DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA

Received by way of transfer Consumer Complaint No.120 of 2018

                                            Date of institution: 21.02.2018

                                            Date of Decision:16.08.2022

1. Shobin Dawar son of Shri Rajinder Dawar
2. Smt. Kamlesh Dawar wife of Shri Rajinder Dawar

Both resident of 268-C, New Kitchlu Nagar, Ludhiana

…….Complainants

Versus

1. HDFC Ergo General Insurance Company Limited, Registered & Corporate Office: Ist Floor, 165-166, Backbay Reclamation, HT Parekh Marg, Churchgate, Mumbai-400 020
2. HDFC Ergo General Insurance Company Limited, 5^th Floor, Surya Tower, 88, Mall Road, Ludhiana through its Manager.                                                 ……..Opposite Parties

 QUORUM:   

   HON’BLE MR. RANJIT SINGH, PRESIDENT.

                  HON’BLE MRS. RANVIR KAUR, MEMBER

PRESENT:

Sh. Paramjit Singh Bal, Adv. counsel for complainant

Sh. Vyom Bansal, Adv. For OPs

ORDER

RANJIT SINGH, PRESIDENT

1. The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Party on the ground that the complainant No.1 is having saving account in HDFC Bank Limited, Mata Rani Chowk, Ludhiana. HDFC Bank Limited lateron issued a Credit Card No.4893771601710732 to the complainant No.1 by seeing his performance of his account. In the year 2014, a telephonic call was received from the executive of opposite parties and on his allurement, the complainant No.1 was convinced to get health insurance and accident policy and believing upon representations of the execution of opposite parties, complainant No.1 agreed for it and as such the opposite parties issued health Suraksha Policy as well as Sarv Suraksh Policy- Personal accident policy in the name of complainant No.1. The complainant No.1 paid Rs.14916/- as premium  for these policies and these policies were effective from 11.07.2014 to 10.07.2015.  The opposite party renewed the policies for next period from 11.7.2015 to 10.07.2016. The complainant No.1 or complainant No.2 never got any claim benefit for these insurance policies. The Opposite parties issued a health card in the name of the complainant No.1 as well as his mother Smt. Kamlesh to present the same to the hospital for getting insurance benefit as it is a cashless policy. Thus, the complainants are consumers as defined under the provisions of Consumer Protection Act. On 30.05.2016, the complainant No.2 suffered a heart attack and she was admitted in CMC and Hospital, Ludhiana, and complainant No.1 applied for cashless treatment being his policy as cashless policy, however, the opposite parties raised objection that there is non disclosure of material facts at the time of taking the policy (patient had history of hypertension since last 15 years all before policy inception) and as such the cashless facility cannot be accorded under 10-R ii of policy terms and conditions. Then the complainants intimated the opposite parties that the complainant No.1 has disclosed about this disease in the policy documents and then the opposite parties asked the complainant No.1 to get treatment of his mother and to make the payment and thereafter to apply for medical reimbursement from the opposite parties. As such, the complainant No.1 paid the entire treatment expenses from his own pocket i.e. a sum of Rs.2,37,206/- vide bill dated 07.06.2016. Beside this, the complainant No.1 also incurred expenses for the purchase of medicines and total amount of Rs.2,53,000/- was spent by the complainant No.1 on the total treatment of his mother, which is also payable by the opposite parties as per terms and conditions of the policy. The complainants lodged the claim with the opposite parties for the above said amount immediately thereafter. However, the opposite parties always assured the complainants that the matter is under process and as such the opposite parties continuously delayed the matter on one pretext or the other. Hence, this complaint. It is, therefore, prayed that the complaint may kindly be accepted and to pay the amount of Rs.2,53,000/- to the complainant to compensate the complainant to the tune of Rs.1,00,000/- plus Rs.60,000/- and litigation expenses of Rs.20,000/-. 

2. In reply, the OPs No.1 & 2 have filed written reply stating therein that the claim of the complainant was repudiated on the ground of pre existing disease and non disclosure of material facts under the policy conditions. The complainant has concealed the true and material facts from this Court. There is history of hypertension for the last 15 years. The complainant intentionally did not disclose the fact of pre existing disease at the time of procuring policy from the opposite party. Present complaint is any form is not maintainable before this forum. There is no cause of action arose to the complainant within the territorial jurisdiction of this court. The complainant had a duty of disclose of information related to all kinds of pre existing disease i.e. hypertension which the applicant had prior to commencement of the policy. Rest of allegations made against the complainant have been denied and prayed for dismissal the complaint.

3.     In support of the complaint, the complainant has tendered various documents. On the other hand, the OPs also tendered certain documents in support of their version.

4.     We have heard the learned counsel for the parties and have gone through the record of the file, carefully.

5.     After perusing the file, we feel hypertension is not a disease. So, the complainant is entitled for the claim prayed for. The OPS are directed to pay the amount of Rs. 2,53,000/- to the complainant along with interest @ 7% per annum. The complainant is also entitled a compensation to the tune of Rs. 25,000/- along with Rs.11,000/- as litigation expenses. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

August 16, 2022

(Ranjit Singh)

(Ranvir Kaur)

RBT/ CC No.120 of 2018

Present:    Sh. Paramjit Singh Bal, Adv. counsel for complainant

               Sh. Vyom Bansal, Adv. For OPs

Vide our separate detailed order of today, the complaint stands allowed. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the Record Room.

August,16 2022

(Ranjit Singh)

(Ranvir Kaur)