Orissa

Cuttak

CC/97/2022

Manoj Kumar Dash - Complainant(s)

Versus

HDFC ERGO General Insurance Co Ltd - Opp.Party(s)

15 Jul 2023

ORDER

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.97/2022

          Manoj Kumar Dash,

           S/o: Radha Mohan Dash,

           At:BlockColony,Athagarh,

           Dist:Cuttack.                                                                     ... Complainant.

 

          Vrs.

 

1.       HDFC,ERGO General Insurance Company Limited,

Bombay, represented by its Head of operation,

                  1^st floor,HDFC House,165/166,Back Bay

Reclamation H.T Parekh Marg,Church Gate,

                   Mumbai-400020

 

2.       Branch Manager,

HDFC,ERGO General Insurance Company Limited,

Bhubaneswar Branch,3^rdFloor,Hotel Pal Regency Pvt. Ltd.,

J 7,Jayadev Vihar Road,JayadevVihar,Bhubaneswar,

                 Odisha-751013,Dist: Khurda

 

3.       Branch Manager,

HDFC,ERGO General Insurance Company Limited,

Cuttack Branch,OSL Tower II,2^nd Canal Road,Near KFC,

Badambadi Colony,Cuttack,Odisha-753012,

                 Town/Dist: Cuttack

 

4.        Care Hospital,Bhubaneswar,

Plot No.324,Prachi Enclave,Khurda,

                    Pin-751016,Dist-Khurda

Represented by its Director.                                            ...Opp. Parties.

 

 

Present:            Sri Debasish Nayak,President.

                             Sri SibanandaMohanty,Member.

 

Date of filing:  20.05.2022

Date of Order:  15.07.2023

 

For the complainant:                   Mr. S.Mallick,Adv.& Associates.

For the O.P no.1 to 3    :             Mr. R.Pati,Adv.&Associates.

For the O.P no.4:                    Mr. P.K.Sahoo,Adv. & Associates.

 

Sri Debasish Nayak,President.

          Case of the complainant bereft unnecessary details as made out from the complaint petition in short is that he had obtained insurance policy named & style as “Easy Health Floater Standard” Policy bearing no.2806203602430101000 from the O.Ps no.1,2 & 3 on 8.3.2015 and had paid the premiums.  The said policy was being renewed from time to time and accordingly, it was effective from 8.3.2021 to 7.3.2022.  The complainant had paid the premium to the tune of Rs.23,062/- and it was covering four of the family members of the complainant namely the complainant, Manoj Kumar Dash, his wife Mamata Dash and his two sons Mayuresh Dash & Master Mohitesh Dash.  The assured policy amount was of  Rs.4,80,000/-.  On 28.11.21 the complainant was admitted to the Care Hospital at Bhubaneswar for treatment of Covid-19 as he was found RTPCR test positive and his condition was critical.  He was admitted in the ICU in the said hospital and had remained under treatment from 28.11.21 to 8.12.2021.  After consulting the doctors, he had to leave the hospital on his request having no further financial support to meet the further medical expenses there.  The complainant had produced the policy in order to claim the medical expenses and accordingly as per his request the Care Hospital authorities on 28.11.21 had initiated a claim online requesting the O.Ps in order to meet the expenses but on 29.11.21 the claim of the complainant was turned down with a remark that non-disclosure of Diabetes Mellitesas the complainant was suffering since from the last 8 years.  The treatment papers of the complainant had reflected a remark of the Care Hospital that “exact duration of diabetes for last 8 years old.  No past records.  Not available.  So please kindly approved”.   On 2.12.2021, the O.P no.1 issued a letter to the complainant declaring his policy to be void abnitio on account of non-disclosure of material facts and thereby they had forfeited the paid premium amount.  On 29.12.21, the complainant had written to the O.Ps that he had never suppressed anything nor was he a diabetes patient as alleged and there is no document to show that he was a diabetic mellites patient for the last 8 years.  Moreso, when the complainant was admitted to Care Hospital on 28.11.21, his GRBS was 141 m.g/d.f and according to the normal standard medical range of GRBS less than 140 m.g/d.f indicates normal and greater than 200m.g/d.f is diabetic.  Inspite of his persuasions and repeated representations, the O.Ps had not reconsidered the claim as made by the complainant.  The complainant had to bear himself the medical expenses at the Care Hospital to the tune of Rs.4,22,589/-.  Thus, the complainant has come up with this case before this Commission claiming the money as paid by him at the Care hospital towards his treatment to the tune of Rs.4,22,589/- alongwith compensation of Rs.5,00,000/- for his mental agony and has further claimed a sum of Rs.75,000/- towards his litigation expenses.  Thus, in total the complainant has prayed for a sum of Rs.9,97,589/-alongwith interest @ 12% per annum from the date of due till the actual payment is made.

          The complainant has relied upon a decision of the Hon’ble High Court of Orissa in the case of Kunilata Sahu- Vrs- Senior Divisional Manager,L.I.C of India reported in 109(2010) CLT 94. And another decision of Hon’ble Supreme Court of India in the case of D.SrinivasVrs. SBI Life Insurance Co. Ltd. reported in (2018) 3 SCC 653 have held that in a contract of life insurance acceptance of premium amounts to waiving pre-condition of medical examination of the insured.  Acceptance of premium resulted into concluded contract.  Subsequently repudiation of policy amounts to deficiency in service.

          Alongwith his complaint petition, the complainant has filed copies of several documents in order to prove his case.

2.       Out of the four nos. of O.Ps as arrayed in this case,  though all of them have contested this case, O.Ps no.1,2&3 have conjointly filed their written version whereas O.P no.4 has preferred to file his separate written version.  According to the written version of the O.Ps no.1,2 & 3, the case of the complainant is not maintainable which is liable to be dismissed with cost.  According to them, with an oblique motive, the complainant has filed this case.  They admit about the “Health Surakhya” policy as taken by the complainant.   While obtaining the policy, the complainant had given a declaration that he was not having any diabetes or hypertension.  Accordingly, the “Easy Health Floater Standard” policy was issued in his favour bearing No.2806203602430101 which was covering his wife and two sons and was valid from 8.3.2021 to 9.3.2022.  On 29.11.2021, the complainant had approached through Care Hospital for a cashless claim as he was under treatment of viral pneumonia fever after being diagnosed as Covid-19 positive.  His claim vide no.RC-HS21-12734740 was received and the medical records when placed before the O.Ps, it reflected therein that the complainant had past history of diabetes which he had not disclosed while obtaining the policy which they could know from the report of the Care Hospital and accordingly, they had repudiated the claim of the complainant since because the patient/complainant was having 8 years old diabetic record.  The O.Ps have also relied upon a decision in the case of Ravneet Singh Bagga Vrs. M/s. KLM Royal Dutch Airlines in order to support their stand.  Accordingly, they have prayed for dismissal of the complaint petition it being not maintainable.

          They have also filed several copies of documents alongwith their written version to support their stand.

          From the written version of O.P no.2, it is made out that the case of the complainant is not maintainable on the score of non-joinder and mis-joinder of necessary parties.  There is no claim available to be made by the complainant against O.P no.4.  O.P no.4 in his written version admits that the complainant was under treatment with effect from 28.11.21 to 8.12.21 as he was suffering from Covid-19 and was being treated as an indoor patient.  On the date of admission in the hospital, the complainant had produced insurance policy and wanted for cashless reimbursement of the expenses thereby as incurred but the Insurance authorities had repudiated the claim because of reason that the complainant was having diabetes mellites since for the last 8 years.  O.P no.4 had no knowledge about such past history of the patient/complainant but had mentioned so basing upon the disclosure as made by the patient/complainant himself.  OP no.4 has mentioned that the total expenses incurred towards the medical treatment of the complainant of this case was of Rs.4,22,589/- which was paid by the complainant when he was being discharged from the hospital.  Thus, the O.P no.4 has prayed for dismissal of the complaint petition.

          O.Ps no.1,2 &3 have filed their evidence affidavit through one Bhubaneswar Das working as Deputy Legal Manager(Claims).  While going through the evidence affidavit as filed on behalf of the O.Ps. 1,2 & 3, it is noticed that the same is only the reiteration of the averments as made in their written version.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written versions of all the O.Ps, this Commission thinks it proper to settle the following issues in order to arrive at a definite conclusion here in this case.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps  and if they have practised any unfair trade ?

iii.        Whether the complainant is entitled to the reliefs as claimed by him?

Issue no.II.

Out of the three issues, issue no.ii  being the pertinent issue is taken up  first for consideration here in this case.

          After perusing the details of the averments as made in the complaint petition,also both of the written versions as available in this case record and also after perusing all the copies of documents as filed from either sides, it is made out that the complainant Manoj Kumar Dash had obtained a health insurance policy from O.Ps no.1,2 & 3 name and style as “Easy Health Floater Standard” on 8.2.2015 which was being renewed by him from time to time and was thus effective from 8.3.2021 to 7.3.2022.  The said health insurance also covered the health claims of his wife and two sons alongwith himself and the sum assured therein was of Rs.4,80,000/-.  The complainant being found RTPCR positive was admitted and treated at Care Hospital for Covid-19 from 28.11.21 to 8.12.21.  On 28.11.21 he had asked the medical authorities of the Care hospital to claim from the O.Ps no.1,2 & 3  regarding his medical expenses as he had obtained health insurance policy from them and had also provided the required policy papers accordingly to them.  Admittedly, the claim of the complainant was turned down on 29.11.21 by the O.Ps no.1,2 & 3 on the plea that the patient had chronic Diabetic Mellites for the last 8 years.  It is not in dispute that thecomplainant was admitted to Care hospital as a Covid-19 patient on 28.11.21 and it is further not in dispute that on the said day of admission to the said hospital, the complainant had asked the hospital authorities to claim for his medical expenses from the O.Ps no.1,2 & 3 as he had obtained health insurance policy from them which was effective then.  The claim of the complainant was repudiated by the O.Ps no.1,2 & 3 vide their letter dt.29.11.21 as they could know from the hospital report that the complainant was a diabetic patient having past 8 years history.  Quite interestingly, the said hospital authority arrayed as O.P no.4 in this case; while submitting the written version have mentioned therein that they could only know about the eight years past history of diabetes of the complainant as disclosed by the complainant himself.  They have not whispered a word that if they had made any clinical examination to that effect and could arrive at such a conclusion.  There is absolutely no document filed by the O.Ps in order to establish the fact that infact the complainant was a chronic diabetic patient and was suffering from Diabetic Mellites  for the last 8 years.  In this context, the complainant has submitted that while being admitted to the Care hospital his GRBS was 141 m.g/d.f and not greater than 200 m.g/d.fin order to prove that he was a diabetic patient.  In absence of any cogent evidence to make out that infact the complainant/patient was having diabetes for the past 8 years and the repudiation of the claim as made by the O.Ps so hastily, since because they got the claim on 28.11.21 and had repudiated the same on 29.11.21 without asking for any cogent medical evidence to support their such repudiation.  Thus, this Commission finds the O.Ps to be undoubtedly deficient in their service who have also practised unfair trade. Accordingly, this issue goes in favour of the complainant.

Issuesno.i&iii.

From the discussions as made above, the case of the complainant is maintainable and the complainant is entitled to the reliefs as claimed by him.  Hence, it is so ordered;

                                              ORDER

Case is allowed on contest against all the O.Ps who are found to be  jointly and severally liable here in this case.  Thus, the O.Ps are directed to pay the claim amount of Rs.4,22,589/- alongwith interest thereon @ 12% per annum from 28.11.2022 till the total amount is quantified.  The O.Ps are further directed to pay the complainant a sum of Rs.5,00,000/- towards compensation for his mental agony and harassment alongwith cost of his litigation.   This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 15^th day of July,2023 under the seal and signature of this Commission.          

                                                                        

                                                                                                        Sri Debasish Nayak

                                                                                                                President

                                                                                                          Sri Sibananda Mohanty

                                                                                                                 Member