Before the District Consumer Disputes Redressal Forum, Room No. 208 2nd Floor, District Administrative Complex, Tarn Taran
Consumer Complaint No : 30 of 2017
Date of Institution : 04.05.2017
Date of Decision : 09.05.2019
Manjit Singh son of Gurnam Singh resident of village Jawanda Kalan Tehsil and District Tarn Taran.
...Complainant
Versus
HDFC Ergo General Insurance Com. Ltd. having registered office at First Floor, H.D.F.C House 165/166, Bakbay Reclamation H.T. Prek Marg, Church Gate, Mumbai 400020, through tis M.D.
…Opposite Parties.
Complaint Under Section 12 and 13 of the Consumer Protection Act, 1986.
Quorum: Sh. Charanjit Singh, President
Smt. Jaswinder Kaur, Member
Sh. Jatinder Singh Pannu, Member
For Complainant Sh. H.S. Sandhu Advocate
For Opposite Party Sh. R.P. Singh Advocate
ORDERS:
Charanjit Singh, President;
1 The complainant Manjit Singh has filed the present complaint under Section 12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against HDFC Ergo General Insurance Com. Ltd. having registered office at First Floor, H.D.F.C House 165/166, Bakbay Reclamation H.T. Prek Marg, Church Gate, Mumbai 400020, through tis M.D (Opposite Party) on the allegations of deficiency in service and negligence in service on the part of opposite party with prayer to make reimbursement of the Insurance Claim of Rs. 1,80,000/- to the complainant which he paid from his own pocket for the treatment of his son and prayed Rs.10,000/- as compensation and Rs. 5,000/- as litigation expenses.
2 The case of the complainant in brief is that the complainant is policy holder of medical insurance of the opposite party having policy No. 2952200842639601001 and the policy Number 2952200842639601 was given on the policy card valid from 13.9.2016 to 12.9.2018 . As per this policy, the complainant his wife and his son namely Amansher Pal Singh are the policy holders, the complainant being the actual and two other being dependent other policy holder as per terms and conditions of the policy. The complainant paid Rs. 24,099/- as premium to the opposite party for the period of Insurance from 13.9.2016 to 12.9.2018. Amansher Pal Singh son of the complainant was diagnosed with a disease called ‘Keratoconus’ in both the eyes and as per the policy of the opposite party, this disease was covered for treatment and the complainant got his son admitted at Thind Eye hospital on 8.10.2016 and was discharged from the hospital on the same day after obtaining the treatment and he informed the opposite party for approval of the treatment and the opposite party gave approval for the same and promised to reimbursement of all the expenses borne by the complainant for the treatment of his son. The complainant spent an amount of Rs 1,80,000/- vide two receipt having receipt No. JAL/16-17/72 dated 8.10.2016 and receipt No.Jal 16-17/73 of Rs. 75,000/- each alongwith the bills of Rs. 30,000/- on the treatment of his son namely Amansher Pal Singh and after spending from his own pocket, he lodged a claim on the same day with the opposite party for the reimbursement of this amount but after obtaining the necessary documents from the complainant through some correspondence and after receiving the same documents from him, the opposite party had not reimbursed and amount of Rs. 1,80,000/- and have been delaying the payment on one pretext or the other nor have the opposite party given any reply to response or sent any correspondence regarding the status of his claim/reimbursement case till 27.03.2017. The cause of action of the present complaint occurred after a fortnight from 27.3.2017 when the complainant through his counsel sent a legal notice dated 27.3.2017 to the opposite party to make the reimbursement of Rs. 1,80,000/- to the complainant within 15 days but the opposite party had not complied with the legal notice and had not made and reimbursement till date to the complainant. Feeling dissatisfied by the act and conduct of the opposite party, the complainant perforce has filed this complaint against the opposite party.
3 After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version contesting the complaint on the preliminary objections that the complaint is not maintainable against the opposite party /HDFC ERGO Gen insurance Co. Ltd. as such, the same is liable to be dismissed. The complaint pertains to hospitalization claim of Amansherpal Singh, who is the son of the complainant and was insured under Health Suraksha Policy having vide No.2952200842639601002, for the period from 13.9.2016 to 12.9.2018, subject to policy terms and conditions, which was never disputed by the complainant. The claim was lodged for hospitalization expenses for TICL, which is done for the better quality of vision. After the claim intimation, the opposite party proceeded the claim and documents were sought from the complainants. After the perusal of documents, filed by the complainant, it was found that as per the contents of discharge summery dated 15.10.2016, the patient was admitted on 8.10.2016. After the examination it was found that the patient was suffering from “Keratoconus with post C3R in both the eyes”, he was advised for Toric ICL treatment. Further on 8.10.2016 he was operated upon both eyes for Toric ICL. The discharge summary clearly states that the patient had complaints of diminution of vision in both eyes, he was diagnosed with “Keratoconus”. Keratoconus is a progressive eye disease causing distorted vision. The treatment mention in the discharge summary is itself states that the Toric ICL treatment is for better quality vision. The medical report filed by the complainant dated 10.12.2016 confirms that the patient was given the treatment of Toric ICL. Therefore, from both the documents submitted by the complainant it was established that the treatment underwent by the patent was for the correction of vision which comes under the category of refractive error and the same is excluded as per the policy terms and conditions. Thereafter the claim of the complainant was repudiated as per the policy terms and conditions, and as per the preview of section 9 C x of policy terms and conditions which states that :-
“General Exclusions”
We will not make any payment for any claim in respect of any Insured Person Directly or Indirectly for, caused by arising from or in any way attributable to any of the following unless expressly stated to the contrary in this policy.
............treatment for correction of eye due to refractive error”.
The claim of the complainant stands repudiated after due application of mind as per terms and conditions of the insurance policy and as per the documents submitted by the insured. The repudiation of the claim vide letter dated 13.1.2017 addressed to complainant, was duly send to the insured. The complainant was informed about the repudiation of the claim, specifically stating therein the sanction under which the claim of the insured was repudiated. There is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the opposite party repudiating the claim which is not payable as per terms and conditions of the Insurance Policy does not amounts to any deficiency in service nor any negligence nor any unfair trade practice, as such the complaint against the opposite party is liable to be dismissed. The claim of the complainants has been rightly repudiated as per terms and conditions of the insurance policy after due application of mind vide letter of repudiation dated 13.1.2017 addressed to complainant, was duly send to the insured. The complainant was informed about the repudiation of the claim, specifically stating therein the section under which the claim of the insured was repudiated. There is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the opposite parties. Repudiating the claim which is not payable as per terms and conditions of the insurance policy does not amounts to any deficiency in service nor any negligence not any unfair trade practice, as such, the complaint claim of the complainants has been rightly repudiated as per terms and conditions of the insurance policy after due application of mind vide letter of repudiation dated 13.01.2017. On merits, the opposite party has reiterated the stand as taken in the preliminary objections and denied the other contents of the complaint and prayed for dismissal of the complaint.
4 To prove his case, Ld. counsel for the complainant tendered in evidence affidavit of Manjit Singh complainant Ex. C-1 alongwith documents Ex. C-2 to Ex. C- 19 and closed the evidence. Opposite Party tendered in evidence affidavits of Pankaj Kumar Ex. OP/1, Ex. OP/2 alongwith documents Ex. OP/3 to Ex. OP/13 and closed the evidence.
5 We have heard the Ld. Counsel for the complainant and opposite party and have gone through the evidence and documents placed on the file by the parties.
6 Ld. counsel for the complainant contended that the complainant is policy holder of medical insurance of the opposite party having policy No. 2952200842639601001 and the policy Number 2952200842639601 was given on the policy card valid from 13.9.2016 to 12.9.2018. As per this policy, the complainant his wife and his son namely Amansher Pal Singh are the policy holders, the complainant being the actual and two other being dependent other policy holder as per terms and conditions of the policy which is also mentioned in Ex. C-2. The complainant paid Rs. 24,099/- as premium to the opposite party for the period of Insurance from 13.9.2016 to 12.9.2018 vide Ex. C-2. Amansher Pal Singh son of the complainant was diagnosed with a disease called ‘Keratoconus’ in both his eyes and as per the policy of the opposite party, this disease was covered for treatment and the complainant got his son admitted at Thind Eye hospital on 8.10.2016 and was discharged from the hospital on the same day after obtaining the treatment and he informed the opposite party for approval of the treatment vide Ex. C-5 and Ex. C-7 and the opposite party gave approval for the same and promised to reimbursement of all the expenses borne by the complainant for the treatment of his son. The complainant spent an amount of Rs 1,80,000/- vide two receipt having receipt No. JAL/16-17/72 dated 8.10.2016 Ex. C-6 and receipt No.Jal 16-17/73 of Rs. 75,000/- Ex. C-8 alongwith the bills of Rs. 30,000/- on the treatment of his son namely Amansher Pal Singh. After spending from his own pocket, he lodged a claim on the same day with the opposite party for the reimbursement of this amount but after obtaining the necessary documents from the complainant through some correspondence and after receiving the same documents from him, the opposite party had not reimbursed and amount of Rs. 1,80,000/- and have been delaying the payment on one pretext or the other nor have the opposite party given any reply of response or sent any correspondence regarding the status of his claim/reimbursement case till 27.03.2017. He further contended that the cause of action of the present complaint occurred after a fortnight from 27.3.2017 when the complainant through his counsel sent a legal notice dated 27.3.2017 to the opposite party to make the reimbursement of Rs. 1,80,000/- to the complainant within 15 days but the opposite party had not complied with the legal notice Ex. C-18 and had not made and reimbursement till date to the complainant and receipt of the legal notice is Ex. C-19 . Ld. counsel for the complainant contended that terms and conditions of the policy were not explained to the complainant. Ld. counsel for the complainant prayed that the present complaint may be allowed as prayed for in the complaint.
7 Ld. counsel for the opposite party contended that the complaint is not maintainable against the opposite party /HDFC ERGO Gen insurance Co. Ltd. as such, the same is liable to be dismissed. The complaint pertains to hospitalization claim of Amansherpal Singh, who is the son of the complainant and was insured under Health Suraksha Policy having vide No.2952200842639601002, for the period from 13.9.2016 to 12.9.2018, subject to policy terms and conditions, which was never disputed by the complainant. The claim was lodged for hospitalization expenses for TICL, which is done for the better quality of vision. After the claim intimation, the opposite party proceeded the claim and documents were sought from the complainants. After the perusal of documents, filed by the complainant, it was found that as per the contents of discharge summery dated 15.10.2016, the patient was admitted on 8.10.2016. He further contended that after the examination, it was found that the patient was suffering from “Keratoconus with post C3R in both the eyes”, he was advised for Toric ICL treatment. Further on 8.10.2016 he was operated upon both eyes for Toric ICL. He further contended that the discharge summary clearly states that the patient had complaints of diminution of vision in both eyes, he was diagnosed with “Keratoconus”. Keratoconus is a progressive eye disease causing distorted vision. He further contended that the treatment mention in the discharge summary is itself states that the Toric ICL treatment is for better quality vision. It is further contended that the medical report filed by the complainant dated 10.12.2016 confirms that the patient was given the treatment of Toric ICL. Therefore, from both the documents submitted by the complainant it was established that the treatment underwent by the patent was for the correction of vision which comes under the category of refractive error and the same is excluded as per the policy terms and conditions. Thereafter the claim of the complainant was repudiated as per the policy terms and conditions, and as per the preview of section 9 C x of policy terms and conditions. He further contended that the claim of the complainant stands repudiated after due application of mind as per terms and conditions of the insurance policy and as per the documents submitted by the insured. He further contended that the repudiation of the claim vide letter dated 13.1.2017 addressed to complainant, was duly send to the insured. He further contended that the complainant was informed about the repudiation of the claim, specifically stating therein the sanction under which the claim of the insured was repudiated. There is neither any deficiency in service nor any negligence nor any unfair trade practice on the part of the opposite party. The claim of the complainants has been rightly repudiated as per terms and conditions of the insurance policy after due application of mind vide letter of repudiation dated 13.1.2017 addressed to complainant, was duly send to the insured. The complainant was informed about the repudiation of the claim, specifically stating therein the section under which the claim of the insured was repudiated. Ld. counsel for the opposite party prayed that the present complaint may be dismissed.
8 In the present case, insurance is not disputed. It is also not disputed by the opposite party that the complainant has provided the documents. But the opposite party has repudiated the claim of the compliant on the ground that the patient had complaints of diminution of vision in both eyes, he was diagnosed with Keratoconus. Keratoconus is a progressive eye disease causing distorted vision. On the other hands, Ld. counsel for the complainant contended that the said treatment is covered under the policy and the complainant has argued that the surgery is not as a cosmetic surgery as it is quite evident from the document Ex. OP/11 of Thind Eye Hospital Ltd. which is placed on record by the opposite party which clearly shows that Surgery was not as a cosmetic surgery. The complainant has placed on record insurance policy Ex. C-2 in which the name of Amansherpal Singh is mentioned and sum insured is Rs. 3,00,000/- it also shows the amount of premium of Rs. 24,099/-. It also shows that date of insurance from 13.9.2016 to 12.9.2018. The son of complainant has got the treatment on 8.10.2016 i.e. during the period of insurance policy and the complainant has also placed on record bills receipt Ex. C-6 of Thind Eye Hospital for Rs. 75,000/-, receipt Ex. C-8 of Thind Eye Hospital for Rs. 75,000/- and receipts of Thind Eye Hospital Ex. C-9 to Ex. C-16 on record and the opposite party has not objected the payment vide above said receipt. It has been argued on behalf of the complainant that at the time of agreement the complainant was supposed to sign on dotted line. Ld Counsel for complainant further argued that the opposite parties cannot rely upon the terms and conditions which were never thoroughly explained to the complainant. Reliance in this connection has been placed upon 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. Moreover it is usually seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
It is established on record that the son of the complainant was insured with the opposite party and he took the treatment of his eye during the policy period and as per document produced by the opposite parties Ex. OP/11 the said surgery is not a cosmetic surgery. But by not giving the genuine claim of the complainant, it amounts to deficiency in service, unfair trade practice on the party of the opposite party.
9 In view of the above discussion, the present complaint is allowed and the opposite party is directed to make the payment of Rs. 1,80,000/- (Rs. One Lac and eighty thousand only) i.e. amount of treatment to the complainant. Complainant is also entitled to Rs.7,500/- (Rs. Seven Thousand Five Hundred only) as compensation on account of harassment and mental agony and Rs 5,000/- (Rupees Five Thousand only) as litigation expenses. Opposite party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.
