Haryana

Ambala

CC/328/2018

Kuldeep Singh - Complainant(s)

Versus

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

D.S.Punia

13 Jan 2020

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

 

                                                          Complaint case No.:  328 of 2018.

                                                          Date of Institution           :  08.10.2018.

                                                          Date of decision    :  13.01.2020.

 

Kuldeep Singh son of Jaipal aged 48 years through his wife Neelam daughter of Shri Ram Singh his next friend, resident of village Manakpur, Tehsil Bilaspur, District Yamuna Nagar.

 

Bank Account No.6394001700041139 PNB Branch Ledi Yamunanagar.

 

Aadhar Card No.8669-3685-4581 Kuldeep Singh

Aadhar Card No.7964-4509-6177 Neelam

 

                                                                                       …. Complainant.                                                   Versus

1.       HDFC ERGO General Insurance Company Ltd. Registered and         Corporate office: Ist Floor, 165-166 BackBay Reclamation, H.T.         Parekh Marg, Churchgate, Mumbai-400020 Through its Managing    Director.

 

2.       HDFC ERGO General Insurance Company Ltd., Manager Branch     Office at HDFC Bank Ltd. ward No.1 Naraingarh, near Milk plant,         IFSC-HDFC0001342 District Ambala, Haryana, agent code        201587086428.

 

               ..…. Opposite Parties

         

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Shri D.S. Punia, Advocate, Advocate, counsel for the                                  complainant.

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.4,00,000/-, as compensation as per the medical policy alongwith interest @ 24% per annum till its realization.  
2. To pay Rs.2,00,000/- on account of mental agony and physical harassment suffered by him alongwith litigation costs.
   382.  

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

 

The present complaint has been filed by Smt. Neelam, wife of Kuldeep Singh, who is in coma and unconscious due to the grievous head injury. Brief facts of the case are that the husband of the complainant had purchased one medical policy No.2828100242706600000 for a period of 16.10.2017 to 15.10.2018 for a sum assured of Rs.4,00,000/- from the OPs. On 27.02.2018, husband of the complainant met with an accident and received multiple injuries and fractures. Due to grievous head injury, husband of the complainant went into coma. He was admitted in Jawahar Lal Medical College Hospital, Aligarh (UP), then was shifted to PGI Chandigarh and thereafter to Fortis Hospital Mohali (Pb). Presently he is admitted in Gaba Hospital, Bye Pass Road Yamuna Nagar. She informed the OP No.2, about the treatment taken by her husband and it assured her to pay the medi-claim. Complainant had already spent a sum of Rs.5,00,000/- on the treatment of her husband. Gaba Hospital wrote to the OPs for payment of cashless claim, but the OP No.1 rejected the claim vide E-mail dated 21.03.2018, stating therein that the patient is known case of Coronary Artery Disease before the first inception of the policy, but the insured did not disclose the said fact while purchasing the policy. The complainant repeatedly requested the OPs to pay the claim amount, but they paid no heed to her legitimate requests. Hence, the present complaint.

2.                Upon notice, OPs appeared and filed written version, raising preliminary objections regarding maintainability; jurisdiction, not coming to this Hon’ble Forum with clean hands, concealment of true facts and no cause of action. On merits, it is stated that complainant procured the insurance policy in question for the period from 16.10.2017 to 15.10.2018 by concealing and suppressing the material facts about his pre-existing aliment. The insurance policy in question was issued subject to certain terms and conditions as per information provided by the complainant about his medical status. The complainant was legally duty bound to disclose each and every information and material facts about pre-existing ailment and about his health at the time of availing the policy and in this regard a proposal form was also submitted by the complainant with all his medical treatment. The complainant has withheld the relevant information as to how much amount they have received from the employer department by way of medical re-imbursement. As per treatment record it is quite clear that the insured was a known case of Coronary Artery Disease since, 2012. He was suffering from heart disease for the past 7 years i.e. prior to inception of the first medical insurance policy issued on 16.10.2017. Since, the insured has intentionally and deliberately concealed and suppressed the material facts about pre-existing ailment, to take illegal benefits of the policy, hence the claim was rightly and legally held not maintainable and payable as per exclusion clause 10 r ii. As such there is no deficiency in service on the part of the OPs. Therefore, the present complaint may be dismissed with costs.

3.                Ld. counsel for the complainant has tendered affidavit of  Neelam Rani wife of Kuldeep Singh, resident of village Manakpur, Tehsil Bilaspur, District Yamuna Nagar as Annexure CA alongwith documents as Annexure C-1 to C-158 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs has tendered affidavit of Jai Parkash, Authorized Signatory, HDFC ERGO, General Insurance Co. Ltd. Noida as Annexure OP1/A alongwith documents Annexure OP1/1 to OP1/3 and closed the evidence on behalf of the OPs.  

4.                We have heard the learned counsel for the parties and have carefully gone through the case file.

5.                Admittedly, Shri Kuldeep Singh was duly insured with the OPs for a sum assured of Rs.4,00,000/- under the medi-claim policy for the period from 16.10.2017 to 15.10.2018 vide Insurance Policy Annexure C-3. On 27.02.2018, he met with an accident and suffered grievous head injury, as a result whereof he went into coma. He took the treatment from the Gaba Hospital, and applied for cashless facility, but vide letter dated 21.03.2018, Annexure C-4 the OPs denied to provide the cashless facility by stating that the insured is a known case of Cornary Artery Disease, before the inception of the policy, but he did not disclose the ailment while purchasing the policy. Thus, the claim is being repudiated under Section 10(r)(ii) of policy terms and conditions.

Section 10(r) reads as under:-

Section 10 : General Conditions

               r : Termination

          i. You may terminate this policy at any time by giving us written notice. The cancellation shall be from the date of receipt of such written notice. If no claim has been made under the Policy, then We will refund premium in accordance with the table below:-

1 Year Policy Period		2 Year Policy Period
Length of time Policy in force	% of Premium refunded	Length of time Policy in force	% of premium refunded
Upto 1 month	75.00%	Upto 1 month	87.50%
Upto 3 months	50.00%	Upto 3 Months	75.00%
Upto 6 months	25.00%	Upto 6 months	62.50%
Exceeding 6 months	Nil	Upto 12 months	48.00%
		Upto 15 months	25.00%
		Upto 18 months	12.00%
		Exceeding 18 months	Nil

                   

          ii        We may terminate this Policy on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by You or any insured Person or anyone acting on your behalf or on behalf of an Insured Person. Such termination of the policy shall be from the inception date or the renewal date (as the case may be) upon 30 days notice and by sending an endorsement in this regard at Your address shown in the schedule without refund of any premium.    

                    Meaning, thereby the OPs terminated the policy in question. As per Section 10 (r) (ii) referred to above, it was incumbent upon the OPs to issue a 30 days notice to terminate the policy. However, no such document been placed on record by the OPs to prove that they have served the notice upon the insured. Furthermore, OPs have not placed on record the proposal form to show the declaration given by the insured about the status of his health. Even, otherwise no document has been placed on record by the OPs to prove that the insured was suffering from heart disease before the inception of the policy. In the absence of any documentary evidence, it can easily be inferred that the OPs have terminated the policy in question, in violation of Section 10(r). From the certificate issued by the GABA Hospital Annexure C-11, it is abundantly clear that insured Kuldeep Singh/husband of the complainant met with an accident and suffered head injury and is in coma. It may be stated here that no direct nexus or causation between the assured suffering from coronary artery disease and head injury sustained in an accident by outward, violent, visible means. Medical evidence on record is itself proof that insured went into coma due to head injury and not due to coronary artery disease. The Hon’ble National Commission, New Delhi, has dismissed the Revision Petition No.864 of 2018, in the case titled as Life Insurance Corporation of India Versus Jyotsana, by placing reliance upon the judgment passed by the Hon’ble Supreme Court in Civil Appeal No.8254 of 2015 in the case of Sulbha Prakash Motegaonkar & Ors. Versus Life Insurance Corporation of India, decided on 05.10.2015, wherein it is held that the death of the insured due to ischemic heart disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. Since, the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified. The facts of the present case are very much similar to the facts of the cases referred to above. In this view of the matter, we do not hesitate to conclude that OPs were wrong in terminating the policy in question and are thus liable to pay the sum assured of Rs.4,00,000/- under the policy in question, alongwith interest but are also liable to pay the compensation for the mental agony and physical harassment suffered by insured alongwith litigation expenses.

6.                In view of the aforesaid discussion, we hereby allow the present complaint and direct the OPs, in the following manner:-

1.           To pay Rs.4,00,000/- to the insured alongwith interest @         7% per        annum from the date of repudiation of the claim i.e. 21.03.2018          till its realization.
2.           To pay Rs.8,000/- as compensation for mental agony and        physical harassment suffered by the complainant alongwith         litigation expenses.

                   The OPs are further directed to comply with the aforesaid direction, within the period of 45 days from the date of receipt of the certified copy of this order, failing which the amount mentioned at serial No.(i) shall carry penal interest @ 9% per annum instead of @ 7% per annum and the amount mentioned at serial no.(ii) shall carry interest @ 9%  till its realization. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on: 13.01.2020.

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

              Member                                  Member             President