no history of BT/drug.  Upon his admission in the Hospital ‘cashless claim’ was raised with the TPA however the same was declined. Complainant’s husband remained admitted in the Hospital up till 15.11.2018 and since there was no improvement in his health his family decided to shift him to Institute of Liver and Biliary Sciences (ILBS) Delhi. He was discharged by Sir Ganga Ram Hospital on 15.11.2018.
3. On 16.11.2018 at 12:30 AM Complainant’s husband was admitted in ILBS where he underwent further treatment however unfortunately he could not survive and expired on 23.11.2018 at 01:15 AM and the reason of death recorded in Death Summary dated 23.11.2018 was ‘Multi Organ Failure with shock’. 
4. For the above treatment at Sir Ganga Ram Hospital the Complainant spent Rs.4,61,388/- and in ILBS an amount of Rs.3,19,996/- was spent.  Claim was submitted to the OP by the Complainant enclosing all relevant documents on 23.01.2019 however the same was repudiated vide letter dated 20.02.2019.  Prior to rejecting the claim, OP had sent one Letter dated 19.02.2019 demanding certain documents but before the Complainant could respond the OP abruptly sent Repudiation letter dated 20.02.2019, the very next day.
5. Thereafter, the Complainant got issued Legal Notice dated 02.06.2019 to the OP which was replied vide letter dated 12.07.2019.  Aggrieved by the above the Complainant has filed the present complaint before this Commission with the prayer seeking direction to OP to pay Rs.7,81,384/- towards medical expenses along with interest @18% w.e.f. 23.11.2018, compensation for mental agony and harassment Rs.1,00,000/-, litigation expenses of Rs.35,000/- and cost of Rs.35,000/-. 
6. Initially Complainant had impleaded Religare Health Insurance Co. as OP however later, she amended the Memo of Parties since  Religare Health Insurance Co. is now known as Care Health Insurance Co. Ltd. and the same was impleaded and Memo of Parties was amended. Hence present OP is Care Health Insurance Co. Ltd.
7. Reply was filed on behalf of OP wherein the Insurance Policy bearing no.10008367 has been admitted to have been issued to late Sh. Mahesh Kumar Aggarwal along with his wife, daughter and son as ‘CARE Floater Policy’ on 28.12.2012 and the last renewal was done for the period 28.01.2018 till 27.01.2019.  With regard to the Cashless request made by the Complainant when Sh. Mahesh Kumar Aggarwal was admitted in Sir Ganga Ram Hospital New Delhi on 29.10.2018 the same was declined on 30.10.2018 with the following observation:

• PERMANENT EXCLUSION – CONDITION CAUSED BY SUBSTANCE ABUSE. K/C/O ALCOHOL LIVER DISEASE
• PERMANENT EXCLUSION

8. When the Complainant finally approached OP for settlement of the claim then OP issued a ‘Deficiency Letter’ dated 19.02.2019 seeking documents pertaining to the illness and exact duration and past history of ailment with first consultation paper and all past treatment records – Cirrhosis of Liver, Hepatitis B. 
9. As per OP, upon perusal of the documents received in reply and investigation the OP observed that the Complainant’s husband had habit of alcohol consumption and therefore the claim was rejected under clause 4.2 (23) vide their letter dated 25.02.2019. 
10. Since for further management the Complainant’s husband was admitted in ILBS from 16.11.2018 to 23.11.2018 and claim was raised, then also on the perusal of documents received in query/reply and investigation, the OP came to the conclusion that Complainant’s husband had habit of alcohol consumption and the claim for this hospitalization was rejected under Clause 4.2 (23) vide letter dated 20.02.2019.
11. The Complainant’s husband Case Summary of Sir Ganga Ram Hospital diagnosed ‘Cirrhosis’ of Liver (Ethanole related) and as per prescription paper dated 26.10.2018 of Prof. Anil Arora of Sir Ganga Ram Hospital, he was diagnosed with ALD (Alcoholic Liver Disease).  Further as per OPD record dated 09.11.2018 the Complainant’s husband was shown having history of alcohol intake regularly for at least 3-4 times in a week. 
12. OP has stated that based on the above, the claim of the Complainant’s husband was rejected and there is no deficiency in service on their part and as far as legal notice dated 02.06.2019 issued by the Complainant, the same was replied vide letter dated 12.07.2019.
13. Complainant has filed Rejoinder to the Reply of the OP refuting the contentions raised there in and has reiterated the contents of her complaint.  It is also stated in the Rejoinder that the Complainant’s husband was not suffering from any disease and was never earlier treated for any substance abuse or liver disease.  OP has not filed any documents which may support their claim that the Complainant’s husband was diagnosed with ALD since long.  The OP has falsely alleged that the Complainant’s husband was diagnosed with ALD and wrongly assumed that the meaning of ALD as Alcoholic Liver Disease despite the fact that in medical language ALD means Adrenoleukodystrophy (a disease which is a result of fatty acid built up caused by a defect in a very long chain of fatty acids transporter in peroxisones, which then causes damage to the myelin sheath of the nerves, resulting in siezures and hyperactivity).  Even otherwise consumption of alcohol does not amount to suicide or substance abuse as claimed by the OP.
14. The Complainant has filed her evidence by way of affidavit wherein she has marked following documents as exhibits:

• Copy of the Repudiation Letter dated 20.02.2019 exhibited as Annexure C-1.  
• Copy of Health Insurance cover Note No.10008367 of the OP w.e.f. 28.01.2018 till 27.01.2019 alongwith covering letter dated 01.02.2018 exhibited as Annexure C-2 (Colly). 
• Copy of premium payment receipt dated 27.01.2018 issued by OP exhibited as Annexure C-3. 
• Acknowledgment of receipt of death claim issued by the OP dated 23.01.2019 exhibited as Annexure C-4 (Colly).
• Copy of Discharge Summary of Sir Ganga Ram Hospital for the period 29.10.2018 to 15.11.2018 exhibited as Annexure C-5 (Colly). 
• Copy of Death Summary of the deceased issued by Institute of Liver and Biliary Sciences for the 16.11.2018 to 23.11.2018 exhibited as Annexure C-6 (Colly).
• Copy of letter dated 19.02.2019 issued by the OP to the Complainant thereby demanding certain documents exhibited as Annexure C-7 (Colly). 
• Copies of Bills/Cash receipts issued by Sir Ganga Ram Hospital exhibited as Annexure C-8 (Colly).
• Copies of Bills/Cash receipts issued by Institute of Liver and Biliary Sciences exhibited as Annexure C-9 (Colly). 
• Copy of the Notice dated 27.06.2019 exhibited as Annexure C-10. 
• Copy of the Postal Receipt of Speed Post dated 27.06.2019 exhibited as Annexure C-11.
• Tracking Report of Speed Post exhibited as Annexure C-12. 
• Copy of the Reply dated 12.07.2019 of the OP exhibited as Annexure C-13. 

15. OP has filed its evidence by way of affidavit wherein following documents have been marked as exhibits:

•  Copy of insurance policy certificate as Exhibit -R1.
• Copy of policy renewal as Exhibit - R2.
• Copy of pre-authorisation form as Exhibit - R3.
• Copy of query letter dated 29.10.2018 is marked as Exhibit -R4.
• Copy of query reply dated 29.11.2018 as Exhibit -R5.
• Copy of denial letter dated 13.10.2018 as Exhibit -R6.
• Copy of claim form dated 16.2.2019 as Exhibit -R7.
• Copy of doctor's prescription dated 9.11.2018 as Exhibit -R8.
• Copy of death summary dated 16 to 23.11.2018 as Exhibit -R9.
• Copy of investigation report dated 18.11.2018 as Exhibit -R10.
• Copy of Denial letter dated 20.2.2019 as Exhibit -RII.
• Copy of claim form dated 16.2.2019 as Exhibit -R12.
• Copy of doctor's prescription dated 26.10.2018 as Exhibit -R13.
• Copy of discharge summary dated 29.10.2018 to 12.11.2018 as Exhibit - R14.
• Copy of investigation report dated 25.10.2018 as Exhibit - RI5.
• Copy of query letter dated 19.2.2019 as Exhibit -R16.
• Copy of claim denial letter dated 25 12 2009 as Exhibit -R17.
• Copy of legal notice dated 27.6.2019 as Exhibit -R18.
• Copy of legal notice reply dated 12.7.2019 as Exhibit -R19.

16. Both sides have also filed their written arguments. 
17. This Commission has heard the arguments of both sides and has perused the records.

It is not in dispute that the Complainant’s husband Sh. Mahesh Kumar Aggarwal was having a valid Medical Policy bearing no. 10008367 (Annexure C2) at the time of his illness and he was hospitalized in Sir Ganga Ram Hospital between 29.10.2018 and 15.11.2018 and was further hospitalized in Institute of Liver and Biliary Sciences (ILBS) between 16.11.2018 to 23.11.2018.  Unfortunately, the Complainant’s husband expired on 23.11.2018 at 01:15 AM. 

18. It is also not in dispute that initially the Complainant’s husband had taken ‘Easy Health Floater Standard Policy’ from Apollo Munich Health Insurance Co. Ltd. in the year 2009 which was renewed from time to time covering himself, his wife, his son and his daughter and in the year 2012 he ported this Policy to the OP as ‘CARE Floater Health Insurance Policy’ and Policy No.10008367 was issued by the OP which also was renewed from time to time and the last renewal was for the period 28.01.2018 to 27.01.2019.  The Complainant’s husband had also not made any claim of reimbursement during these years and as per the last policy he was also shown entitled for ‘No claim bonus’ for Rs.2,10,000/- and also ‘No claim bonus SUPER’ for Rs.5,00,000/-.  As per the Complainant no insurance policy was provided by the OP and only Cover Note was issued and therefore no terms and conditions or any other document was ever provided by the OP to them. OP has enclosed copy of terms and conditions of the policy with their Reply at page 93 to 131. OP has enclosed letter dated 01.02.2018 at page 39 of their Reply whereby it renewed the Policy in question for the period 28.01.2018 to 27.01.2019 and the said document states that OP had only enclosed Policy Certificate and Premium Acknowledgement alongwith their letter and not the complete Terms & Conditions of Policy. Hence Terms & Conditions of the Policy in question were not provided to the Complainant. 
19. When the Complainant’s husband was admitted in Sir Ganga Ram Hospital on 29.10.2018 then the diagnosis was ‘Cirrhosis of Liver (Ethanole related) and acute Chronic Liver Failure Grade-I’ and in the clinical history it was written that ‘there is no history of BT/drug’.  He remained admitted there and underwent treatment however as there was no satisfactory improvement in his health, the family members decided to shift him to ILBS and he was referred by Sir Ganga Ram Hospital on 15.11.2018 to ILBS and after discharge from Sir Ganga Ram Hospital (Annexure C-5 (Colly) he was admitted in ILBS on 16.11.2018 at 12:30 AM and there it was observed in recording the history of the patient that he was suffering from ‘Hypertensive Chronic Alcoholic’ with last intake 20 days back and thereafter he developed jaundice in ILBS he was administered medical treatment however he developed sepsis with septic shock and also bradycardia f/b cardiac arrest on 23.11.2018 at 00:45 AM and despite CPR and other protocols he was declared dead on 23.11.2018 at 01:15 AM and the cause of death recorded in the Death Summary was ‘multi organ failure with shock’ Annexure C-6 (Colly).
20. The contention of the Complainant is that despite of having valid Medical Insurance Policy, initially cashless request was denied by the OP and subsequently their claim of both the Hospitals i.e. Sir Ganga Ram Hospital and ILBS were also rejected by the OP vide letter dated 20.02.2019 attributing the reason (Exhibit – R II) :

• Permanent exclusion for condition caused by suicide or substance abuse
• Permanent exclusion: Condition caused by suicide or substance abuse / intoxication. 

The Complainant has contended that her husband was never treated for any substance abuse or liver disease earlier and therefore the stand of the OP that her husband died on account of his alcohol dependence which resulted in liver disease and ultimately caused his death is wrong. 

21. As per the Discharge Summary of Sir Ganga Ram Hospital dated 15.11.2018 (Annexure C-5 (Colly) where the Complainant’s husband was treated between 29.10.2018 and 15.11.2018, the diagnosis was ‘Cirrhosis of Liver (Ethanole related) and accute chronic liver failure Grade-I’ and it was also recorded in the Discharge Summary that ‘there is no history of BT /drug’. 
22. In the death summary of ILBS (Annexure C-6 (Colly), the history of the patient was recorded that he was suffering from hypertensive chronic alcoholic with last intake 20 days back and he developed jaundice and the cause of death recorded was ‘multi organ failure with shock’. 
23. The OP is relying on the OPD document of the Complainant’s husband dated 09.11.2018 (Annexure-H at page 54 of its Reply - Exhibit -R8) however in the said document it is also recorded ‘patient not brought’ obviously for the reason on that date the patient was admitted in Sir Ganga Ram Hospital and it appears that somebody approached ILBS for their opinion and it was recorded in the said document that the Complainant’s husband had alcohol intake and was regularly taking 3-4 times/week. This cannot be taken as reliable evidence as neither the patient was examined nor there is any name mentioned on the said OPD Card as to who gave that information.  The patient namely Sri Mahesh Kumar Aggarwal was not  examined by the Doctor of ILBS on 09.11.2018 and only the observation was recorded and it is also not clear as to who went for this opinion and for what purpose. The Complainant in her Rejoinder had disputed this aspect and has stated that her husband was not suffering from any disease and was never treated earlier for any substance abuse or liver disease.  Hence, the stand of the OP cannot be accepted in the absence of corroborative evidence. Further the document marked as Investigation Reports  (Exhibit – R10 & R15) mainly reveal about the condition of Complainant’s husband Liver and other organs whereas OP has denied the claim under Clause 4.2(23) having suicide angle.
24. In both the Hospitals i.e. Sir Ganga Ram Hospital it is recorded that ‘there was no history of BT/drug’ and only in the history of the patient recorded by ILBS in the Death Summary it is mentioned that the Complainant’s husband was ‘hypersensitive chronic alcoholic with last intake 20 days back’. Both these do not attribute suicide as reason for death.
25. Now, coming to the aspect of whether OP provided details of terms and conditions of the Insurance Policy issued by them to the Complainant since the OP heavily relies on the Exclusion Clause 4.3 (23) of the Terms & Conditions of the Policy. 
26. The Complainant’s husband got the medical policy ported with the OP and the Policy No.10008367 was initially issued by the OP for the period 23.12.2012 till 22.12.2014.  No ‘Proposal Form’ has been filed by the OP along with their Reply which would have thrown light on the critical issue on which this case is revolving around as to whether the Complainant’s husband was a chronic alcoholic, which led to suicidal tendency in him, and whether the same was declared by him in the Proposal Form in reply to the query of OP.  The onus and duty was casted upon the OP to provide this important information to the Commission but it failed to do so. On account of omission in filing of the ‘Proposal Form’ by the OP for the reason best known to it, this Commission is deprived of the opportunity to examine as to what was the declaration given by the Complainant’s husband about his health condition at the time of porting of the Policy in the year 2012 and also in subsequent years till the cause of action has arisen in this case. Further OP who could not establish that it had sent Terms & Conditions of the Policy to the Complainant.   
27. OP kept on renewing the Policy year after year till the last renewal period i.e. 28.01.2018 to 27.01.2019 and it has not been explained by the OP that on what basis the renewals were done and how the health condition of the insured was assessed by them. 
28. It is also worth mentioning to note that OP issued letter dated 19.02.2019 which is ‘deficiency letter’ wherein besides other it had sought details about exact duration and past history of the present ailment with first consultation paper and all past treatment records regarding Cirrhosis of liver, Hepatitis B and treating Doctor certificate for alcohol/any other drug abuse.  However, the OP has not stated as to when they received these details and examined the case of the Complainant whereas on the very next date i.e. 20.02.2019 they rejected the claim of the Complainant and again on the similar grounds they rejected the claim of the Complainant vide letter dated 25.02.2019.  This amounts to non-application of mind/pre-deciding the issue and mechanical disposal (rejection) of the claim by relying upon Exclusion Clause 4.2(23) of the Policy which was never provided to the Complainant. 
29. The OP has relied upon para 2.4 (23) of the Terms & Conditions of the Policy which states as follows:

• Act of self destruction or self inflicted injury, attempted suicide or suicide while sane or insane or illness or injury attributed to consumption use, mis-use or abuse of intoxicating drugs, alcohol or hallucinogens.   

30. The above para of the Policy does not match with the treatment which the Complainant’s husband underwent in both the Hospitals as nowhere it has been recorded that he had done any act of self destruction or self inflicted injury on account of alcohol use whereas it is observed in the Discharge Summary of Sir Ganga Ram Hospital that ‘there is no history of BT/drug’ and it is only recorded in the Death Summary of ILBS in the history column that the patient was ‘hypersensitive chronic alcoholic with last intake 20 days back’.  Thus, it cannot be said that the Complainant’s husband committed self inflicted injury/destruction which were suicidal in nature which caused his death on 23.11.2018 as the reason for the death has been recorded as ‘multi organ failure with shock’. The cases relied upon by the OP are not para-materia to the facts of the case.
31. Hon’ble Supreme Court in Gurmel Singh Vs National Insurance Co. Ltd (2022 SCC Online SC 666) has held that ‘Insurance Companies should not be too technical while settling the claims and ask for documents that the insured is not in a position to produce due to circumstances beyond his control’. In the present case OP sought certain details of previous treatment of the Complainant’s husband however without waiting for the reply from the Complainant on their Deficiency Letter dated 19.02.2019, the OP proceeded to reject the claim vide letters dated 20.02.2019 and 25.02.2019 which were otherwise also not in conformity with the Exclusion Clause 4.2(23) of the Policy. For the reasons stated above, the Repudiation Letters 20.02.2019 and 25.02.2019 are not sustainable and the case of the Complainant’s husband does not fall under the Exclusion Clause 4.2(23) of the Policy as OP could not establish that the Complainant’s husband did any act which was suicidal in nature and therefore OP is liable for deficiency in service in not settling the Claim of the Complainant.  
32. The OP in their Reply has also stated that the Complainant was having Insurance Policy of Rs.4,00,000/- whereas as per their own document Annexed at Page 40 of their Reply, the sum insured is Rs.5,00,000/- and it is also mentioned that Insured were entitled for ‘No claim bonus’ of Rs.2,10,000/- and also ‘No claim bonus SUPER’ of Rs.5,00,000/- and thus the total cover available to the Complainant’s husband and family members was to the extent of Rs.12,10,000/- in total. In the said document OP has also mentioned that ‘Subject to the Policy Terms & Conditions’ the Cumulative Bonus available will be addition of the No Claim Bonus and No Claim Bonus super upto this maximum amount of Rs. 7,10,000/- for all this insured collectively.   
33. For the reasons stated supra this Commission holds OP liable for deficiency in service and orders as follows:

• OP to pay Rs.4,61,388/- and Rs.3,19,996/- thus totalling Rs. 7,81,384/- to the Complainant with interest @7% p.a. with effect from 23.11.2018 within 30 days of receipt of this Order.
• OP to pay Rs.20,000/- towards mental agony and harassment to the Complainant.
• OP to pay Rs.15,000/- towards Legal Expenses to the Complainant. 

This Order shall be complied with by OP within 30 days from the date of receipt of the order failing which OP shall pay interest on all the above amounts @ 9% p.a. till the date of realization.

Copy of the Order be supplied/sent to the parties free of cost as per Rules.

File be consigned to Record Room.