Delhi

East Delhi

CC/200/2015

SAUMAN BOSE - Complainant(s)

Versus

HDFC ERGO GEN. INS. - Opp.Party(s)

06 Oct 2015

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, SAINI ENCLAVE, DELHI-92

 

CC No.200/2015:

In the Matter of:

Sh.Saumen Bose

S/o. Sh. Amitabha Bose

Flat No. 398,Pocket D,

Dilshad Garden,

Delhi – 110 095

            Complainant

Vs

 

 

HDFC Ergo General Insurance Co. Ltd.

(Through its Manager)

Ground Floor, Eros Tower,

Nehru Place,

New Delhi - 110 019

•  

 

     

                                                                                               Date of Admission -24/03/2015            Date of Order          -01/01/2016

 

O R D E R

 

Poonam Malhotra, Member :

 

This complaint has been filed with the allegation that the complainant had purchased a Health Suraksha Policy from the respondent bearing Policy No.2952 2008 8130 7400 000 showing first inception policy as 08/11/2012.  On 12/11/2014 while playing daughter of the complainant collapsed suddenly after complaining of severe headache and vomiting and became unconscious.  She was immediately taken to the Red Cross Hospital and thereafter to Max Super Speciality Hospital where she was diagnosed to be suffering from Right Middle Cerebral Artery Bleed (Aneursymal) and was treated from 13/11/2014 to 04/12/2014 and a bill of Rs.6,96,205.81 was raised by the hospital.  Out of the said bill, Corporate Health Insurance paid Rs.3,00,000/- and the complainant was left to pay the balance amount of Rs.3,96,205.81 as claim of the complainant was repudiated by the respondent on the ground that the waiting period of 30 days have not been completed from the date of policy.It is alleged that the waiting period of 30 days is not applicable to the present case as the daughter of the complainant had suffered injury by banging her head on a wall while playing and the policy had been in continuance since 08/11/2012.  Again on 19/12/2014 the daughter of the complainant was hospitalized in Fortis Hospital and a bill of Rs.33,881.79 was raised.  A claim was lodged with the respondent for the reimbursement of Rs.33,881.79 raised by and Rs.32,292.41 were paid to him and the balance Rs.1,589.38 were not paid. The Cerebral Bone Flap of the daughter of the complainant had been kept open/ removed after previous surgery and she was admitted to Max Super Speciality Hospital on 25/12/2104 for Cranioplasty (Replacement of Bone Flap). She was discharged on 29/12/2014 from the Max Hospital and a bill of Rs.1,60,696.83 was raised by it.  The subsequent claim of the complainant was also repudiated vide letter dated 03/02/2015 holding that the injury of daughter of the complainant was suffering from Congenital Internal Disease and waiting period of two years was applicable in such cases.  It is alleged that the respondent had repudiated the claim despite the certificate of the treating doctor that she was a case of CVA (Cerebro Vascular Accident).  The complainant has prayed for payment of Rs.5,56,903.64 with 24% p.a. interest from the date of the respective claims till the date of actual payment.  She has also prayed for compensation of Rs.1,00,000/- for harassment & agony and Rs.1,00,000/- as the litigation cost.

In response to the notice issued to the respondent it appeared and filed its written statement wherein it has admitted the fact of issuance of the Health Suraksha Policy for a sum of Rs.3,00,000/- valid for the period 08/11/2014 to 07/11/2015 to the complainant Sh. Saumen Bose, Alimpia Bose, Olivia Bose & Saunak Bose. It is also submitted that out of Rs.3,00,000/- , the total sum assured, Rs.32,292.41 has been paid to the complainant against his claim for the hospitalization of his daughter on 19/12/2014 in Fortis Hospital.  It has taken the pleas of territorial jurisdiction, concealment of material facts on the part of the complainant, this matter is exclusively triable by a civil court.It has also pleaded that the complainant is not a consumer under the The Consumer Protection Act, 1986.  It is further contended that the claim with regard to the treatment at Max Hospital was repudiated vide letter dated 05/01/2015 as the daughter of the complainant was admitted into hospital just five days after the issuance of the policy for the treatment of AV Malformations which is a Congenital InternalDefect for which there is a waiting period of two years and this fact was duly intimated to the complainant.Rest all of the allegations have been denied.

Evidence by way of Affidavit filed by the parties in support of their respective cases.

Heard & perused the record.

A short question which arises for adjudication is whether the respondent is justified in repudiating the claims of the complainant or not?  This fact is not in dispute that the daughter of the complainant was insured with the respondent alongwith the other family members under the Family Floater Health Suraksha Policy SILVER PLAN vide Policy No.2952 2008 8130 7400 000 for the period 08/11/2014 to 07/11/2015 for a sum of Rs.3,00,000/-.  It is also not in dispute that the complainant had made three claims to the respondent under the said policy of insurance with regard to the treatment & hospitalization of his daughter firstly from 13/11/2014 to 04/12/2014, secondly from 19/12/2014 to 20/12/2014 and thirdly for the period from 25/12/2014 to 29/12/2014 and all the said three claims fell within the period of insurance from 08/11/2014 to 07/11/2015.  It is also evident from the record that the respondent had repudiated two out of the three claims made by the complainant. The first claim was repudiated vide its Repudiation Letter dated 05/01/2015 on the ground that since the date of issuance of the policy is 08/11/2014, the 30 days waiting period is applicable to the said claim. Hence, in view of Section 9A(i) of the Policy terms & conditions, it had repudiated the first claim of the complainant.  The second claim of the complainant of Rs.33,881.79/- was allowed to the extent of Rs.32,292.41/- after deducting Rs.1,589.38/- in all on account of Admission Charges (Rs.1,000/-), Documentation Charges (Rs.250/-) and Food & Beverages (Rs.339.38/-) with regard to the hospitalization  & treatment of his daughter at the Fortis Memorial Research Institute for the period 19/12/2014 to 20/12/2014.  The third claim of the complainant was repudiated vide its Repudiation Letter dated 03/02/2015 on the ground that since the cause of illness of the daughter of the complainant is AV Malformations which is a Congenital Internal Defect for which there is a waiting period of two years and the date of inception of the first insurance policy is 08/11/2014, in view of Policy Clause No.9.A.ii.a, the claim made by the complainant is, thus, repudiated.

In the present complaint, firstly without going into the aetiology of the illness of the daughter of the complainant, on bare perusal of the copy of the said policy filed on record as Annexure C-1 which is Paper 6 of the complaint it is evident that the date of 1^st Policy Inception is 08/11/2012 and not 08/11/2014 as taken by the respondent while repudiating the claims of the complainant.  Further, it is mentioned in the said policy that the insured had also earned a Cumulative Bonus of Rs.20,000/-.  Had the date of inception of the first policy been 08/11/2014 the question of cumulative bonus would not have arisen.  This shows that insured person had been insured under a Health Suraksha Policy continuously and without any break in the previous year since 08/11/2012.  Further, it is not the case of the respondent that the date of first inception of the policy is not 08/11/2012.  It is an admitted fact that the policy in question, copy of which is filed on record as Annexure C – 1 to the present complaint and has been exhibited by the respondent alongwith its affidavit in evidence as Ex.RW-1/1, has been issued by it.  Taking all these facts into consideration, there is no room for doubt that the date of first inception of the policy was 08/11/2012 and not 08/11/2014 as alleged by the respondent and it had been renewed continuously & without any break since 08/11/2012.  As such the repudiation of the first claim by the respondent is unjustified & arbitrary. The other query which needs to be decided is whether the daughter of the complainant suffered from CVA (Cerebro Vascular Accident) on 13/11/2014 or she was suffering fromCongenital Internal Defect, AV Malformations, the ground taken by the respondent while repudiating the third claim of the complainant pertaining to the period 25/12/2014 to 29/12/2014. It is evident from the reply given by the treating doctor to a query raised by the TPA of the Insurance Company filed on record by the complainant, as Paper 21 which is Annexure C -10 of the complaint, whereinthe treating doctor has categorically stated that the patient, Olivia Bose, suffered from CVA (Cerebro Vascular Accident) on 13/11 for which decompressed craniectomy was done & Bone Flap removed which was replaced on 26^th December, 2014 (Cranioplasty).  The said reply given by Dr.Sanjeev Dua to the query raised by the TPA is further authenticated by the contents of the Discharge Summary of Max Super Speciality Hospital with Date of Discharge 29/12/2014 filed on record by the complainant as Annexure C – 6, Papers 15 to 17 wherein under the heads “Past History” & “Procedure Performed” these facts have been specifically mentioned.  Also, though the respondent has not controverted the Treating Doctor’s reply to the query raised by the TPA of the respondent but it has turned a blind eye to the said reply and did not take it into account  while repudiating the said claim of the complainant.  In the Discharge Summary of the Max Hospital with Date of Discharge 04/12/2014 under the heads “History of Present Illness” and “Past History” it is mentioned that the present illness of the patient was since 13/11/14 and she had no significant past history respectively.All the above facts leave no room for doubt that the daughter of the complainant was suffering from CVA (Cerebro Vascular Accident) and not from Congenital Internal Defect as asserted by the respondent.  Since it is an accident case and the daughter of the complainant had been insured under a Health Suraksha Policy continuously and without break since 08/11/2012, it is clearly covered by Section 6 a. “Exclusions – Waiting Period”of the Policy Wording that if any insured person suffers an accident the insurance company shall be liable to reimburse the cost of his treatment and the waiting periods clause shall not be applicable in such cases. The respondent has blatantly erred in repudiating the claims of the complainant on the said grounds under the policy when the date of first inception of the policy is 08/11/2012.  The repudiation of the claims of the complainant by the respondent is wholly arbitrary and unjustified. 

It is highly astonishing that from 13/11/2014 to 29/12/2014 when the daughter of the complainant was hospitalized thrice for the same illness, the respondent had not repudiated the first claim of the complainant on the ground that his daughter was suffering from a Congenital Internal Defect & had further allowed his second claim of the complainant of Rs.32,292.41 for the treatment of his daughter for the same ailment with regard to her hospitalization at the Fortis Memorial Research Institute for the period 19/12/2014 to 20/12/2014 but has repudiated the subsequent third claim made by the complainant with regard to her hospitalization at Max Super Speciality Hospitalfor further treatment from 25/12/2014 to 29/12/2014 on the ground that she was suffering from Congenital Internal Defect.  From the above observations, there is not a scintilla of doubt that the working of the respondent is prejudiced and against the interest of the people who approach them for taking policy of insurance.  They repudiate the claim of the insured, if made, on arbitrary grounds and thrust upon the insured unwanted litigation besides burdening the redressal system relating to consumer disputes. Working with an opinionated mind, the respondent erred to consider the fact that the claim/s of the Complainant could only be allowed by it to the extent of the sum insured under the policy.  The respondent was well within its rights to have restricted the claim of the complainant to the extent of the sum insured under the policy which is Rs. 3,00,000/- in the present case and disallowing the claim/s made beyond the sum insured under the policy instead of repudiating the claims on arbitrary grounds. 

 

In this era of corporate culture booming in medical profession the need for health insurance cover has become a necessity as well as a priority for one and all to meet the exorbitant medical treatment costs.  The private insurance companies in order to augment their business are taking to malpractices to entrap the simple citizens on the pretext of providing health insurance cover to them. They collect premium from the persons so insured and thereafter fleece them of their hard earned money by repudiating their genuine claims when madeby taking refuge of the Exclusion Clauses forming part of the Terms & Conditions of the Policy.  The Forums are receiving large number of such complaints in which the Officers and Officials of such insurance companies are repudiating the genuine claims of the insured persons on flippant grounds.These malpractices need to be taken care of by IRDA and other competent authorities besides the Government of India.  If need be the license of such insurance company, found indulging in unfair trade practice, should be terminated and they be prosecuted for defrauding the innocent customers under the guise of providing an insurance cover and later on repudiating their claims when made on facetious grounds. 

 

Taking into consideration the observations and discussion made supra, we arrive at an inference that the repudiation of the claims of the complainant by the respondent is wholly illegal and, thus, not tenable. Taking into consideration the facts that the total sum insured under the insurance policy in question is Rs.3,00,000/- for the period of insurance from 08/11/2014 to 07/11/2015 and the complainant had already been reimbursed to  the extent of Rs.32,292.41 for his second claim made by the complainant under this policy for the hospitalization of her daughter from 19/12/2014 to 20/12/2014,we allow this complaint and direct the respondent insurance company to reimburse to the complainant to the extent of Rs.2,67,708/- only as against Rs.5,56,903.64/- claimed by the complainant in his complaint.  We, further, award interest on Rs.2,67,708/- @ 9% p.a. from the date of filing of this complaint till the amount awarded supra is finally paid by the insurance company to the complainant.  Since the rejection in this case is found to be sheerly unjustified it has caused immense harassment, mental pain and agony to the complainant.  We award a compensation of Rs.30,000/-payable by the respondent to the complainant for the harassment meted by him and it shall also include the cost of the present litigation.  The respondent shall comply with the order within 45 days from the date of this order.  If the amount of compensation and cost so awarded is not paid within 45 days from the date of the order, the complainant shall also be entitled to interest @ 9% p.a. on the amount of compensation and cost so awarded from the date of this order till it is finally paid to the complainant.

Copies of the order be supplied to the parties as per rule.

 

 

(Poonam Malhotra)                                                                                                 (N.A.Zaidi)

Member                                                                                                         President