Chandigarh

DF-I

CC/697/2021

Pawan Sharda - Complainant(s)

Versus

Star Health and Allied Insurance Company - Opp.Party(s)

Ritesh Pandey

12 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/697/2021
Date of Institution	:	29/09/2021
Date of Decision	:	12/10/2023

 

Pawan Sharda S/o Sh.Nanad Lal Sharda, R/o H.No.358, Sector 4, Mansa Devi Complex, Panchkula at present R/o Sector 10, Chandigarh.

… Complainant

V E R S U S

1. Star Health and Allied Insurance Co. regd. and corporate office, New Tank Street, Valluuvar Kottam Road, Nungambakkam, Chenni.
2. Star Health and Allied Insurance Co., Area Office, SCO 5A, 2^nd Floor Madhya Marg, Sector 7-C, Chandigarh.

… Opposite Parties

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                                

ARGUED BY	:	Complainant in person.
	:	Sh.Inderjit Singh, Advocate for OPs.

 

Per Suresh Kumar Sardana, Member

1.      Averments are that the complainant had obtained the health insurance policy from OP No.1 through its area branch OP No.2 for himself as well as his family for the period started from 20.10.2020 to 19.10.2021 (Annexure C-1 & C-2). The complainant suddenly got ill while he was on his work and taken to Fortis Hospital Mohali on 9.7.2021, since the applicant was fully insured for his medical cashless policy and he was sanctioned Rs.10,000/- by OP No.1 on 10.7.2021. However, in that letter the diagnosis was “Meningitis” and doctor has specifically mentioned on the letter that “viral meningitis is not related to alcohol intake” (Annexure C-3). Thereafter, the complainant submitted his claim for Rs.6,27,449/- to the OP No.2, but vide impugned letter dated 11.09.2021, the claim of the complainant was wrongly rejected on the basis of wrong diagnosis and observation that the complainant was the patient of “Acute Delirium, Wernickes Encephalopathy” (Annexure C-4 & C-5). It has no where come in the medical record that the complainant was treated for alcoholism thus the OPs have wrongly rejected the medical claim of the complainant. Hence, is the present consumer complaint.
2.     OPs contested the consumer complaint, filed their written reply and stated that the complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is observed from the submitted medical records that the complainant is a chronic alcoholic. Based on this finding, it was observed as per medical record that the present admission of the complainant is for treatment of disease due to use of alcohol. As per Exclusion No.12-Code Excl 12 of the policy, it is not liable to make any payment in respect of expense incurred at hospital for treatment for alcoholism, drug or substance abuse or ay addictive condition and consequences thereof. Hence, claim of the complainant is not payable & rightly rejected. On these lines, the case is sought to be defended.
3.     Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the complainant and learned counsel for the OPs and gone through the record of the case.
6.     On perusal of complaint, it is gathered that the main grievance of the complainant is that inspite of having proper insurance cover his legitimate claim was rejected illegally by the OPs.
7.     We have perused Annexure C-5, wherein it is mentioned that insured person is under treatment of disease due to use of alcohol and as per exclusion clause 12 of the policy, the company is not liable to make any payment. We have also perused Annexure C-3, wherein the doctor of fortis hospital under whom, the complainant has undergone the treatment endorsed that the viral meningitis is not related to alcohol intake. 
8.     Now we shall scrutinize the record, whether consumption of alcohol had any connection with cause of disease of the complainant. The doctor though had referred the history of the deceased taking alcohol, but, it has not been mentioned about the quantity of alcohol being consumed & whether it was on higher side, which could have led to disease with which complainant had suffered. The disease which the complainant developed admittedly had no nexus with the intake of alcohol. Therefore, much credence could not have been attached to the stray sentences written in the medical history of the patient by the doctor regarding intake of alcohol.  Alcohol in itself is not a poison, if taken in small quantity as it is admixture of water, sugar and fermenting agent.  In other words, it is a sugar content and, if taken in limit, it cannot be said he was an alcoholic or it could have caused the disease with which the complainant suffered. Thus, there is clear-cut case of deficiency in service on the part of the OPs.
9.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to pay an amount of ₹6,27,449/- to the complainant alongwith interest @ 9% per annum w.e.f the date of repudiation i.e., 11.09.2021 till realization.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him.
3. to pay ₹10,000/- to the complainant as costs of litigation.

10.     This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11.     Pending miscellaneous application, if any, also stands disposed of.
12.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
12/10/2023			[Pawanjit Singh]
Ls			President
			Sd/-
			[Surjeet Kaur]
			Member
			Sd/-
			[Suresh Kumar Sardana]
			Member