Punjab

Ludhiana

CC/21/300

Raghubir Singh - Complainant(s)

Versus

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

Raghubir Singh

17 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 300 dated 11.06.2021.                                                        Date of decision: 17.01.2023.

Raghubir Singh Uppal S/o. Sh. Amar Singh Uppal, R/o. House No.38-GF, Nirmal Chhaya Apartment, Rishi Nagar, Ludhiana.                                                                                                                                ..…Complainant

                                                Versus

1. M/s. HDFC Ergo General Insurance Company Limited (Formerly HDFC General Insurance Limited/L&T General Insurance Company Limited), Registered and Corporate Office: 1^st Floor, HDFC House, 165-166, Backbay Reclamation, H.T. Parekh Marg, Churchgate Mumbai-400020, through its Managing Director/Authorized person. 
2. M/s. HDFC Ergo General Insurance Company Limited (Formerly HDFC General Insurance Limited/L&T General Insurance Company Limited) Surya Tower, 5^th Floor, 88, The Mall Road, Ludhiana, through its Manager.                                                                                                                                                                            …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Raghubir Singh Uppal in person.

For OPs                          :         Sh. Vyom Bansal, Advocate.

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the complaint are that the complainant had booked his ticket to England to take flight on 20.10.2019. The complainant availed travel insurance policy No.2919100559932100000 from the opposite parties on 19.10.2019 on premium of Rs.2740/- for himself and his wife. As per the said policy, the complainant and his wife were covered for a sum of US $50000 as per Travel Insurance Policy. The complainant and his wife boarded the flight on 20.10.2019 for England. On 20.10.2019 evening, the complainant was feeling uneasy and went to Ealing Broadway Hospital at London but all of sudden in the waiting room of hospital, the complainant got collapsed and was immediately admitted in emergency/ICU where he was given electric shock and revived him and retain his consciousness and later on they diagnosed that the complainant is suffering from some heart problem. Then the complainant was referred to Hammer Smith Hospital, London where he was medically checked up and procedure was performed and stunt was inserted in the heart of the complainant. The complainant was discharged on 25.10.2019 from the said hospital after the treatment. The complainant submitted that at the time when he was admitted in the said hospital, opposite party company was informed regarding this claim vide claim No.C291919001342/1 but the official of opposite party company has not given any satisfactory reply. The complainant incurred an amount of £16760.71 (or Rs.17,30,543.31) in the hospital and thereafter, the complainant lodged claim with the opposite party company and sent all the necessary related documents as demanded by opposite party company and email correspondent was also made by the complainant with the opposite party company. The opposite party company rejected the claim vide letter/email dated 25.03.2021 on the ground that the complainant had the pre-existing disease whereas the complainant had only old aged minor disease. The complainant further submitted that he was not suffering from any disease with regard to heart problem and prior to purchase of the policy it has been written that he is suffering from diabetes and after disclosing this fact, the policy in question was issued to the complainant. The opposite parties have declined the medical reimbursement of the complainant in illegal manner in order to cause wrongful gain to them and wrongful loss to the complainant which is the unprofessional attitude and unfair trade practice on the part of the opposite parties as well as deficiency in service on the part of opposite parties due to which the complainant has suffered harassment. Hence this complaint whereby prayer has been made to direct the opposite parties to reimburse the medical bill to the tune of £16760.71 the  (INR Rs.17304543.31) along with compensation of Rs.10,00,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections under the head of factual submission and objections that the complainant and his spouse were insured for the period of 20.10.2019 to 03.11.2019 vide policy No.2919100559932100000 under the Travel Insurance Policy by them for benefits detailed in Coverage Details of the policy subject to conditions and exclusions of the policy wordings. The policy was purchased online by the complainant through Web Aggregator, Policy Bazaar Insurance Brokers Private Limited. The policy was issued by the opposite parties in good faith on the basis of details entered by the proposer/insured/complainant on online platform of the Web Aggregator. The benefits under the policy are governed by the terms and conditions of the policy and the liability of the opposite parties is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and conditions of the policy. The opposite parties alleged that a request on 23.10.2019 for availing cashless facility by the complainant regarding medical expenses was received which was replied vide email dated 23.10.2019 stating that for admissibility of the claim, the insurance company would require treatment paper, consultation note and medical record details which were not provided by the complainant. Thereafter, the complainant filed reimbursement claim on 14.03.2020 which was registered vide claim No.C291919001342/1 and intimation of same was sent to the complainant. The complainant submitted multiple medical documents to the opposite parties including discharge summary dated 21.10.2019 of Ealing Hospital where he was provisionally diagnosed with Cardiac Arrest and discharge summary of Hammersmith Hospital dated 25.10.2019 where he was diagnosed with heart failure due to Coronary Artery Disease. Indoor case paper notes of the complainant dated 20.01.2020 and discharge summary dated 20.01.2020 from DMC Hospital was also collected. Perusal of the indoor case paper notes revealed that the complainant has past history of Hypertension & Diabetes. The said indoor paper also recorded that the complainant had undergone PTCA in England in 2010. It was also recorded that the patient had not undergone any hospitalization in the last 6 months. The opposite parties further averred that upon receipt of the said documents, the authorized official of insurance company applied their mind to the documents and came to the conclusion that the present was a case where the insured/complainant had a past history of Diabetes Mellitus  and is known case of CAD Primary PTCA and insured had been treated for the same ailment before his travel and has not disclosed the ailment at the time of issuance of the policy.  As such, the claim of the complainant was found to be not payable under Non-Disclosure of material facts and the ailment being a pre-existing condition under Section 3 and general exclusions of the policy. The intimation of the said rejection of the claim was given to the complainant vide letter dated 25.03.2021 as the complainant was not entitled for the claim and the policy conditions were also elaborated therein. The opposite parties alleged that the complaint is false and frivolous and the complainant is trying to mislead this Forum by suppressing and twisting the true facts. Moreover, complicated questions of law and facts are involved in the present complaint which cannot be tried and decided in summary jurisdiction of this Forum.

                   On merits, the opposite parties reiterated the facts stated in preliminary objections and denied the deficiency of service on their parties. In the end, a prayer for dismissal of the complaint has been made.

3.                The complainant filed replication reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement filed by the opposite parties.

4.                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 i.e. Ex. C1 is the copy of  Imperial College Healthcare policy, Ex. C2 is the copy of indoor treatment, Ex. C3 is the copy of final report, Ex. C4 is the treatment record of the complainant, Ex. C4a and closed the evidence.

5.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Mrs. Shweta Pokhriyal, Manager Legal-Claims of the opposite parties along with document Ex. R1 is the copy of travel insurance policy, Ex. R2 is the copy of email dated 23.10.2019, Ex. R3 is the copy of discharge summary of London North West University Healthcare NHS Trust, Ex. R4 is the copy of claim ref. No. C291919001342/1, Ex. R5 is the copy of proposal form of Travel Insurance Policy and closed the evidence. 

6.                We have heard the arguments of the complainant in person and the counsel for the opposite parties and also gone through the complaint, rejoinder affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties. We have also gone through the written arguments (s) submitted by the complainant  

7.                Undisputably, the claim of the complainant was declared inadmissible vide letter dated 25.03.2021, the operative part of which is reproduced as under:-

“From the information received, it would appear that this claim falls within the following condition.

Section 3

Emergency Medical Expenses

If, during the period of insurance, an insured person sustains bodily injury or sudden unexpected sickness then the Company will reimburse the insured person the necessary usual and reasonable medical expenses, incurred within two (2) months from the date of loss up to the sum insured stated in the schedule. The deductible or franchise, if applicable, shall be deducted from the compensation payable.

Sickness means any fortuitous somatic illness or disease but excluding any disease or illness which is, arises out of or is caused by a condition or defect for which medical treatment was recognized, advised, sought out or should have reasonable sought out, or received at any time before the period of insurance. 

General Exclusions

The company shall not be liable to pay any benefit in respect of any insured person:

21. any medical expenses incurred, the need of which arises out of pre-existing condition.

Pre-existing Disease- Any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice.

General Conditions

2. This policy shall be voidable in the event of misrepresentation, misdescription or non-disclosure by any or on behalf of the insured person of any material particular.

In this present claim as per the medical documents submitted insured had undergone surgery for PTCA. Insured has a past history of Diabetes Mellitus and is known case of CAD Primary PTCA and insured had been treated for the same ailment before his travel and has not disclosed the ailment at the time of policy issuance. So the claim is not payable under non disclosure of material facts and present ailment is related to pre-existing.

Hence we regret to inform that your claim is inadmissible as per the policy terms and conditions.

8.                Perusal of the letter dated 25.03.2021 and file reveals that the reimbursement claim bearing No. C291919001342/1 was filed on 25.03.2021 along with supporting medical documents. During the scrutiny, discharge summary dated 21.10.2019 of Ealing Hospital, discharge summary of Hammersmith Hospital dated 25.10.2019 were examined. The indoor case paper notes of the complainant dated 20.01.2020and discharge summary dated 20.01.2020 from DMC &Hospital, Ludhiana was also collected and examined and the perusal of the same reveals a past history of hypertension and diabetes mellitus when the complainant had gone to England in 2010. On this ground, due to non-disclosure of the material facts and the pre-existing conditions, Section 3 of the General Exclusions of the policy was invoked and the claim was repudiated. 

9.                During the pendency of this complaint, the complainant has adduced a certificate having reference No.HDHI/MRD/2022/97/22-1-22 dated 19.01.2022 issued by Dayanand Medical College & Hospital, Unit-Hero DMC Heart Institute, Ludhiana whereby history given by the complainant was reviewed and found that a clerical error had been occurred in the history notes where it was required to be mentioned “October 2019 (England)” instead of “(2010, England)”. Further the complainant has also produced the photocopies of his earlier passport which shows that the complainant never visited England in the year 2010.

10.              Further the complainant has also produced the photocopies of his earlier passport which shows that the complainant never visited England in the year 2010. The copies of passport were brought on record in response to the application of the opposite parties. Now it has become crystal clear that there was no misrepresentation, mis-description or non-disclosure on the part of the complainant with regard to material particulars adversely affecting his claim with the opposite parties. In fact, this repudiation has occurred on the perusal of documents of DMC & Hospital referred by the investigation of the opposite parties where history recorded by the hospital inadvertently shows history of PTCA 2010 in England. In fact, it was October 2019. The investigator or the opposite parties could have sought explanation from the complainant before repudiating the claim. In the given set of circumstances, the claim of the complainant is admissible and the letter of repudiation dated 25.03.2021 is now declared nonest.

11.              Now the question arises that how much amount is liable to be reimbursed to the complainant?

12.              At the time of submission of the complaint, the complainant has submitted the estimate of expenses incurred by him during his treatment in England. During the pendency of this complaint, on 23.06.2021, the complainant received a letter captioned as ‘Receipt for Overseas patient medical fees’ issued on behalf of Imperial College Healthcare, London summarizing invoices and payments along with their dates which are reproduced as under:-

Invoice Number	Invoice date	Amount paid         £	Date Paid
H0179114	29/10/2019	14,517.60	31/10/2019
H0183676	05/03/2020	1,787.00	27/05/2021
H0194263	25/05/2021	456.00	31/05/2021
	Total paid	16,760.60

This letter confirms the payment of all treatment fees in full to the Trust. In the given facts and circumstances, it would be just and appropriate if the opposite parties are directed to reimburse the claim of £16,760.60 in Indian currency at the prevailing conversion rate of Reserve Bank of India at the time of payment of said amount to the complainant along with composite costs of Rs.25,000/- to the complainant.

13.              As a result of above discussion, the complaint is partly allowed with an order that the opposite parties shall reimburse the claim of £16,760.60 to the complainant in Indian currency at the prevailing conversion rate of Reserve Bank of India at the time of payment of said amount within 30 days from the date of receipt of copy of order failing which the complainant will be held entitled for interest @8% per annum from date of filing of complaint till actual payment.  The opposite party shall further pay a composite cost of Rs.25,000/- (Rupees Twenty Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

14.              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:17.01.2023.

Gobind Ram.

 

 

Raghubir Singh Uppal Vs HDFC Ergo GIC                             CC/21/300

Present:       Complainant sh. Raghubir Singh Uppal in person.

                   Sh. Vyom Bansal, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the opposite parties shall reimburse the claim of £16,760.60 to the complainant in Indian currency at the prevailing conversion rate of Reserve Bank of India at the time of payment of said amount within 30 days from the date of receipt of copy of order failing which the complainant will be held entitled for interest @8% per annum from date of filing of complaint till actual payment.  The opposite party shall further pay a composite cost of Rs.25,000/- (Rupees Twenty Five Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. 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:17.01.2023.

Gobind Ram.