Haryana

StateCommission

A/718/2015

HDFC ERGO GIC LTD. - Complainant(s)

Versus

ARCHANA SHUKLA - Opp.Party(s)

VISHAL AGGARWAL

11 May 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA.

                                                           

First Appeal No.           718 of 2015

                                                Date of the Institution:           01.09.2015

                                                Date of Decision:-        11.05.2016

 

HDFC Ergo General Insurance Company Limited, Corporate Office, 6^th Floor, Leela Business Park, Andheri Kurla Road, Andheri East, Mumbai – 400059 and at 5^th Floor, Tower 1, Stellar IT Park, C-25, Sector 62, Noida – 201301 through Pankaj Singh.

                                                Appellant-Opposite Party No.1

Versus

 

1.      Archana Shukla wife of Laxmi Shankar Shukla, resident of AGM Spinning Essma Felts Limited, 20^th Mile Stone, G.T Road, Rai, District Sonepat.

Respondent-Complainant

2.      Saxena Multispecialty Hospital Private Limited, 112-113, TP Scheme, Delhi Road, Sonepat through Dr. Akhil Saxena.

Respondent -opposite party No.2 

 

 

CORAM:    Hon’ble Mr. Justice Nawab Singh, President.

                   Mr. B.M. Bedi, Judicial Member.

 

 

 

Present:-    Mr. Vishal Aggarwal, Advocate for the appellant

                   None for the respondent No.1

                   Mr. Varun Chawla, proxy counsel for Mr. Ashish Chaudhary, Advocate for the respondent No.2

 

 

O R D E R

 

NAWAB SINGH J, (ORAL)

 

          By filing the present appeal, HDFC Ergo General Insurance Company Limited-opposite party No.1 (Insurance Company) has challenged the order dated July 21^st, 2015 passed by District Consumer Disputes Redressal Forum, Sonepat (for short, ‘District Forum’) whereby complaint filed by Archana Shukla-complainant was allowed.  Operative part of the order is reproduced as under:-

                   “……Accordingly, we hereby direct the respondent No.1 to make the payment of Rs.5,000/- to the complainant within a period of one month from the date of passing of this order, failing which, the above said amount shall fetch interest at the rate of 09% per annum from the date of this order till its realization.”

 

2.                Notice was issued to Archana Shukla-respondent No.1. She has been served through her husband as reported by the Process Server and attested by Sh. Sanjay Jain, Advocate, Hisar.  Despite service, nobody has appeared on her behalf. 

3.                Archana Shukla-complainant purchased Health Suraksha with Hospital Cash policy from the Insurance Company for the period November 16^th, 2012 to November 15^th, 2013.  She fell ill and surgical operation was performed on August 03^rd, 2013.  She was discharged on August 07^th, 2013 from Saxena Multispecialty Hospital Private Limited-respondent No.2 (hospital).  The complainant spent Rs.53000/- on her treatment.  She submitted her claim with the Insurance Company but it was not settled.   

4.                Insurance Company-appellant in its reply pleaded that during investigation, it was found that the complainant was diagnosed with chronic cholecystitis with cholelithiasis, which was a disease relating to gall bladder.  The treatment of said disease falls under the two years exclusion of the policy and thus, the cashless authorization was denied. 

5.                Respondent No.2 (hospital) in its reply pleaded that pre-authorization request form of Insurance Company was filled by the complainant.  The amount of Rs.54,450/- was paid by the complainant.  Cashless authorization request of the complainant was denied by Insurance Company on the ground that her ailment was not covered as per section 4(c) of the insurance policy. 

6.                Indisputably, complainant purchased Health Suraksha Policy for the Second Year, from the Insurance Company with effect from November 16^th, 2012 to November 15^th, 2012.  Her gall bladder was removed on August 03^rd, 2013 as is evident from the medical record (Annexures A-4 & A-5).  Section 4 (c) of the insurance policy (Annexure A-3) reads as under:-

          “c)     The illnesses and treatments listed below will be covered subject to a waiting period of two years in the third policy as long as the insured person has been insured under an Health Suraksha Policy continuously and without any break.

          (i)      Illnesses: Internal congenital diseases, arthritis if non infective, calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (Each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.

          (ii)      xxxxxxxx

          (iii)     xxxxxxxx

 

          A reading of aforesaid section clearly shows that the disease of gall bladder could be covered subject to the waiting period of two years in the third policy.  So, the complainant was not entitled to the expenses incurred by her on the treatment taken by her. The District Forum fell in error in allowing the complaint and the impugned order cannot be allowed to sustain.

7.      For the reasons recorded supra, the appeal is accepted, the impugned order is set aside and the complaint is dismissed.

8.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

 

May 11th, 2016

B.M.Bedi Judicial Member

Nawab Singh President

(U.K.)