Chandigarh: Consumer panel directs insurer to pay for ‘unjust denial’ of claim
Complainant was admitted to PGIMER, Chandigarh, where he was referred to the gastroenterology ward. Doctors found that due to the gall bladder stone, his pancreas was affected — a condition they ruled was not caused by alcohol. Singh, an occasional drinker as confirmed by his family, was discharged on March 18, 2020, after spending ₹4,59,291 on treatment.
The District Consumer Disputes Redressal Commission (DF-1) has directed Star Health and Allied Insurance Company to pay ₹4 lakh under a health insurance policy, and awarded ₹20,000 in compensation for mental harassment and litigation costs, after rejecting the insurer’s contention that the complainant’s ailment was alcohol-related.
The complainant, Inderjit Singh of Sector 49, represented by advocate Harpreet Saini, took a health insurance policy in 2014 and had never filed a claim before. On January 17, 2020, he suffered stomach pain and consulted Jain Clinic, Sector 21 D, where Dr Davinder Jain advised an ultrasound. The ultrasound revealed a small stone in his gall bladder, requiring removal.
Singh was admitted to PGIMER, Chandigarh, where he was referred to the gastroenterology ward. Doctors found that due to the gall bladder stone, his pancreas was affected — a condition they ruled was not caused by alcohol. Singh, an occasional drinker as confirmed by his family, was discharged on March 18, 2020, after spending ₹4,59,291 on treatment.
The insurance firm admitted Singh had obtained the policy and undergone treatment at PGIMER, where he was diagnosed with Acute Necrotizing Pancreatitis (ANP), Acute Kidney Injury (AKI), and Acute Lung Injury (ALI). The insurer claimed the cause of ANP was ethanol-related, arguing that pancreatitis is commonly caused by gallstones or excessive alcohol consumption and denied liability to make payment on this ground.
The commission found no conclusive evidence in the discharge summary that Singh’s condition was caused solely by alcohol. “Further when there is no concrete and convincing evidence on record that he was drinking a lot of alcohol and that was not the only reason for the aforesaid diseases and as such it cannot be presumed that the complainant has suffered aforesaid diseases due to the use of the alcohol…,” they observed.
The commission directed the insurer to pay the ₹4 lakh policy amount, along with ₹10,000 as compensation for mental harassment and ₹10,000 as litigation costs.