Haryana

Kurukshetra

109/2018

Subhash Chand - Complainant(s)

Versus

HDFC AGRO - Opp.Party(s)

08 May 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

                                                     Complaint Case No.109 of 2018.

                                                     Date of institution: 15.05.2018.

                                                     Date of decision: 08.05.2019.

 

1. Subhash Chand s/o Sh. Matti Ram,
2. Madhu w/o Sh. Subhash Chand, both residents of VPO Umarpur, Karnal now residents of House No.136/18, Kailash Nagar, Thanesar, Kurukshetra.

…Complainants.

                        Versus

1. The Managing Director, HDFC ERGO General Insurance Company Limited Registered office 1^st Floor, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai- 400020.
2. The Managing Director, HDFC ERGO General Insurance Company Limited 5^th Floor Tower-1 Steller IT Park, C-25 Sector 62, Noida- 201301. 

….Opposite parties.

Before:      Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Trikha, Member.

       

Present:     Sh. Ashok Kumar, Advocate for complainant.   

                Sh. Atul Mittal, Advocate for opposite parties.

               

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Subhash Chand & another against the Managing Director, HDFC Ergo General Insurance Company Limited and another, the opposite parties.

2.            It is stated in the complaint that upon the persuasion of the ops, the complainants had purchased a medi claim insurance policy for a sum of Rs.four lacs bearing No. 2825 1002 4173 6800 000 and the premium of Rs.13,669/- was paid by the complainants to the ops and the said policy was for a period of one year i.e. from 12.10.2017 to 11.10.2018. It is further averred that ops had obtained the signature of the complainants on certain blank printed papers. The complainants disclosed each and every fact to the ops without concealing anything. Thereafter, the ops before issuance of the policy got thorough medical checkup of the complainants and after being satisfied with the medical reports, the policy was issued to the complainants. It is further averred that complainant Madhu Swami felt some severe pain in her abdomen and was admitted on 12.3.2018 in Cygnus Super Speciality Hospital and doctors advised the complainant Madhu for operation of rasoli and operation was conducted. The complainants spent an amount of Rs.50,000/- on the treatment. That thereafter the complainants approached the ops and deposited all the requisite documents with the ops and ops assured the complainants that ops would pay the insured amount to the complainants. The complainants continuously approached the ops for the medi claim but they postponed the matter on one pretext or the other. It is further averred that ops have caused mental agony and harassment to the complainant. That thereafter the complainants served a legal notice dated 9.4.2018 upon the ops but to no effect. Hence, this complaint.

3.             On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that policy is a legal contract between the policy holder and the insurance company and the parties to the said contract are bound by its terms and conditions. The terms of the policy are in the nature of the contract and their interpretation has to be made in accordance with the strict construction of the contract. Thus, the words in an insurance contract must be given paramount importance and interpreted as expressed without any addition, deletion or substitution. It is further submitted that no cause of action has arisen in favour of the complainant against the answering ops because as per the reports, discharge summary and hospital treatment records of the hospitals the patient was admitted in the hospital on 12.3.2018 with the diagnosis of Fibroid uterus and was managed surgically with abdominal hysterectomy. As per Section 9 A.II.a of policy, a waiting period of 2 years is applicable for the said ailment and procedure. As date of inception of policy is 12.10.2017, the policy is in first year. But the said complainant is in the standard exclusions within the waiting period from the commencement of the policy, on account of which, the claim of the insured was repudiated by their letter dated 13.3.2018. It is also submitted that this Forum at Kurukshetra has no territorial jurisdiction to try and adjudicate the present complaint as the policy of insurance was issued from Noida where the op is having its office. The op is having no branch at Kurukshetra, as such present complaint is not maintainable before this Forum. Remaining contents of the complaint are also denied and prayer for dismissal of complaint made.   

4.             Learned counsel for complainants tendered affidavits Ex.CW1/A, Ex.CW2/A and documents Ex.C1 to Ex.C7. On the other hand, learned counsel for ops tendered affidavit Ex.O-1/A and documents Ex.O1 to Ex.O4.

5.             We have heard learned counsel for the parties and have perused the case file carefully.

6.             In so far as preliminary objection of opposite parties that this Forum at Kurukshetra has no territorial jurisdiction to try and decide the present complaint is concerned, it may be mentioned here that complainant Subhash is having a saving bank account with HDFC Bank at Kurukshetra and a premium of Rs.13,669/- was deducted from his said account as is evident from copy of pass book Ex.C6. Further, in the copy of policy schedule, the name of agent is mentioned as HDFC Bank Ltd. meaning thereby that policy in question was purchased by complainants through HDFC Bank branch Kurukshetra and the policy in question was also issued to the complainants at Kurukshetra and therefore this Forum has every jurisdiction to entertain and try the present complaint and the contention of ops in this regard is hereby repelled.

7.             Now coming to the merits of the case, it is evident that health policy was issued to the complainants Subhash Chand and Madhu Swami which was effective from 12.10.2017 to 11.10.2018 and a sum of Rs.13,669/- was charged by the opposite parties from complainant Subhash Chand as premium against the insured amount of Rs.4,00,000/- as is evident from copy of policy schedule Ex.C5. From the copy of detailed final bill of the Cygnus Superspeciality Hospital, Kurukshetra Ex.C4, it is evident that complainant Madhu was admitted in the hospital on 12.3.2018 and was operated for rasoli (Fibroid uterus) and was discharged on 17.3.2018 and an amount of Rs.50,000/- was charged by that hospital from the complainants. The said admission and discharge of the complainant Smt. Madhu is during the subsistence of the policy. However, the claim submitted by complainants has been repudiated by the ops on the ground that as per exclusion clause 9A.II.a of the policy, a waiting period of two years is applicable for the said ailment and procedure. However, the ops have not proved on record through any reliable and cogent evidence that the terms and conditions of the policy were duly supplied to the complainants alongwith policy schedule  and they were explained about the terms and conditions of the policy in verbatim. The ops have also failed to prove that the above said disease was a pre-existing disease to the complainant Smt. Madhu and that complainants have failed to disclose about any pre-existing disease to the ops at the time of taking the policy. It is seen that insurance companies charges huge premium from the insured and when the liability of the insurance companies to pay any claim comes, they repudiate even the genuine claim on one pretext or the other or by placing reliance on the terms and conditions which the ops have done in the present case and have caused deficiency in service towards the complainant.

8.             In view of the above, we allow the present complaint and direct the opposite parties to pay a sum of Rs.50,000/- to the complainants as expenses incurred by complainants on the treatment of complainant Smt. Madhu within a period of 45 days from the date of receipt of copy of this order, failing which the complainants will be entitled to interest @9% per annum from the date of order till actual realization. We also direct the ops to further pay a sum of Rs.10,000/- as compensation to the complainants for harassment, mental agony and litigation expenses. . A copy of said order be supplied to the parties free of cost.  File be consigned to record-room after due compliance.           

Announced in open Forum:

Dt.: 08.05.2019.                                                  (Neelam Kashyap)

                                                                        President.

 

(Sunil Mohan Trikha),           (Neelam)       

Member                             Member.