Delhi

East Delhi

CC/275/2018

RUBY SHARMA - Complainant(s)

Versus

STAR HEALTH & ALLIED - Opp.Party(s)

17 Feb 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. 275/2018 

 

1     2   3     4     5	Ruby Sharma w/o Lt. Sh. Rinku Sharma Through SPA holder Tarzan Sharma   Santosh Devi w/o Sh. Naresh Kumar Sharma   Diksha Sharma d/o Late Sh. Rinku Sharma aged about 12 years   Pari Sharma d/o Late Sh. Rinku Sharma aged about 8 years   Vaishnavi Sharma d/o Late Sh. Rinku Sharma aged about 5 years   R/o B-275 Alpha-1, Greater Noida, Gautam Budh Nagar, Uttar Pradesh-201310   Permanent resident of   Village Dhamera Nara Post Roopwas Pachgain, Sikandrabad, Bulandshahr, U.P. 203131   Complainant No.4, 5 and 6 (wrongly mentioned in the Memo of Parties as there are only 3, 4 and 5) being minor are represented by Complainant No.1 their mother and natural guardian.	….Complainant
Versus
	Branch Manager  Star Health and Allied Insurance Company Limited, 209-210, Lakshmi Deep Building, DIST Centre, Lakshmi Nagar, Delhi-110092	……OP
	Ravindra Kumar Pant. Agent 209-210, Lakshmi Deep Building, DIST Centre, Lakshmi Nagar, Delhi-110092	……OP
	Manager Star Health and Allied Insurance Company Limited Regd. & Corporate. 1, New Tank Street, Valluvar Kottam High Road, Cheenai-600034	……OP

 

Date of Institution: 27.08.2018

Judgment Reserved on: 14.02.2023

Judgment Passed on: 17.02.2023

                  

CORUM:

Sh. S.S. Malhotra (President)

Ms. Rashmi Bansal (Member)

Sh. Ravi Kumar (Member)

 

Order By: Shri S.S. Malhotra (President) 

 

JUDGEMENT

1. By this order the Commission would dispose of the claim of the complainants with respect to deficiency in service in not paying the mediclaim amount of Rs.500000/- i.e. the sum assured despite having a mediclaim policy by the complainants.
2. Brief facts as stated by the complainants in the complaint are that Sh. Rinku Sharma the Husband of the complainant No.1 and father of the complainant No.2 to 5 (herein all jointly referred as complainants) was the policy holder of Policy No.P/161111/01/2018/002841 issued on 15.02.2013 i.e. Family Health Optima Insurance Policy for Rs.500000/- starting from 15.02.2013 onwards and the last policy was for the period of 31.05.2017 to 30.05.2018.  Sh. Rinku Sharma was admitted in JP Hospital, Sector-128, Noida on 04.10.2017 with acute Chronical Liver Disease and underwent living donor liver transplant on 05.10.2017 but he could not survive and ultimately died on 14.10.2017 and all expenses were incurred by the complainants to the extent of Rs.14,12,951/- for which they lodged a claim with OP but OP never communicated any fact i.e. neither rejected nor allowed the claim and constrained by the intactness of the OP, Legal notice was served upon OP on 16.04.2018.  In reply to the legal notice, OP rejected the claim by stating that the live donor liver transplant of the diseased was on account of complications for alcohol consumption by the diseased and as such the same is not covered in the policy and therefore the claim was rightfully rejected.       
3. Aggrieved by such reply, the Complainants have filed the present complaint thereby seeking directions to the OP to release the claim amount of Rs.14,12,951/-, seeking compensation of Rs.500000/- for the harassment caused by OP jointly and severally along with, cost of litigation of Rs.55,000/-.        
4. OPs have filed their Written Statement taking preliminary objection that the complaint filed by the complainants is misconceived and otherwise is barred by Section 26 of the Consumer Protection Act, which deals with the frivolous and vexatious complaints. 
5. It is further submitted that the policy of contract is contractual in nature and claim arising there from are subject to the terms and conditions following part of the policy and insured in this matter was admitted in the Hospital towards the treatment of ACUTE ON CHRONIC LIVER DISEASE, POST LIVING DONOR LIVER TRANSPLANT and such disease was on account of excessive consumption of Alcohol by Mr. Rinku Sharma.  Although the insured raised the pre authorization request for cashless which was denied on 09.10.2017 and as per objection dated 05.10.2017 the operative diagnosis from the Hospital was Alcohol induced ACLF i.e. ACUTE ON CHRONIC LIVER FAILURE.  It is further submitted that the insured was in the habit of consuming alcohol since last 4 years and as such this diseased is the direct consequence of alcoholism and therefore the claim was rejected rightfully as it comes within exclusion clause which was a part of the policy and its terms and conditions.  A copy of the Operation Card dated 05:10 2017 is annexed herewith and marked as ANNEXURE-OP-1. A copy of the Policy terms and conditions is annexed herewith and marked as ANNEXURE-OP-2 A copy of the Proposal form is annexed herewith and marked as ANNEXURE-OP-3. A copy of the Rejection letter is annexed herewith and marked as ANNEXURE-OP-4. A copy of the Anesthetic Record is annexed herewith and marked as ANNEXURE-OP-5 A copy of the Legal notice is annexed herewith and marked as ANNEXURE-OP-6. A copy of the reply to the legal notice is annexed herewith and marked as ANNEXURE-OP-7.  It is ultimately prayed that complaint of the complainants be dismissed as no cause of action has ever arisen in favour of the complainants.   
6. Even otherwise complainant has only a sum assured of Rs.500000/- and even if this Forum finds any liability upon the OP that may be limited to Rs.500000/- i.e. the sum assured.  The claim with respect to compensation and litigation charges is stated to be highly exaggerated and not permissible.      
7. The complainants then filed Rejoinder thereby denying the contents of Written Statements and also relied upon the Order of Hon’ble State Commission in National Insurance Company Vs. Preeti Sharma on 8 October 2007, wherein it was inter alia held that:

 “Respondent was a young man of 35 years or so.  To say that he was alcoholic because he had been taking alcohol for the last 10-15 years it self –defeating.  Had he been so he would have landed in the hospital for treatment or hospitalized for the effects emanating from the vice of alcoholism at earlier point of time”. 

 

And in the sight of this judgment, it is prayed that the claim of the complainants be allowed.      

8. Complainants filed evidence of Complainant No.1 and exhibited the following documents:

 

a. Copy of the policy is exhibited as Ex. CW-1/1.

b. Copy of the claim form is exhibited as Ex. CW-1/2.

c. Copy of legal notice dated 16.04.2018 alongwith postal receipt is exhibited as Ex. CW-1/3 (Colly).

d. Copy of the reply dated 05.05.2018 is exhibited as Ex. CW-1/4.

 

9.  OPs have also filed their evidence and he exhibited the Annexure as stated herein above.  Both the parties have filed their Written Arguments.   
10. The Commission has heard the arguments and perused the record.  The facts are in narrow compass.  The insurance policy taken by Sh. Rinku Sharma for Rs.500000/-, he suffered certain complications of the liver and was admitted in the Hospital in the fourth year of policy, the sum assured was Rs. Rs.500000/-, the complainants spent about Rs.14,12,951/-, raised the claim and the same was repudiated on the ground of Alcoholic nature of the diseased, are admitted facts.      
11. The only issue therefore is as to whether the rejection of the claim by the OP on the ground of Alcoholic nature of the diseased is sufficient to repudiate the claim.  To appreciate this contention of OP the OP has not filed any document on Commission’s record as to how the OP has come to the opinion about the approximate cause of death.    
12. The OP has exhibited 7 documents in its evidence but none of the document is sufficient to appreciate the contention of the OP nor they have any evidence in their possession to co-relate that the deceased was chronic user of the Alcohol or was excessive user of Alcohol at the cost of his health. 
13. Counsel for the Complainants on the other hand has relied upon the Order of Hon’ble State Commission in National Insurance Company Vs. Preeti Sharma on 8 October 2007, which was almost on same facts and in that matter the OP had repudiated the claim of the complainants while invoking exclusion clause of the policy by taking cause of death as ‘Alcohol Cirrhosis of liver’ which means that  he had been consuming much quantity of Alcohol and the Commission held that the doctor nowhere suggested even remotely that the respondent had died due to ‘Alcohol Cirrhosis of liver’ and the Para 5, 9 and 10  of that judgment reads as under: 

 

(5) It is the misfeasance of the appellant company that it jumped to the Conclusion that mere taking of liquor or alcohol in any quantity causes liver cirrhosis and excludes person from getting his rightful insurance claim against his health or life. Such a view is highly preposterous and tantamounts to logic chopping. In case after case we have taken View that unless and until the cause of death has been specifically assessed as alcoholic liver cirrhosis, the claim the insured cannot be repudiated. This views based upon the international studies done by highly reputed universities of world that taking liquor in small quantities is healthful and not injurious to health. 

 

(9) In modern day social life people take drinks that may be known as social drink or red if person drinks every day in moderation it does not mean that he should be deprived of the benefit of mediclaim policy which he has obtained after requisite medical examination to rule out any such disease that may be pre-existing and may disentitle him to obtain the policy itself. Even otherwise unless and until the doctors give certificate that the disease for which the patient was admitted and treated was solely because of his having used, intoxicating drugs or alcohol in heavy quantity, no insured can be deprived of the rightful claim towards mediclam expenses.    

 

(10) We fail to understand as to what are the criteria adopted by the Insurance Companies for issuing mediclaim or life insurance policy. They first subject the insured to medical test to find out whether he suffers from such disease that may deprive him from obtaining insurance policy if the panel doctors of the Insurance Company give certificate that the insured is having sound and good health and does not suffer from any disease any kind of explanation, excuse or any treatment obtained by the insured for any disease cannot come to the rescue of the Insurance Company for invoking the exclusion clause 4:8.

   

14. Therefore, the Commission is of the opinion that this judgment is befitting reply to the contention raised by OP in this matter and therefore the contention of OP is not well found and the Commission is of the opinion that it is a fit case where rejecting the claim by the OP on the ground that deceased was taking Alcohol, without any basis as to how much alcohol he was consuming or what is the basis of the OP to form this opinion, amounts to deficiency in service.    
15. The complainants are claiming of Rs.14,12,951/- but sum assured was only Rs.500000/-.      
16. The Commission is of the opinion that the contention of OP to that extent is well found that the sum assured was only Rs.5,00,000/-.  Complainants therefore would not be entitled for Rs.14,12,951/- i.e. the expenses of whole treatment but would be entitled of Rs.5,00,000/-.     
17. The Commission therefore directs the OPs to pay the following:

• OPs to pay Rs.5,00,000/- with interest @ 9% p.a. w.e.f. the date of filing the complaint and Rs.50000/- for compensation including legal expenses to the Complainant No.1 for herself and for on behalf of all the LRs.    

This order be complied with within 30 days from the date of receipt of the order.

Copy of the order be supplied/sent to the parties free of cost as per rules. 

File be consigned to Record Room

Announced on 17.02.2023

Delhi