State Consumer Disputes Redressal Commission
Anil Grover vs Reliance Life Insurance Co.Ltd. & ... on 17 July, 2012
CHHATTISGARH STATE
CONSUMER DISPUTES REDRESSAL COMMISSION
PANDRI, RAIPUR
Appeal No.585/2011
Instituted on 22.10.11
Anil Grover, S/o: Late Shri Amarnath Grover,
R/o: 198, 1st Street, Baldev Bag, Rajnandgaon,
Dist. RAJNANDGAON (C.G.) ... Appellant.
Vs.
1. Reliance Life Insurance Co. Ltd.
Midas Wing, Shahar Plaza, Andheri,
Kurla Road, Andheri (East)
MUMBAI - 400 059
2. Reliance Life Insurance Co. Ltd., Mumbai,
Through: Customer Service Center, Branch - Bhilai,
Dist. DURG (C.G.)
3. Chetan Anand Choudhari, Adviser,
Reliance Life Insurance Co. Ltd.,
R/o: P.Q.9 B., B.N.C. Mils Parisar, Parsi Lane, Baldevbag,
RAJNANDGAON (C.G.) ... Respondents.
PRESENT: -
HON'BLE JUSTICE SHRI S.C. VYAS, PRESIDENT
HON'BLE SHRI V.K. PATIL, MEMBER
COUNSEL FOR THE PARTIES: -
Shri R.K. Bhawnani, for appellant.
Shri Shekhar Amin, for respondent nos. 1&2.
None for respondent no.3.
ORDER
Dated: 17/07/2012 PER: - HON'BLE JUSTICE SHRI S. C. VYAS, PRESIDENT Feeling aggrieved by the impugned order dated 27.09.2011, passed by District Consumer Disputes Redressal Forum, Rajnandgaon (hereinafter called "District Forum" for short), the complainant of complaint case No.49/2010 has preferred this appeal. The complaint was dismissed by the District Forum on the finding that the complainant has failed to establish the allegation of deficiency in // 2 // service against the respondent and has directed the appellant / complainant to pay Rs.1,000/- as cost of litigation to respondent No.1 & 2 and Rs.500/- to respondent No.3.
2. Indisputably, the complainant purchased a Reliance Wealth + Health Plan (Regular) Reliance Life Insurance policy from respondent Nos.1 & 2 w.e.f. 20.02.2008 for next 15 years on payment of premium of Rs.28,637/-, as demanded by the insurance company. Under the terms of the policy, the insurance company was to pay hospital charges and surgical charges on treatment of the insured on his admission in a Hospital. The case of the complainant before District Forum was that he fell ill and was required to be admitted in BSR Hospital Bhilai, District Durg for treatment. He was treated in the Hospital after full examination and a bill of Rs.7,498/- was paid by the complainant on 11.06.09 and similarly an amount of Rs.8,504/- was paid as per bill dated 25.08.09 and thus, in all Rs.16,200/- was paid by the complainant. He preferred a claim before the respondent Company for reimbursement of that amount. When the insurance company did not pay any amount to him, then he filed consumer complaint before the District Forum, which was contested by the respondent / insurance company on the ground that the complainant had suppressed several material facts for the purpose of getting undue advantage. It has also been averred in the written version that the // 3 // patient was admitted for treatment of pancreatitis, which usually caused by gallstones or by consumption of too much alcohol and as there was no history of gallstones, so probably the cause of pancreatitis was alcoholism only. It has also been averred that doctors have also certified that the cause of pancreatitis was alcoholism, which comes under the exclusion clause 12 of the insurance policy, so the insurance company was not required to pay any amount under the terms of the policy.
3. Learned District Forum agreed with the defence taken by the insurance company and dismissed the complainant by the impugned order.
4. We have heard arguments advanced by both parties and perused the record of the District Forum.
5. Learned District Forum in paragraph No.12 of the impugned order after considering the evidence of Dr. Satish Chandra Mishra and Dr. Harish Chandra Sharma came to the conclusion that the complainant appellant was suffering from acute pancreatitis since 2007 and he was suffering from that disease as he was chronic alcoholic. So, this conclusion has been drawn that as the complainant was // 4 // consuming alcohol for a long time so he suffered from this disease and thus, the case comes under the exclusion clause of the insurance policy.
6. Copy of the insurance policy has been filed by the OP as document No.06 and the exclusion clause of the insurance policy, clause 5 sub-clause 12 says that : -
"5. Exclusions No benefits are available hereunder and no payment will be made by the Company for any claim for Hospital Cash Benefit under this policy on account of hospitalization directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following :
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2. --------------------
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12. Self afflicted injuries or conditions (attempted suicide), and / or the use or misuse of any drugs or alcohol."
Thus, if the insurance company wants to take benefit of this exclusion, then the Company is required to show that the hospitalization was caused or was based on or was arising out of or attributable to the use or misuse of any drug or alcohol. This can only be established by any positive medical evidence.
7. The insurance company has examined Dr. Harish Chandra Sharma and Dr. Satish Chandra Mishra. Dr. Satish Chandra Mishra was present in the hospital on 07.03.09, when the complainant Anil // 5 // Grover came there with complaints of severe stomach pain, which was extending up to back. He was admitted in the Hospital and was advised for blood test and thereafter the treatment was carried out by Dr. Harish Chandra Sharma and Dr. Satish Chandra Mishra was only responsible for getting the patient admitted in the Hospital and for advising blood test. He examined the patient at that time and found that he was suffering from acute pancreatitis. He has also gone through the treatment papers of the patient of the year 2007 and found that at that time also he was suffering from acute pancreatitis and was treated by Dr. Solanki. After reading the treatment papers of Dr. Solanki, Dr. Satish Chandra Sharma has further stated that at that time also the complainant was suffering from pain from upper portion of stomach extending up to back and it was acute pancreatitis at that time also. He has further stated that at that time it was informed by him that he was suffering from that pain for last two years. It has also been stated by him that in the report of 2007, it has been mentioned that he was chronic alcoholic meaning thereby that he was consuming alcohol for a long time. So far as the document Annexure P-2 is concerned, in the history it has been stated that he was ethanol related and '?' mark was put against that entry. It was admitted by the doctor that ethanol is available in other substance also apart from wine and liquor. It has also been admitted by him that in the treatment paper, document No.9, the blood examination, sonography of abdomen, x-ray of stomach and // 6 // ECG of the heart was advised and then detailed report of those tests is also available on the second page. It has been stated by him in this document that there is no reference that the complainant was chronic alcoholic or he was found so. It has also been admitted by him that if a person is chronic alcoholic then naturally his liver and pancreas got damaged.
8. Dr. H.C. Sharma in his examination has simply stated that he has examined the patient Mr. Anil Grower and treated him. He was taking treatment for pancreatitis and was a patient of chronic pancreatitis. Medicines which were prescribed by this doctor to him were effective for acute pancreatitis as well as peptic ulcer because he was suffering from that also. He has also admitted that in the report Annexure P-2, mention of ethanol related has been made and question mark '?' has been put against it. In respect of presence of ethanol in the body of a person, it has been admitted by him that it can be because of some other substance also than liquor or wine or one can get ethanol exceeded in the body even after consumption of anything orally having fermentation effect.
9. In the whole of the statement of these two witnesses it has nowhere been stated by any of them that the patient / complainant Mr. Anil Grover was suffering from chronic pancreatitis as an effect of // 7 // consuming alcohol. It is just possible that he might be having history of consuming alcohol for a long time, but the quantity has not been mentioned by anyone, as to how much effect of consumption of that quantity of alcohol was, on the body of the patient and in the report Annexure P-1 (treatment paper of 2007), at the time when the patient came to the hospital then this word chronic alcoholic has been used and then it has been stated that he was having severe epigastric pain one day, radiate to back also. There was recurrent vomiting and there was symptom of a case of acute pancreatitis. It has also been mentioned in this treatment paper that the etiology was alcohol related and question mark '?' was put.
10. Learned counsel for the respondent / insurance company has laid much stress on these words of mention of chronic alcoholic at the beginning of the report and submitted that the patient was suffering from acute pancreatitis because of the consumption of alcohol. But, looking to the fact of question mark '?' which has been put before alcohol related, it appears that the doctor was having some suspicion in this regard and was not sure that the disease was on account of consumption of alcohol that is why he has prescribed many examinations and tests to conclude the cause of disease. Ultimately, in the remaining report nothing has been stated as to whether the disease from which the patient was suffering was on account of consumption // 8 // of alcohol nor any advice was given of stopping consuming alcohol or to reduce the quantity of consumption of alcohol. This treatment paper was in respect of the disease suffered by the patient in the year 2007, whereas the present case is in respect of the treatment taken in the year 2009 in the month of March and June. The treatment papers for the month of March have been marked as Ex.P-3, non-applicant document No.8, in which in the history there is no reference of consumption of alcohol. On the second page, at the last, it has been stated that the patient give chronic alcoholic history. Thus, it appears that at that time the history was given by the patient that he was in habit of consuming alcohol, but then nothing was concluded by the doctor, on this line, to the effect that the abdominal pain from which the complainant was suffering was on account of consumption of alcohol. One more treatment paper, non-applicant document No.15, is also available on record which is of 13.03.2009 and in this paper on the left hand side acute pancreatitis has been mentioned and under which (? ethanol related) has been mentioned. Then there was prescription. So in this paper also remark ethanol related has been questioned (?).
11. A very important paper which is available in the record of the District Forum is in the form of the whole abdominal sonography of the patient dated 09.06.2009 of the same hospital Apollo BSR Hospitals. Whole Abdominal Sonography was done by Dr. Nidhi Agrawal, who // 9 // has found that the liver was normal in size, shape and echotexture. No focal or diffuse lesion seen. IHBR's & CBD were normal in appearance. Similarly, portal vein was also found normal in size. IVC & HV were also found normal in size, respiratory variations was also normal. Gall Bladder lumen was well distended and echofree. No calculus or sludge was seen. Spleen was found normal in size, shape and echotexture. No focal lesion was seen. Splenic vein was normal. Retroperitoneum on examination was found that pancreas was of normal size and echotexture. No retroperitoneal / paraaortic lymphadenopathy was found and the aorta was normal. Ascites, no free fluid was seen in peritoneal cavity. Both kidneys were found normal in size, shape and echotexture. Cortical thickness and corticomedulary differentiation was normal. No calculus was seen. No hydronephrosis was noted.
12. This report clearly establish that neither the liver, portal vein, gall bladder, kidneys nor any other vital organ of the patient was found having any abnormality, whereas if it was a case of consuming excessive alcohol or of sufferance of some ailments on account of consuming alcohol, then normally the liver was required to be suffered damages of having large size and it should have been found fatty. Similarly, there should be some malfunctioning of kidneys and at least in pancreas there should be some malfunctioning or there should be // 10 // some abnormality. But, the sonography report is telling that each and every organ of the complainant was of normal size, shape, echotexture and function. So this allegation appears baseless that the ailments from which the complainant was suffering was on account of consuming alcohol.
13. Learned counsel for the respondent / insurance company has drawn out attention towards API Textbook of Medicine, editor-in-chief Siddharth N. Shah, 7th Edition. Chapter 25 of which relates to Acute Pancreatitis. In the definition clause it has been stated that "acute pancreatitis is an inflammatory disorder of the pancreas characterized clinically by abdominal pain, biochemically by elevated amylase and lipase in the serum". Thus, there should be inflammation of pancreas, whereas in the whole abdominal sonography report, no such inflammation was found. This chapter further shows that Aetiological Factors for acute pancreatitis are many, including alcoholism and gallstone disease. However, it has been stated that alcoholism and gallstone can cause nearly 80% acute pancreatitis, but remaining 20% cases of pancreatitis were found to be on account of some other reasons listed in Table 2 of this chapter, enumerated in Aetiological Factors, which are : -
"Gallstones Alcoholism Medications (See list below) // 11 // Hypertriglyceridaemia (Type I, IV, V hyperlipidaemia) Obstruction of the pancreatic duct Pancreatic tumour Pancreas divisum Roundworm obstruction Infections - Viral, Mycoplasma, HIV, Kawasaki disease Hyperparathyroidism, Hypercalcaemia, Vascular disease (e.g., SLE) Trauma Post-surgical (abdominal, coronary artery bypass surgery, post-organ transplant surgery) Post-ERCP/sphincter of Oddi manometry Hereditary Scorpion / snake bit Toxins - Organophosphorus Sphincter of Oddi dysfunction Chronic renal failure, haemodialysis Diabetic ketoacidosis Hypothermia Refeeding pancreatitis (anorexia nervosa) Idiopathic Miscellaneous causes: ?Pregnancy, Crohn's disease, total parenteral nutrition, afferent loop obstruction after Billroth II surgery "
Thus, from this chapter it is clear that there were many and many factors apart from alcoholism, which can be said responsible for acute pancreatitis.
14. Learned counsel has also drawn our attention towards page No.1389 Chapter 8 of the same book, which is in respect of Alcohol and Substance Abuse. This chapter says that "content of ethanol in whisky, brandy, rum, vodka and gin is 35-50% wines 12% and beers 4%. Ethanol concentration is responsible for blood alcohol concentration // 12 // (BAC). However, Table 2 is containing Summary of Systemic Effects of Alcohol, out of which acute and chronic pancreatitis has been highlighted by learned counsel for the respondent / insurance company stating that it is also an effect of alcohol. There can be no quarrel with this argument that if this can be one of the effect, but the same list shows that systemic effects of alcoholism would be in respect of pancreas diabetes (endocrine dysfunction), malabsorption (exocrine dysfunction), in case of liver fatty liver, alcoholic hepatitis, cirrhosis, hepatic encephalopathy and there was many more other effects.
15. From the report of whole abdominal sonography, it has also been observed that there was no effect on pancreas or liver and these organs were found normal in their size, shape and echotexture. So, it can safely be said that the patient was having no effect in his body of consumption of alcohol. Therefore, it cannot be said that the ailments from which he was suffering was on account of consumption of alcohol. The insurance company has brought on record document O-2, which appears to be a letter to the complainant of Medi Assist which happens to be TPA appointed by the insurance company for examination of claims under health policy. We find that this letter contains inaccurate information. It has been stated in the letter that ailments for which the patient has been treated was pancreatitis and that acute pancreatitis is usually caused by gallstones or by drinking // 13 // too much alcohol, whereas the medical literature says that there are many more factors which are responsible for this disease apart from gallstone and consuming too much alcohol. In this letter thereafter it has been stated that there was no history of Gall stones recorded in the Discharge Summary or any report, hence the probable cause of pancreatitis is alcoholism only and which is contrary to the medical literature brought on record by the insurance company itself. If there was no gallstones then also there were many other probable causes including alcoholism. Then, there was a misstatement of fact in this letter under sub-clause (d) that the treating doctor in the certificate dated 07.03.2009, 19.03.2009, 26.03.2009 states the cause of pancreatitis is alcoholism, whereas no such diagnosis was ever made by any of the treating doctors. There was merely a suspicion that this may be a cause, but there was no ultimate finding or diagnosis of any doctor that the cause of pancreatitis was alcoholism.
16. In view of this, the report of Medi Assist, which has been brought on record by the insurance company, was not required to be acted upon by the insurance company being totally contrary to the facts of the case.
17. Thus, we find that there is no positive evidence to establish that the ailments from which the complainant was suffering was on // 14 // account of use or misuse of alcohol. In view of this, exclusion clause No.12 of the insurance policy does not provide any shelter to the insurance company in repudiating the claim of the complainant and the insurance company has committed deficiency in service in not paying the amount claimed by the complainant.
18. In view of this, the appeal succeeds and is allowed. The respondent / insurance company is directed to pay the amount of Rs.16,002/- to the complainant of reimbursement of his medical bills and also to pay Rs.5,000/- as compensation for mental agony suffered by him and Rs.3,000/- as cost of litigation of the complaint case as well as of this appeal. With these directions, the appeal is disposed of.
(Justice S.C.Vyas) (V.K. Patil)
President Member
/07/2012 /07/2012