Complaint Case No. CC/60/2023 | ( Date of Filing : 16 Oct 2023 ) |
| | 1. Subash Chandra Agrawal, aged about 60 years | S/o-late Radhe Agrawal, Ward No. 4, Kesinga , Near Post office, Dist-Kalahandi |
| ...........Complainant(s) | |
Versus | 1. HDFC EGRO General Insurance Company Ltd. | D-301, 3rd Floor, Eastern Business District (Magnet Mall) LBS Marg, Bhandup (WEST) Mumbai-400078 | 2. HDFC EGRO General Insurance Company Ltd | Registered & Corporate office, 1st Floor, HDFC House, 165/166 Backbay Reclamation, H.T Parekh Marg, Churchgate , Mumbai-400020 | 3. Manager Litigation and TP Claims | HDFC EGRO Genreal Insurance Company Ltd. OSL Automobiles, Badambari, Cuttack, Odisha-753012 |
| ............Opp.Party(s) |
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Final Order / Judgement | Shri A.K.Patra,President: - The captioned consumer complaint is filed by the complainant named above inter alia alleging deficiency in service & unfair trade practice on the part of the Ops for denial of cashless treatment & repudiation of insurance claim under the health insurance policy.
- The complainant seeks for the following reliefs:- (i) An order directing the Ops to settle the claim of the complainant and to disburse the claim amount along with additional, (ii) direct the Ops to issue another policy with the same terms and conditions as per the policy No.2825 1007 9856 5502 000 on dt.07.06.2022 in favour of the complainant or in alternative the Ops be directed to refund the premium amount collected from the complainant along with additional interest, (iii) direct the Ops to pay a sum of Rs.50,000/- as compensation for the mental agony and harassment,(iv) direct the Ops to pay a sum of Rs.5,000/- towards the cost of the case and advocate fees.(v) any other equitable relief(s) as the Hon’ble commission deems fit and proper may also be granted in favour of the complainant.
- The factual matrix leading to the case of the complainant as emerged from the case record is that ,the complainant has purchased an insurance policy termed as “HEALTH SURAKSHYA POLICY(SILVER SMART) vide No. 2825 1007 9856 5500 000 on dt .09.06.2020 covering the period from 09.06.2020 to 08.06.2021 from the OP/HDFC ERGO General Insurance Company Ltd. paying proper premium where in the said policy the complainant along with spouse & dependent son are the beneficiary to get cashless treatment and the same policy was renewed for the financial year 2021-2022 vide policy No vide No. 2825 1007 9856 5501 000 on dt .09.06.2020 covering the period from 09.06.2021 to 08.06.2022 and further it is renewed for the financial year 2022-2023 vide No. 2825 1007 9856 5502 000 on dt .07.06.2022 covering the period from 09.06.2022 to 08.06.2023.During the policy period i.e on 07.07.2022 his insured wife namely Mamata &Son Piyus Agrawal under gone necessary medical examination by Metropolis Inner Health Revealed Lab and the expenditure of Rs 5,000/- incurred there for was indemnified by the insurer under the subject insurance policy through NEFT to the SBI A/C of the complainant . Later on the wife of the complainant undergone spine surgery as indoor patient in Shri Ganga Ram Hospital New Delhi for which he has incurred more than Rs.5,00,000/- and on being asked the OP insurer had denied cashless treatment however, assured for reimbursement of medical expenditure as per the term of the policy which caused him mental harassment & financial burden . The complainant somehow manage to arranged the required medical expenditure of more than Rs. 5,00,000 for his insured wife. She got discharge on dt. 12.07.2022. After getting discharge of his wife ,the complainant lodged claim before the OP/ insurance company for reimbursement of the medical expenditure sustained for the treatment of his insured wife. Unfortunately the OP Insurer has repudiated his claim vide repudiation letter dt.5.8.2022 on the ground of non disclosure of material fact DM during purchasing of the policy and for suppression of exists history of diabetes for last 15 years 7 HTM for last 10 years so also vide letter dt.5.8.2023 the OP insurer has cancelled the subject insurance policy w.e.f. 6.9.2022 due to non disclosure of PED without refund of premium amount .Hence, this complaint.
- To substantiate his claim the complainant has filed the documents vide Sl.No.1 to 33 as per list of document there with the complaint petition. The averment of complaint petition is also supported by an affidavit of the complainant.
- On being notice the Ops appeared through their learned counsel Shri D.R. Bohidar and filed their written version challenging the maintainability of this complaint stating therein that, there is no cause of action to bring this complaint against the Ops. However, the Op Insurance Company has not disputed the valid insurance policy as on the date of medical treatment under gone by the insured wife of the complainant. The Op/insurance Company also not disputed the treatment of the wife of the complainant as well as expenditure incurred in this respect. The Op /Insurance compny has claim that they have rightly repudiate the insurance claim of the complainant on the ground of disclosure of material fact DM during purchasing of the policy and for suppression of exists history of diabetes for last 15 years 7 HTM for last 10 years so also vide letter dt.5.8.2023 the OP insurer has rightly cancelled the subject insurance policy w.e.f. 6.9.2022 due to non disclosure of PED without refund of premium amount. The Ops urged that, the complainant is not entitle for any relief as claimed and this complaint is liable to be dismissed with cost ..
- The Ops to substantiate his claim has filed the documents vide Annexure-A,B,C,D,E,G with their written version. The averment of the written version is also supported by one Avik Ghosh, the Manager, Legal Claim ,HDFC EGRO General Insurance Company Ltd.
- Both the parties filed their evidence on affidavit as prescribed under C.P.Act, contains of which are corroborated with their respective pleadings.
- Heard. Perused the material available on record. We have our thoughtful consideration on the submission of the rival parties. So also we have our thoughtful consideration on the argument placed by learned counsel for both parties.
- Here in this case insurance as well as treatment of the insured wife of the complainant during insurance period is not disputed. So also it is not disputed that, the complainant has incurred heavy expenditure for the treatment of his wife .The Insurer has repudiated the claim of the complainant and also rejected the insurance policy from the date of its inception without returning paid premium on the ground of suppression of material facts i.e. “ existing history of Diabetes Mellitus for last 15 years and HTN for last 10 years prior to getting admitted for surgery & prior to policy inception date of subject insurance policy .Thus, onus lies on the Ops insurance company to prove their contention.
- The Op /insurance company has proved on affidavit evidence of Avik Ghosh, the Manager, Legal Claim ,HDFC EGRO General Insurance Company Ltd that, the documents Annexed therewith the written version are the true copy of the original which remain unchallenged .Accordingly we have taken those documents as evidence.
- It reveals from the undisputed document vide Annexure-E i.e the proposal form vide No. 2825 1007 9856 5500 000 ,period of insurance :- 09/06/2020 to 08/06/2021 that, the complainant /insured had answered to the question on pre existing disease of proposed insured as :-‘No’ .The undisputed document vide Annexure - 6 of the complaint petition & Annexure -D of the written version of the OP/insurer placed on the record is the OPD Case Paper there in the name of the insured Mrs.Mamata Agrawal vide UHR No. :- UDID-32498 dt. 28/06/2022 of the Queens NRI Hospital, Visakhapatnam clearly shows that, Mrs.Mamata Agrawal /the wife of the complainant was suffering from Diabetes Mellitus for last 15 years and HTN for last 10 years as on 28.06.2022 and those documents remain unchallenged which clearly proved the contention of the OP/insurance company that, the insured/complainant has suppressed the existing disease while purchasing subject insurance policy.
- Law is well settled that, the proposer is duty bound to disclosed all material fact asked for assessing the risk in true & prudent manner and that ,availing any insurance policy suppressing the material facts /pre-existing diseases certainly went against the fundamental principle of “utmost good faith” there in insurance contracts and the policy so obtained is to be void and the insured/complainant is not entitled for any insurance benefit rather premium paid thereon shall be forfeited to the insurance company .
- Based on above findings, we are of the opinion that, the OP Insurance Company has rightly repudiated the insurance claim of the complainant under the subject insurance policy and also there is nothing arbitral on forgetting of the premium paid as per the term of the policy. No deficient service & unfair trade practice is found there on the part of the op/Insurance company.
- We found no merit on this complaint and the complainant is not entitling for any relief as prayed for. Hence, it is ordered.
ORDER This consumer complaint has no merits, hence dismissed on contest against the Ops. However, no order as to costs. Pending application if any is also stands disposed of accordingly. Dictated and corrected by me. President I agree. Member Pronounced in open Commission today on this 20th day of March 2024, under the seal and signature of this Commission. The pending application if any is also disposed off accordingly. Free copy of this order be supplied to the parties for their perusal or party may download the same from the Confonet be treated as copy served to the parties. Complaint is disposed of accordingly. | |