Haryana

Ambala

CC/66/2019

Smt Rajni - Complainant(s)

Versus

HDFC ERGO Gen Inss Co Ltd - Opp.Party(s)

In Person

08 Mar 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case No.:   66 of 2019.

                                                          Date of Institution           :   05.03.2019.

                                                          Date of decision     :   08.03.2021.

 

Smt. Rajni wife of Shri Rakesh Kumar, resident of House No.52, Kamal Nagar, Industrial Area, Ambala Cantt.

……. Complainant.

                                                Versus

 

1. HDFC EGRO General Insurance Co. Ltd. Head Office, 5^th Floor, Toer 1, Stellar IT Park, C-25, Sector-62, NOIDA-201301, through its Regional Manager.
2. HDFC EGRO General Insurance Company Ltd. Manager Branch Office at HDFC Bank Ltd. Ward No.1 Naraingarh, near Milk Plant, IFSC HDFC0001342, District Ambala, Haryana..

     ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Complainant in person.

Shri Mohinder Bindal, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President.

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay Rs.12,462/- (i.e. claim amount) to the complainant alongwith interest from the date of submission of claim till realisation.
2. To pay Rs.50,000/- as compensation for the mental agony and physical harassment suffered by the him.
3. To pay Rs.11,000/- as litigation charges.
382.  

Any other relief which this Hon’ble Commission may deem fit.

 

 

                   Brief facts of the case are that the complainant is a holder of combined insurance policy alongwith her husband Shri Rakesh Kumar and daughter Aastha, issued by the Insurance Company vide policy No.2866201782184501 having validity upto 24.05.2019, covering risk upto Rs.5,00,000/-. The daughter of complainant fell ill and took treatment from various doctors and she was also admitted in Aarogyam Hospital, HUDA, Sector-18, Jagadhri Road, for the period from 20.07.2018 to 22.07.2018. and had incurred an amount of Rs.12,462/- for the treatment of her daughter. She lodged the claim with the OPs as per the terms and conditions of the insurance policy for reimbursement of the expenses incurred by her on the treatment of her daughter. On 24.08.2018, complainant completed all the requisite formalities and submitted her claim of Rs.12,462/- through courier, which was duly received by the office of OP. The officials of the OP assured the complainant that claim amount will be paid to her shortly. Vide letter dated 08.09.2018, the officials of OPs told the complainant to furnish some additional papers/information, which were duly supplied to the OPs. The OPs despite of receiving the required information/papers form the complainant, refused to pass the claim amount of Rs.12,462/- with the reasons best known to them. As per the terms and conditions of the insurance policy, the OPs are legally bound to pay the claim amount. Before issuing the insurance policy, the representative of the OPs, allured the complainant and his other family members that this is the best policy and all family members are covered with the risk of Rs.5,00,000/-. However, complainant was surprised to know that the OPs have refused to pay the claim amount, which she has actually spent on treatment of her daughter. She requested the OPs several time to pay the claim amount, but the officials of the OPs did not pay any heed to the genuine request of the complainant. Complainant also served a legal notice upon the OPs, but of no avail. By not paying the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.

2.                 Upon notice, OPs No.1 and 2 appeared through counsel and filed written version, raising preliminary objections regarding cause of action, estoppal and locus-standi etc. On merits, it is stated that, complaint pertains to Insurance claim under Health Medisure Super Top up having insurance policy No.2866201782184501000 valid from 25.05.2018 to 24.05.2019, subject to terms and conditions of the policy. Daughter of the complainant fell sick and was hospitalized for the period from 20.07.2018 to 22.07.2018. She was having pain & vomiting and was diagnosed with acute or chronic gastritis. After the getting discharged from the hospital, complainant lodged a claim with the OPs, seeking reimbursement of the expenditure incurred during the said hospitalization. It is further stated that the claim was lodged under the said policy for reimbursement of Rs.12,462/-, which was less than the chosen deductable amount i.e. Rs.5,00,000/-, as such as per the terms and conditions of the policy, the claim amount is not payable to the complainant. Rest of the allegations levelled by the complainant were denied for lack of knowledge and prayer has been made for dismissal of the present complaint.

3.                Complainant tendered her affidavit as Annexure CA alongwith documents as Annexure C-1 to C-25 and closed the evidence. On the other hand, learned counsel for OPs tendered affidavit of Shri Shweta Pokhriyal, Assistant Manager-Legal, HDFC ERGO General Insurance Company Ltd., Noida, as Annexure OP-A alongwith documents Annexure OP1 and OP2 and closed the evidence on behalf of OPs.

4.                We have heard the complainant and learned counsel of the OPs and carefully gone through the case file.

5.                Ld. counsel for the complainant has submitted that that his duly insured daughter of the complainant namely Aastha fell ill and took treatment from Aarogyam Hospital, HUDA, Sector-18, Jagadhri Road, where she was hospitalised for the period from 20.07.2018 to 22.07.2018 and incurred medical expenses of Rs.12,462/-. The claim was lodged with the OPs, but they refused to pay the said amount. By denying to pay the medical expenses incurred on the treatment of the daughter of the complainant, the OPs have committed deficiency in service.

                   The Ld. counsel for the OPs submitted that the claim was lodged under the health medisure super top up insurance policy. It is a policy, which offers coverage of medi-claim above the chosen deductible limit along with extra ordinary features. It offers financial relaxation in the event, when the hospitalization claim bill crosses the sum assured under any other medi-claim policy. It acts as a cushion and comes into action, when one has exhausted the choosen limit. In the present case, allegedly complainant has spent Rs.12,462/- for treatment of her daughter. Since, the amount spent on the treatment of the daughter of the complainant is less than the choosen deductible limits i.e. Rs.5,00,000, therefore claim is not payable.

                   From the perusal of the policy document Annexure C23/OP1, it is evident that it is a Medisure Super Top Up Insurance Policy. Under this policy Mr. Rakesh Kumar, Rajni Rakesh Kumar (wife) and Aastha Rakesh Kumar (daughter) were duly insured for a period from 23.05.2018 to 24.05.2019, for a sum of Rs.5 lacs having deductible amount of Rs.5 lacs. It is not disputed that the daughter of the complainant was hospitalised for the period from 20.07.2018 to 22.07.2018 and an amount of Rs.12,462/- was incurred on her treatment. However, the OPs refused to pay the said amount. It may be stated here that parties are bound by the terms and conditions of the policy. In Section A: Preamble of the terms and conditions of the Policy Annexure OP2, it is clearly stated that ‘ If during the Policy Period, you suffer from any illness or accident which requires Hospitalization as an inpatient, we will reimburse the amount of such Medical Expenses as per the benefits given under Section C-Scope of Covers, in excess of Aggregate Deductible and subject to a maximum of the Sum Insured as stated in the Schedule’. Since, the amount spent on the treatment of the daughter of the complainant was less then the choosen deductible limit, which is Rs.5,00,000/-, therefore as per terms and conditions of the policy it is not payable. Be that as it may, we do not find any merits in the present complaint, consequently we dismiss the same against the OPs.

6.                In view of the aforesaid discussion, we hereby dismiss the present complaint being devoid on merit. The parties are left to bear their own cost. Certified copy of this order be supplied to the complainant, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :08.03.2021.

 

          (Vinod Kumar Sharma)            (Ruby Sharma)               (Neena Sandhu)

          Member                                    Member                          President