DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (CENTRAL) ISBT KASHMERE GATE DELHI
CC/198/2018
No. DF/ Central/
Mahamaya Roy Bhowmik,
W/o Late Sh. Santi Bhaumik,
R/o H. No. – 4 B/24 (Third Floor),
Old Rajinder Nagar, New Delhi - 110060
.....Complainant
VERSUS
1. MD & CEO, HDFC ERGO General Insurance Company Ltd.,
1st Floor, 165-166, Backbay Reclamation, HT Parekh Marg,
Church Gate, Mumbai – 400020
2. CEO, Policy Bazaar Insurance Web Aggregator Private Limited,
Ground Floor, 119, Sector – 44, Gurgaon – 122001, Haryana
…..Opposite Parties
Coram: Ms. Rekha Rani, President
Sh. R.C. Meena, Member
ORDER
Shri R.C. Meena, Member
1. Complainant had filed the instant complaint under Consumer Protection Act 1986 wherein complainant has stated that she had taken a health insurance policy named Health Medisure Classic Policy Number: 2864100295472500000 and Transaction Number: LH1803004191 from HDFC Ergo Insurance Company Ltd., through Policy Bazar.com Online mode by paying premium advance Rs. 13164/- and policy was issued on 30/03/2018 and policy term started from 01/04/2018 to 31/03/2018 midnight. Before issuing the policy, the insurance company had conducted a detailed medical checkup of the complainant and imposed a loading charge for Diabetic of Rs. 1014/-. The HDFC ERGO has issued a policy bond with term and conditions by mentioning that “No benefit shall be payable to Mahamaya Roy Bhowmik under this policy in respect of medical expenses being incurred arising directly or indirectly due to diabetes including investigations, treatment or direct
complication thereof for a period of first 3 continuous years from the date of risk of commencement’’. During the taking of policy, the complainant was not explained by Policy Bazar agent or HDFC Ergo Agent about any special condition of not giving benefits within one month or policy issuing or not giving benefit for ACUTE PANCREATITIS for two years. No such condition mentioned in the complainant policy bond also. It is pertinent to mention that complainant is a senior citizen of the age of 62 years having a pension for her survival and financially not so sound. She had a sudden pain in her upper abdomen on 18/04/2018 at 2: AM and the complainant were admitted to PGIMS Rohtak but on 19/04/2018 the Doctor has discharged her by referring to an urgent operation due to ACUTE PANCREATITIS AND Gall Bladder Stone. The complainant’s condition was life-threatening and she was admitted to BLK Hospital, Pusa Road. It was the panel hospital for HDFC ERGO. Then the doctor has treated the complainant urgently and send her claim to HDFC ERGO. The HDFC ERGO has sought queries from BLK Hospital which was duly replied to by the BLK Hospital but the HDFC ERGO has declined her claim on the following conditions –
‘‘As per the submitted documents, the patient was admitted on 19/04/2018 with the diagnosis of Actual Pancreatitis.As per Section 9.A. ii, an of policy, a waiting period of 2 years is applicable for the said ailment. As the date of inception of the policy is 01.04.2018, the policy is in the first year. Hence the claim the repudiated under the above-mentioned section of the policy terms and conditions. Also as the hospitalization falls within the first 30 days from the inception of the policy, the claim is being repudiated under section 9 A I which states that a general waiting period of 30 days is applicable for all claims payable under the policy except those arising due to accident.’’
2. During that time complainant was in critical condition and the doctor put her in INTENSIVE CARE UNIT (ICU) and later on, she was operated on and under constant observation as it was a life-threatening condition and she had to continue her treatment at BLK Hospital, Pusa Road as she had no other option due my critical condition. She was discharged on 27/04/2018 and she had to pay the bill of Rs. 327184/- plus Rs. 15500/- as an ambulance charge from BLK Hospital to PGIMS Rohtak.
3. Complainant has however submitted that policy Bazar/ HDFC Ergo issued Insurance not informed that up to one month of issuing policy no claim will be considered neither she was informed that up to 2 years of issuing policy no claim will be considered for acute pain. The complainant stated that his policy was issued if a complete medical checkup by a panel of doctors with an extra charge of Rs. 1014/- for diabetes. The HDFC Ergo has repudiated her claim arbitrarily without considering the medical representations and documents and hence the complainant prayed in that:
Neither Policy Bazar nor HDFC Ergo has informed about no claim will be considered within one month of issuing policy and in order to claim will be considered up to 2 years of issuing the policy. Neither 2 years of issuing policy no claim will be considered for acute pancreatitis. The complainant had prayed that Forum may issue an order for a refund of Rs. 3 lacs as the medical cost along with compensation of 2 lacs for physical mental and financial suffering.
4. OP in his written statement in para 1 to 13 stated that of the grounds of denial of policy. A complainant with full consciousness and after going through details of the policy including its terms and conditions as available in the website was chosen to avail this policy. Policy conditions are available on the web site and after availing the policy clearly states that a general waiting period of 30 days is applicable for all claims payable under this policy.
5. It is denied that the complainant was not informed by the Policy Bazar agent/ HDFC as the policy was issued online through the policy Bazar website portal. The policy was issued as per the proposal form filled by the complainant through the internet. The complainant, with full consciousness and after going through the details of the policy including its terms and condition as available on the website has chosen to avail of this policy. Thus, it is vehemently denied that during talking about the policy, she was not explained and informed about the conditions. The policy conditions are available on the website and after evaluating the benefits the customer chose to avail of the policy online. The policy was issued along with policy wording. In the policy conditions, it is clearly mentioned that a general waiting period of 30 days
applicable for all claims payable under the policy except those arising due to accidents. The rest of the para is wrong and denied except that a pre-authorization was denied by the respondent received from BLK Hospital. It is denied that the complainant had paid a sum of Rs. 3,27,184/- plus Rs. 15500/- as ambulance charges as alleged. OP has further stated in his written statement.
1. That the contents of the Para 1 of the grounds are wrong and denied. The complainant, with full consciousness and after going through the details of the policy including its terms and conditions as available on the web site has chosen to avail of this policy. Thus, it is vehemently denied that during taking the policy she was not explained and informed about the conditions. The policy conditions are available on the website and after evaluating the benefits the customer chose to avail of the policy online. Though a valid policy was issued on 01.04.2018 but the liability, if any, was always subject to the policy wording.
2. That the contents of Para 2 of the grounds are wrong and denied. It is denied that the complainant was not informed by the policy Bazar agent or HDFC ERGO that up to one month of issuing policy no claim will be considered as alleged. The rest of the para is wrong and denied. As stated above under the policy it is clearly mentioned that a general waiting period of 30 days is applicable for all claims payable under the policy except those arising due to accident. It is to mention here that the policy wording is always a part and parcel of the policy schedule.
3. That the contents of Para 3 of the grounds are wrong and denied. It is denied that the complainant was not informed by the policy bazaar agent or HDFC ERGO that up to two years of issuing policy no claim will be considered for acute pancreatitis and gall bladder stone as alleged. The rest of the para is wrong and denied.
As the policy was issued online, therefore, the question of medical check-up does not arise. The policy was issued as per the proposal form submitted by the complainant online.
Both the parties have filed their affidavit of evidence, written arguments, and heard oral arguments of both the parties during on line hearing.
6. Complainant had purchased an online health insurance policy after taking into consideration all the terms and conditions of the insurance policy. The HDFC Ergo (OP) has placed on record the insurance policy which has exclusion clause no. (d) (i) and (ii) which are as mentioned below:
‘‘1. All pre-existing diseases/illness/injury/ conditions as defined in the policy until 36 months of continuous covers have elapsed since inception of the first policy with us.
2. Any disease contracted and /or medical expenses incurred in respect of any disease/ illness by the insured/ Insured Person during the first 30 days from the commencement date of the Policy except in case of accidental injuries. This exclusion doesn’t apply for insured/Person having any health insurance indemnity policy in India at least for 1 year prior to taking this Policy as well as for subsequent renewals with the Company without a break.’’
7. The claimant had purchased Insurance Policy on 31.03.2018 for the period of 01.04.2018 to 31.03.2019. The claimant had submitted her claim before the OP for the period of illness from 18 April 2018 to 27 April 2018.
8. In view of the above discussion we are of the opinion that the repudiation of the claim of the complainant by the OP is justified under the exclusion clause of a general waiting period of 30 days under the policy and the complaint is dismissed. Copy of this order is sent to the parties. File be consigned to record room.
Announced this 26th Day ofOctober2020.
