State Consumer Disputes Redressal Commission
Star Health And Allied Insurance ... vs Arun Kumar on 15 December, 2025
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No. 263 of 2024
Date of institution : 22.05.2024
Reserved on : 20.11.2025
Date of Decision : 15.12.2025
Star Health and Allied Insurance Company Limited, First Floor, above
State Bank, RI Branch Thiara Complex, 404, Bishamber Nagar,
Jalandhar Road, Near Bus Stand, Hoshiarpur having its office at 1st
Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi -
110001 through its Authorized Person.
....Appellant/Opposite Party
Versus
Arun Kumar, aged 60 years, S/o Sh. Sudesh Kumar, Resident of
Village Ajjowal, District Hoshiarpur.
....Respondent/Complainant
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 18.03.2024 passed by the District
Consumer Disputes Redressal Commission,
Hoshiarpur in C.C. No. 469 of 2022.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, Member
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No Present:-
For the appellant : Sh. Neeraj Khanna, Advocate
For the respondent : Sh. Navneet Kumar, Advocate
First Appeal No. 263 of 2024 2
VISHAV KANT GARG, MEMBER :
Appellant/Opposite Party i.e. Star Health and Allied Insurance Co. Ltd., has filed the present Appeal through its Authorized Person to challenge the impugned order dated 18.03.2024 passed by the District Consumer Disputes Redressal Commission, Hoshiarpur (in short, "the District Commission"), whereby the Complaint filed by the Respondent/Complainant-Arun Kumar had been partly allowed.
2. It would be apposite to mention here that hereinafter the parties will be referred, as were arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the Respondent/Complainant in the Complaint filed before the District Commission are that the Complainant had purchased the Health Insurance Policy since the year 2017, wherein all his family members had been insured. The Complainant was having Policy No. P/211213/01/2018/002476, valid for the period 28.03.2019 to 27.03.2020 issued on paying the premium of Rs.19,417/-. On 15.08.2019, the Complainant had a problem of fever and swelling in left leg and was admitted in DMC, Ludhiana and lateron got discharged on 04.09.2019. After being admitted to the DMC Hospital, the Complainant had applied to the cashless treatment with the OPs. The OPs had approved the cashless treatment of Rs.50,000/- on 18.08.2019 but lateron on 26.08.2019, the ops had withdrawn the cashless treatment facility on the basis that the patient was a case of alcoholic dependence. On his medical treatment, he had incurred an amount of Rs.4,98,474/- in the DMC, Ludhiana. The Complainant was referred to Government Hospital, Sector 32, Chandigarh by the DMC, where he remained admitted w.e.f. 10.09.2019 to 14.09.2019 and had also spent another sum of Rs.8,979/-. The Complainant for the First Appeal No. 263 of 2024 3 reimbursement of the claim has filed Complaint No. 140 of 2019 on 03.10.2019 before the District Commission, Hoshiarpur, which was disposed off by the District Commission on 13.04.2022 with the directions to the Complainant to lodge the claim for reimbursement of balance amount with the Insurance Company within 45 days from the receipt of this order and the Insurance Company was directed to decide the claim within 45 days after the receipt of the claim. The Insurance Company had rejected the claim on 01.07.2019 on vague and baseless grounds. Hence, the Complainant filed the Complaint on 27.07.2022.
4. It was averred that at the time of issuance of the insurance policy, he was thoroughly physically examined and the OP after fully satisfied from his reports had insured him. It was denied that he was suffering from any chronic liver disease. It was also denied that he was alcoholic dependent and due to that he was suffering with chronic liver disease. It was averred that his claim was wrongly, illegally and arbitrarily repudiated.
5. Stating the act of the opposite party to be a case of 'deficiency in service' and 'unfair trade practice', it was prayed in the Complaint that the OP be directed to pay the treatment charges of Rs.5,07,453/- along with interest @ 9% p.a. as well as Rs.1,00,000/- be awarded as compensation on account of suffering from harassment and mental agony. Rs.25,000/- be demanded as litigation expenses.
5. Upon issuance of notice in the Complaint, the Appellant/ Opposite Party had filed written statement by raising certain preliminary objections to the extent that the Complaint was not maintainable against the OP as the claim of the Complainant had been rightly repudiated vide letter dated 01.07.2022. It was revealed on verifying the medical record that the Complainant had undergone for the treatment of Alcohol First Appeal No. 263 of 2024 4 dependence chronic liver disease. The treatment related to use and consequences arisen from the use of alcoholism, drug or any addictive substance was prohibited under Exclusion Clause No. 12 of the Policy. It was proved on record that the Complainant was habitual alcoholic but concealed the said fact while purchasing the insurance policy. The Complainant has not approached the District Commission with clean hands, hence, not entitled for any relief. From the medical record, it was proved that he had taken the treatment of Alcohol Dependence Chronic Liver Disease (CLD) and the said treatment was not covered under the terms and condition of the policy. It was denied that the Complainant had spent an amount of Rs.4,98,474/- on his medical treatment. On receiving pre-authorization request, cashless treatment to the tune of Rs.50,000/- had been approved on 18.08.2019 but on evaluating the Hospital documents, it was transpired that the Complainant was admitted due to suffering from Chronic Liver Disease due to regular use of Alcohol and the said approval had been withdrawn. The insurance policy had been issued on the basis of information provided by the Complainant, wherein he had concealed the material information. It was pleaded that the claim had rightly been repudiated, being falls under exclusion clause and prayed for the dismissal of the Complaint.
6. After considering the contents of the Complaint and the reply thereof filed by the Opposite Party as well as on hearing the oral arguments raised on behalf of both the sides, the Complaint filed by the Complainant was partly allowed by the District Commission vide order dated 18.03.2024. The relevant portion of said order as mentioned in Para- 13 is reproduced as under:
First Appeal No. 263 of 2024 5
"13. Thus, we partly allow this complaint and ORDER the OP insurers to pay the full amount of the impugned claim for the complainant's hospitalization cum medical expenses in terms of the related policy along with other accrued benefits, if any, accrued and/or pertaining to the policy with interest @ 6% PA w.e. from the date of admission/ hospitalization besides to pay him a sum of Rs. 20,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of copy of these orders, otherwise the entire awarded amount shall attract additional interest @ 3% PA from the date of the orders till realization, in entirety."
7. The aforesaid order dated 18.03.2024 passed by the District Commission has been challenged by the Appellant/Opposite Party by way of filing the present Appeal by raising a number of arguments.
8. There was delay of 10 days in filing the Appeal. M.A. No. 658 of 2024 was filed for condonation of delay in filing the Appeal, which was supported by an affidavit. The delay of 10 days in filing the Appeal, was condoned vide order dated 27.06.2024.
9. Mr. Neeraj Khanna, Advocate, learned Counsel for the Appellant has argued that the claim of the Complainant had been repudiated only on the ground that during the investigation of the claim of the Complainant, it had transpired that the Complainant was having history of Alcohol Consumption for the last 20 years and during admission it was pointed out that he was suffering with Chronic Liver Disease (CLD) due to consumption of alcohol. The Complainant in his Proposal Form had concealed the fact of consuming alcohol and use of tobacco products and he was guilty of suppression of material fact. Said fact of history of alcohol consumption had been proved from the discharge summary of the Treating Hospital and as the Complainant had undergone for the treatment of CLD, therefore, his claim had fallen under the Exclusion Clause No. 12 of the terms and conditions of the Insurance Policy, which specifically prohibits the claim in respect of use of intoxicating substances, substance abuse, drugs / alcohol, smoking and tobacco chewing. By considering the above First Appeal No. 263 of 2024 6 circumstances, the Appellant had repudiated the cashless claim of the Respondent/Complainant. The District Commission had ignored the evidence available on the record that the Complainant was consuming alcohol since 20 years and had passed the impugned order on the basis of assumptions and presumptions. It was prayed that the Appeal be accepted and the impugned order be set-aside.
10. On the other hand, Sh. Navneet Kumar, Advocate learned Counsel for the Respondent has argued that it had not been proved from medical record that the Complainant was suffering with liver disease, caused due to alcohol consumption. The Complainant was admitted in the DMC Hospital due to problem of fever and swelling in the legs and his liver problem had no relation with alcoholism. Neither the Complainant was found in the habit of consuming alcohol nor he had suffered with the issues related to the presence of alcohol in the body. The Appellant had levelled hearsay allegations of alcoholism upon the Respondent/Complainant only to reject the genuine claim of the Respondent. The Appeal being without any merit, be dismissed and impugned order be upheld.
11. We have heard the oral arguments of the learned Counsel for the parties and have also carefully perused the impugned order passed by the District Commission, written arguments submitted by the parties and all the relevant documents available on the file. We have also gone through the judgments cited by both the parties.
12. It is not in dispute that the Complainant's Policy No. P/211213/01/2018/002476 was valid for the period w.e.f. 28.03.2019 to 27.03.2020 and during the validity period of the policy, he had suffered from the medical problem. For the treatment of the same, he was admitted in DMC, Ludhiana on 15.08.2019 and discharged from the said Hospital on First Appeal No. 263 of 2024 7 04.09.2019. Thereafter, he again remained admitted at Govt. Hospital, Sector 32, Chandigarh w.e.f. 10.09.2019 to 14.09.2019. It was claimed that on these treatments, he had incurred an amount of Rs.4,98,474/- at DMC, Ludhiana and Rs.8,979/- at Govt. Hospital, Sector 32, Chandigarh. The claim submitted by the Complainant with the OP for cashless hospitalization was firstly approved but lateron it was withdrawn by the Insurance Company on noticing that the disease of the Complainant was related to alcohol dependence i.e. Chronic Liver Disease. As per the version of the OP, the said disease of the Complainant was not covered under Clause No. 12 of the terms and conditions of the Policy.
13. Now the issue for consideration in the present case is as to whether alcohol consumption was the only cause for the occurrence of Chronic Liver Disease (CLD) and whether the OP had rightly repudiated the claim of the Complainant?
14. The allegation of the OP is that the Complainant was having history of Alcohol Consumption since last 20 years and due to said habit, he had suffered with Chronic Liver Disease (CLD).
15. Now we have examined the allegations of the OP for rejecting the Mediclaim of the Complainant. It has been noticed from field visit report (Ex. OP-7, LCR pg. 371) by the OP's official, under the column of 'Medical History & Duration' at Sr. No. 6 about Alcohol Intake of the Complainant has mentioned as 'Yes 20 Y'. On seeing this Field Visit Report under Column No. 8 Trigger Point No.1 : Verify when was CLD first diagnosed in this patient, the answer is "CLD 1ST DIAGNOSED - AS PER PATIENT/ICP
- RECENTLY". However, on perusal of the said Report reveals that the said official had not mentioned, as to on what basis he had came to the First Appeal No. 263 of 2024 8 conclusion that the Complainant was in the habit of intake of alcohol for the last 20 years.
16. There is another document on record that the copy of 'Patient Notes' dated 18.8.19 (Ex.OP-10, LCR pg. 391), wherein the Hospital Staff had mentioned that "c/o Alcohol + Tobacco dependence" but in the next line, it is specifically mentioned that "does not known to wife". It is unbelievable that a person, who consumed Alcohol and Tobacco products for the last 20 years but his family members were not aware about that habit of the person. Thereafter, it was specifically mentioned in the said note "currently no craving". Mentioning said fact in the medical record reveals the patient was not have an urgent desire for alcohol, meaning thereby that he was not addicted to consume alcohol. The Counsel for the OP had argued that the said fact of history of alcohol consumption had been proved from the discharge summary of the Treating Hospital submitted by the OPs (LCR pg. 403). There is no doubt that in the said Discharge Summary of DMC, under the column Diagnosis, it was mentioned 'Alcohol Dependence and Tobacco Dependence' but also under the Personal History column it was mentioned "Veg, Non Alcoholic, Non Smoker". Therefore, it was clear that nowhere the Complainant had mentioned to the medical staff that he was consuming alcohol and tobacco for the last 20 years and it is only an assumption of the OP, while repudiating the claim of the Complainant. Also in the DMC record submitted by the OPs, under column "Course in the Hospital and Discussion", it was mentioned "no evidence of DVT Fibroscan was done which was suggestive of S3S4 CLD (?NASH RELATED)" (pg. 429). With the help of google, we are trying to find out the meaning of above reference:-
First Appeal No. 263 of 2024 9
"Fibroscan: This is a non-invasive test (also called transient elastography) that uses ultrasound to measure the stiffness of the liver, which helps assess the degree of fibrosis (scarring) and fat (steatosis).
S3S4: These are stages of liver involvement, with S indicating steatosis (fat accumulation) and F indicating fibrosis (scarring), though sometimes S and F are used interchangeably depending on the specific scale. o S3 typically indicates advanced steatosis (significant fat accumulation). o S4 typically indicates the most advanced stage of fibrosis, known as cirrhosis, which is irreversible scarring that prevents the liver from working properly.
CLD: This stands for Chronic Liver Disease, a progressive deterioration of liver functions over a period of more than six months.
(?NASH RELATED): This suggests the doctor suspects the cause of the chronic liver disease and advanced scarring/fat is Nonalcoholic Steatohepatitis (NASH).
o NASH is a type of nonalcoholic fatty liver disease (NAFLD) where fat buildup is accompanied by inflammation and liver cell damage. It is a serious condition that can progress to cirrhosis and liver failure."
17. There is no dispute that CLD was not only caused due to use of Alcohol or tobacco consumption whereas there were many other conditions/factors which play important role for occurrence of CLD problem. Further the medical record of the DMC, Ludhiana had also revealed that the problem of the Complainant related to NASH. NASH means that the Doctor suspected the cause of the Chronic Liver Disease as Non-Alcoholic Steatophepatitis.
18. Therefore, in view of the above discussion and allegations levelled by the OP were found baseless as there was no medical evidence available on record to prove the fact that the Complainant was addicted to use alcohol and tobacco products. Rather on the other hand, the medical record itself had proved that he was not in the habit of consuming alcohol like an addicted person. Use of alcohol in a limited quantity is not barred and harmful. There was no allegation/evidence on the part of the OP that the Complainant had used the alcohol in huge quantity or he was in the habit of taking alcohol in a routine manner. Hence, the allegations of the First Appeal No. 263 of 2024 10 OP are only on the basis of assumptions and presumptions, having no solid reasoning. Similar controversy was subject matter and dealt by this Commission in First Appeal No.1585 of 2006 titled as "Branch Manager, LIC, Unit No.2, Hall Bazar, Amritsar and another Versus Rahul Sehgal"
decided on 20.12.2007 and observed as under : -
"11. The learned counsel for the appellants submitted that this medical record has proved that Rohit Sehgal was alcoholic for the last 15 years, and therefore, this habit of the insured led to the disease and had become a cause of his death.
12. This submission has been considered. It is a far fetched argument. Taking liquor is not a material fact. Moreover, taking liquor is not a disease. Almost everybody takes liquor with few exceptions. Again, it varies whether one takes liquor in larger quantity or takes only small dose like medicine; whether one takes regularly or occasionally. This report does not clarify these details. If consumption of liquor was a disease, the insured would not have survived for 15 years. He would have died even prior to filling of revival form. Therefore, taking alcohol was not a material fact the suppression of which can entitle the appellants to repudiate the claim."
The facts of the present case are similar to the facts of above case. In the present case also, nowhere it was brought on record that if it is presumed for the sake of arguments that the Complainant had consumed the liquor daily, it was not clarified whether the same had been consumed in large quantity or in small quantity. Whereas no authenticated document proves that the Complainant was in the habit of consuming liquor. Therefore, we are of the opinion that the OP had no justification/basis to reject the claim of the Complainant.
19. In view of the above discussion, we are of the view that the impugned order passed by the District Commission is justified in the given circumstances. There is no merit in the justifications given by the Appellant/OP to set-aside the impugned order. Accordingly, the Appeal First Appeal No. 263 of 2024 11 of the Appellant being devoid of any merit is hereby dismissed and the order passed by the District Commission is upheld.
20. Since the main case has been disposed off, so all the pending Miscellaneous Applications, if any, are accordingly disposed off.
21. The Appellant had deposited a sum of Rs.3,36,049/- at the time of filing of the Appeal and Rs.3,49,479/- in compliance of the orders dated 05.08.2024 and 02.12.2024. Said amounts, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The Concerned Party may approach the District Commission for the release of the same and the District Commission may pass appropriate order in this regard in accordance with law.
22. The Appeal could not be decided within the statutory period due to heavy pendency of Court Cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER December 15, 2025. (VISHAV KANT GARG) as MEMBER