PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Complaint No.- 9/2023

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member

1. Nandini Satapathy, Aged about 56 years,
2. Radhay Baarsanna Naandini, Aged about 19 years,

D/O-Uttam Charan Hota.

Both R/O-Jharsuguda Municipality Colony Qr. No.3,

Near Womens College, Jharsuguda,

PS/Dist-Jharsuguda.                                   .……….......Complainant.

Vrs.

1. H.D.F.C. ERGO General Insurance Co. Ltd.

IRDAI Regd No. 146, CIN-U66030-MH-2007-PLC 177117,

1^st  floor, HDFC House-165/166 Backbay Reclamation, H.T. Parekh Marg, Churchagate, Mumbai-400020.

WWW. Hdfcergo.com, Email-healthclaims@hdfc engro.com

2. H.D.F.C. ERGO G.I.C. Ltd.

Branch Office, 2^nd Floor, Platinum Chamber,

Budharaja Marg, Sambalpur,

Dist-Sambalpur, Orissa-768004.                         ...……….Opp. Parties

Counsels:-

1. For the Complainant         :- Smt. Manisha Mishra, Advocate
2. For the O.P. No.1 & 2        :- Sri. R.C.Panigrahi, Adv. & Associates

Date of Filing:24.01.2023,  Date of Hearing :24.07.2023  Date of Judgement : 28.08.2023

Presented by Sri Sadananda Tripathy, Member.

1. The case of the Complainant is that being the legal heirs of health policy holder of the deceased Uttam Charan Hota, the Complainants are consumer of the OPs and filed this case alleging to deficiency in service of the OPs, the deceased could not get immediate cashless service benefit, the treatment of the deceased was delayed, the Complainants and the attendants were harassed and ultimately no result was found. With the hope of better treatment a policy holder purchasing policy, whereas at the time of need, refusal is not only shocking but also painful for the insured family. The husband of the Complainant No. 1, namely Uttam Charan Hota purchased one policy after payment of Rs. 33,974.45 P, since 17.05.2017 (Optima Restore Floater Policy) from the OPs. In an offer of Appolo Munich Health Insurance Ltd. Uttam Charan Hota with Multiple benefit insured for Rs. 15,00,000/- and paid Rs. 43,456.00 premium to the company. The policy was for the period upto 16.05.2018. At the time of issuing the policy for application No. OR 10581916J, AMHI check list was made by Dr. Raj Ashok Dash Medicine specialist and cardiologist, Bhubaneswar on behalf of the company and thereafter policy was issued. Uttam Charan Hota was suffering from Crohn’s disease with intestinal obstruction since February 2017 and was admitted in Appolo Hospital, Hyderabad and undergone surgery and thereafter in healthy and stout condition Apprehending future any complicacy and better treatment the policy was taken. From year to year the policy has been renewed by the said Health Insurance Company. At the time of taking policy the fact is also discussed with intermediary Pratap Kumar Dash (Code-80177117) and on his advise the policy has been continued till 2022-23. Appolo Munich Health Insurance Ltd in the meantime is named as HDFC ERGO G.I.C. Ltd.. The company is having its branches all over India. On 03.10.2022 Uttam Charan Hota complained seviour abdominal pain and immediately Dr. Salil Kumar Parida, Gastologist was consulted on 04.10.2022. The consulting doctor immediate, suggested for surgerical intervention. The patient was admitted in Appolo Hospital, Bhubaneswar, treatment continued. When the doctor advised for immediate operation, the attendant of the patient consulted the intermediary and on his advise “Cashless” service was applied before the OPs. On 06.10.2022 the Ops replied that “as per available documents, we have observed that there is a non-disclosure of Crohns disease which may have impact would not be possible at this juncture”. The OPs denied the cashless claim facility. During the subsistence of Health Policy (valid period 06.06.2022 to 05.06.2023) denial of cashless claim facility by the OPs is a deficiency in service. Uttam Charan Hota had paid Rs. 36,152.25, Rs. 14,856.05 and Rs. 5,044.50 for himself, wife and daughter and the base sum insured is Rs. 10.00 Lakhs plus benefit Rs. 10.00Lakhs. During the treatment (05.10.2022 to 07.10.2022) the Complainants have spent a sum of total Rs. 2,87,546.00 in the treatment of Uttam Charan Hota. The Complainants with their efforts took the pain of medical treatment but on 07.10.2022 the patient died due to deficiency in service of the OPs and non-supply of service in time. The cause of death of the patient was cardiac arrest. On 04.11.2022 after all the death rituals of the deceased the Complainant No. 1 submitted all the documents with the OPs for the health claim but on 10.11.20223 the OPs sent e-mail and informed “We regret to inform you that we are unable to register the claim for above mentioned policy, as the same has already been cancelled at our end on account of PED Non Disclosure, Disease: Crohn’s disease since 24.01.2017. Hence the claim can not be registered in the policy”.
2. The Written Version of the O.Ps is that the Policy was issued by the OPs in favour of Mr Uttam Charan Hota on 17^th May 2017 and was thereafter renewed up to the period 6^th June 2022 to 5^th June 2023. The OPs had received claim intimation from the Complainant for availing Cashless facility in respect of hospitalization and treatment expenses of insured/patient Mr Uttam Charan Hota. The patient was admitted to Apollo Hospital from 5^th October 2022 to 8^th October 2022 for a total amount of Rs. 1,40,000/-. Subsequent to receipt of the claim intimation for Cashless facility, the medical records of the insured Uttam Charan Hota were reviewed as submitted by the Complainant after which it was ascertained that the patient was suffering from Crohn’s Disease, Minimal Ascites & Splenomegaly since the year 2015 and had underwent surgery for the same in 2015 and 2017 as well prior to hospital admission on 5^th October 2022 and first policy inception date i.e 17^th May, however all of this information were suppressed in the proposal form. In light of aforesaid findings, claim was rejected vide letter dtd. 6^th October 2022 upon gaining knowledge of Non Disclosure of pre existing ailments i.e. Crohns Disease, minimal Ascites & Splenomegaly which is a gross violation of policy terms and conditions. The OPs have relied some case laws.
3. From the above it is found that the Complainant has a valid and continuing health policy since 17.05.2017. The OP Insurance Company rejected vide letter dtd. 6^th October 2022 upon gaining knowledge of Non Disclosure of pre existing ailments i.e. Crohns Disease, minimal Ascites & Splenomegaly which is a gross violation of policy terms and conditions which is found not genuine as because there is no such relevant evidence/documents produced by the OPs and also at the time of issuing the policy for application No. OR 10581916J, AMHI check list was made by Dr. Raj Ashok Dash Medicine specialist and cardiologist, Bhubaneswar on behalf of the company and thereafter policy was issued by the OPs.. So there is no question of pre existing disease. However, almost all diseases cover after three year of continuation of every policy if there is any pre existing disease. In most of the cases it is revealed that many of the insurance company take a common plea of pre existing disease and reject the policy  but it is observed that in case of Cardiac attack, the attack is done sudden and no person has knowledge about the attack. So deficiency of service and unfair Trade practice against the OPs/Insurance company is found. Accordingly it is ordered.

ORDER

The O.Ps are directed to pay Rs. 2,87,546.00/- toward cost of the treatment/medical expenses with 6% interest from the date of 5^th October 2022 to till realisation, Rs. 7,00,000/-(Seven Lakhs) towards deficiency in service as compensation and Rs. 10,000/- towards cost of the petition to the Complainant within 30 days from the date of order,failing which all the amount will further carry with 9% interest per annum till realization to the complainant.

Order pronounced in the open Court today on 28^th day of August, 2023.

Free copies of this order to the parties are supplied.