Punjab

Ludhiana

CC/20/205

Gurdeep Singh - Complainant(s)

Versus

HDFC Ergo General Ins.Co.Ltd - Opp.Party(s)

S.S.Bhatia

23 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:205 dated 29.09.2020.                                                        Date of decision: 23.02.2023.

 

Gurdeep Singh son of Shri Hardev Singh, resident of Village Kadiana Khurd, P.O. Kadiana Kalan, District Ludhiana.                                                                                                                                              ..…Complainant

                                                Versus

1. HDFC Ergo General Insurance Company Limited, 5^th Floor Tower, 1, Steller, IT Park, C-25, Sector 62, Noida.
2. HDFC Ergo General Insurance Company Limited, having its local office Surya Tower, 5^th Floor, 88, The Mall Road, Ludhiana.                                                                                                   …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. S.S. Batra, Advocate.

For OPs                         :         Sh. Vyom Bansal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant got himself medically insured from the opposite party under Health Suraksha Policy, Silver Plan bearing policy No.2952-2014-5291-8101-001 issued on 16.07.2018 having its validity from 25.07.2018 to 24.07.2020 midnight and had been making the premium of the said policy. The complainant submitted that suddenly he fell ill and was got admitted in Max City Hospital & Trauma Centre, Main Bahadur Ke Road, Opp.Khad Factory, Ludhiana on 30.06.2020 and spent Rs.95,457/- on his treatment and he was discharged on 08.07.2020. After his discharge, the complainant applied claim from the opposite party by submitting all the relevant documents. The complainant visited opposite parties time to time with request to settle and refund his medical expenses and also sent number of emails to refund the claim but they lingered on the matter and ultimately rejected the claim on 10.08.2020 by making the reason reproduced as under:-

“As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and condition, if any claim is any manner dishonest or fraudulent or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under section 10 j of policy terms and conditions.”

The complainant further submitted that he again approached the opposite parties with regard that they have wrongly repudiated his claim and the opposite parties told him to sought writing from the doctor to this effect that the said claim is genuine claim upon which the complainant got writing from Doctor of Max City Hospital &Trauma Centre in which he has written that bills receipts are genuine and correct. Then the complainant approached the opposite parties with request to refund the claim but they again flatly refused to return the same. The act and conduct of the opposite parties amounts to deficiency in service on their part which has caused mental tension, harassment and agony to the complainant. In the end, the complainant has prayed for issuing direction to the opposite party to settle the claim and refund the amount of Rs.95,457/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections assailed the complaint on the ground of lack of jurisdiction, suppression of material facts by the complainant, misrepresentation by the complainant etc. The opposite parties alleged that the claim of the complainant was repudiated on the ground of misrepresentation of the claim under policy conditions. The complainant and his family were firstly insured for the period of 25.07.2016 to 24.07.2018 and lastly the policy was renewed for the period 25.07.2018 to 24.07.2020 vide policy No.2952201452918101000 under the Health Suraksha Policy by the opposite parties for benefits mentioned in coverage details of the policy subject to conditions of exclusions of the policy wordings. The benefits under the policy are governed by the terms and conditions of the policy and the liability of the opposite party is limited to the insured perils occurring within the policy period subject to condition and exceptions as mentioned in the terms and conditions of the policy. The opposite parties further alleged that a reimbursement claim was lodged by the complainant vide claim form along with OPD slip, discharge summary, in-patient notes and final bill issued by Max City Hospital & Trauma Centre. Thereafter, deficiency letter dated 15.07.2020 was issued for the submission of necessary documents. As per the discharge summary, the insured was diagnosed with Thrombocytopenia with Typhoid fever, Acute Febrile Illness. However, as per the Widal Test, which is the test used to detect Typhoid Fever, the diagnosis does not match with the results of the Widal Test. The Widal test is positive if TO antigen titer is more than 1:160 in an active infection, or if TH antigen titer is more than 1:160 in past infection or in immunized persons. As per the Widal test report of the insured, TO antigen titer is less than 1:160 which clearly shows that the diagnosis is based on a false report. The opposite parties alleged that for the purpose of verification of the claim, a questionnaire for doctor was sent to Dr. Naveen Mathur who filled the same under his stamp and signatures and also issued a certificate dated 25.07.2020 stating that a sum of Rs.5000/- was added in the bill as per the request of the patient to cover up other expenses from insurance company. The opposite parties further alleged that upon receipt of the documents, their authorized officials applied their mind to the documents and came to the conclusion that the present was a case where the insured/complainant in connivance with the hospital is trying to extract money from the opposite party by misrepresenting his case. As such, the claim of the complainant was repudiated as per policy terms and intimation of the same was given to the complainant vide letter dated 10.08.2020 as the complainant was not entitled for the claim. As the claim was misrepresented as per the policy terms and conditions if any claim is in any manner dishonest or fraudulent or is supported by any dishonest or fraudulent means or devices whether by insured person or anyone acting on behalf of an insured person then the policy shall be void and all the benefits paid under it shall be forfeited and the claim was repudiated vide letter dated 10.08.2020. As per the policy terms and conditions the company is not liable to make any payment on account of any misrepresentation as per clause 10 j of the policy which reads as under:-

          “j. Fraud

If any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or device, whether by you or any insured person or anyone acting on behalf of you or an insured person, then this Policy shall be void and benefits paid under it shall be forfeited.”

Thus the policy is also liable to be cancelled and the opposite parties reserve their right to take all appropriate civil as well as criminal action against the complainant.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties admitted the factum of issuance of the policy for the period 25.07.2016 to 24.07.2018 and its subsequent renewals. The opposite parties denied any deficiency in service on their part and in the end, have prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of policy documents consisting of 3 pages, Ex. C2 is the copy of Claim Form - Part A, Ex. C3 is the copy of hematology report and prescription slips etc. consisting of 9 pages, Ex. C4 is the copy of discharge summary dated 08.07.2020, Ex. C5 is the copy of bills/receipts consisting of 5 pages, Ex. C6 is the copy of OPD slip dated 18.08.2020, Ex. C7 are the copies of emails consisting of 18 pages, Ex. C8 is the copy of claim repudiation letter dated 10.08.2020 and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Ms. Shweta Pokhrial, Manager Legal – Claims of the opposite parties along with documents Ex. R1 is the coy of policy documents consisting of 18 pages, Ex. R2 is the copy of Claim Form – Part A, Ex. R3 is the copy of treatment record of the complainant consisting of 22 pages, Ex. R4 is the copy of bill of Rs.95,457/- dated 08.07.2020 of Max City Hospital & Trauma Centre, Ex. R5 is the copy of deficiency letter dated 15.07.2020, Ex. R6 is the copy of questionnaire for doctor, Ex. R7 is the copy of OPD slip dated 25.07.2020, Ex. R8 is the copy of hematology report, Ex. R9 is the copy of medical literature, Ex. R10 is the copy of claim repudiation letter dated 10.08.2020 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.     

6.                In the present case, the claim of the complainant has been repudiated on the basis of a letter Ex. R10 = Ex. C8, the operative part of which is as under:-

“1. As per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if the claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under Section 10 j of policy terms & conditions.”

Clause 10 j of the policy is also reproduced as under for ready reference:-

          “j. Fraud

If any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or device, whether by you or any insured person or anyone acting on behalf of you or an insured person, then this Policy shall be void and benefits paid under it shall be forfeited.”

Perusal of the medical record relied upon by the opposite parties, shows that the complainant was diagnosed with Thrombocytopenia with Typhoid fever, Acute Febrile Illness. In order to rebut the claim of the complainant, the counsel for the opposite parties referred to Hematology report Ex. R8 and medical literature down loaded from the website https://www.labpedia.net. Perusal of these records shows that in order to infer the Widal test to be positive if then antigen titer is more than 1:160 in an active infection, or if TH antigen titer is more than 1:160 in past infection or in immunized persons. This interpretation raises serious doubts of the diagnosis of the complainant. The complainant has not examined any medical specialist  or placed on record any affidavit of specialist to butter-ace his claim.

7.                There is another aspect of the case. Ex. R7 is the hand written certificate issued by Dr. Naveen Mathur, Medical Specialist in response to the questionnaire sent by the opposite parties with regard to the settlement of the claim. He has clearly mentioned that Rs.5000/- were added in bill as per request of the patient to cover up other expenses from the insurance company. Clearly it is the complainant who is indulging in such mal-practices and also involved the doctor as well.

8.                From the above said facts and circumstances, it becomes crystal clear that the complainant did not prefer any genuine claim and tried to manipulate things in order to gain wrongfully and to cause wrongful loss to the opposite parties. So the opposite parties were justified by invoking clause 10 j of the policy in repudiating the claim

9.                As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                       (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:23.02.2023.

Gobind Ram.

 

 

Gurdeep Singh Vs HDFC Ergo GIC                              CC/20/205

Present:       Sh. S.S. Batra, Advocate for complainant.

                   Sh. Vyom Bansal, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated:23.02.2023.

Gobind Ram.