Orissa

Cuttak

CC/9/2022

Saubhagya Ranjan Dhal - Complainant(s)

Versus

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

L Mishra & associates

17 Jul 2023

ORDER

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

C.C.No.09/2022

          Saubhagya Ranjan Dhal,

           S/o: Chandramani Dhal,

           At/PO:Alara,Via/P.S:Narasinghpur,

           Dist:Cuttack.                                                         ... Complainant.

 

          Vrs.

 

The Head of Operation (India),

HDFC ERGO,General Insurance Company,

Corporate Office:1^stFloor,HDFC House,

165-166 Back bay Reclamation,

H.T. Parekh Marg,

Churchgate,Mumbai-400020.                                           ...Opp. Party.

 

 

Present:            Sri Debasish Nayak,President.

                             Sri SibanandaMohanty,Member.

 

Date of filing:   17.01.2022

Date of Order:  17.07.2023

 

For the complainant:                   Mr. L.Mishra,Adv. & Associates.

For the O.P.                :Mr. R.Pati,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 a “Health Surakhya” Policy from the O.P bearing policy no.2825100257787803000 dt.15.12.2017 for himself, his wife and daughter and was renewing the same by paying the premiums.  The last policy premium paid by the complainant was of Rs.48,624/- which was valid till 14.12.2021.  On 10.11.2020, the daughter of the complainant had some eye problem which was reddish in colour for which she was taken to the Rotary Eye Hospital at Cuttack on 14.12.2020 where it was diagnosed by the doctor to be “glaucoma” and she was advised for surgery within 15 days at L.V.Prasad Eye Institute,Bhubanessar.  On 15.12.2020, the complainant had taken his daughter to L.V. Prasad Eye Institute, Bhubaneswar where he had treated his daughter and had conducted some tests/examinations spending an amount of Rs.7,300/-.  The estimation of the surgery was of Rs.58,810/- but when the complainant had put forth his claim before the O.P, the same was denied by them through his letter dt.5.1.2021.  Thus, the total expenditure was borne by the complainant himself and his daughter was discharged on 21.1.21.  O.P had declined the policy of the complainant as void abnitio on the ground of non-disclosure of material facts.  The complainant had incurred a total expenditure at the hospital and other expenses towards the treatment of his daughter to the tune of Rs.61,773/- and when the claim was not settled, he had to approach this Commission after sending a pleader’s notice dtd.20.4.2021 to the O.P.  The complainant has claimed from the O.P the total medical expenses to the tune of Rs.61,773/- towards treatment of his daughter alongwith a compensation amount of Rs.1,00,000/- towards his mental agony.  

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

2.       The O.P has contested this case and has filed his written version wherein he has submitted that the case of the complainant is not maintainable and that the complainant has filed this case with an oblique motive.  O.P has admitted that the complainant had obtained “Health Surakhya” policy bearing no.2825100257787803000 on 15.12.2020 which was valid up to 14.12.21 covering health risks of himself, his wife and daughter.  The O.P in his written version has stated that the complainant had not disclosed while obtaining the said policy about the pre-existing disease of his daughter.  On 28.12.2020, while treating his daughter at L.V.Prasad Eye Institute,Bhubanessar, the complainant had approached for cashless reimbursement towards the treatment of acute angle-closure glaucoma bi-lateral vide his claim no.RC0HS20-12215275.  The O.P has further mentioned in his written version that on enquiry he could know that the patient was only admitted for examination purpose and no real treatment was done and there was no reason for hospitalisation.  Thus, he had repudiated the claim since it was in violation to the terms and conditions of the agreement.

          The O.P has filed copies of several documents in order to establish his stand.

          The O.P has also filed evidence affidavit of the Deputy Manager,Legal(Claims) of his organisation but when the said evidence affidavit is being perused, it is noticed that the same is only the reiteration of the averments as made in the written version as filed by the O.P.

3.       Keeping in mind the averments as made in the complaint petition and the contents of the written version of the O.P, 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.P?

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 going through the complaint petition, that of the written version and after perusing documents as filed by either sides, it is noticed that infact the complainant had availed a “Health Ssurakhya” insurance policy for himself, his wife and daughter from the O.P which was effective up to 14.12.2021.  It is also not in dispute that his daughter was having some problem in her eye for which the complainant had initially taken her to Rotary Eye Hospital at Cuttack and thereafter to L.V.Prasad Eye Institute, Bhubaneswar where his daughter was treated.  The O.P has repudiated the claim of the complainant on the sole ground that the complainant had not disclosed everything and that there was no real admission of the patient in the said Eye Hospital at Bhubaneswar.  Be that as it may, the copies of series of documents undoubtedly reflect that infact the daughter of the complainant had undergone treatment for her eye, both at Rotary Eye Hospital at Cuttack and L.V.Prasad Eye Institute at Bhubaneswar and the expenditures thereto were met out by the complainant,  when the O.P repudiated the claim of the complainant.   It would be worthwhile to quote the pertinent decision of the Hon’ble Vadodara State Consumer Disputes Redressal Commission wherein it is observed that hospitalization is not mandatory to claim medical insurance.  Insurance Companies insist on hospitalization for at least 24 hours for consumers to claim medical insurance benefits.  This is other than the medical services that are covered under day-care scheme, which need no hospitalization.  The plea taken in that aspect by the O.P is only flimsy grounds and ridiculous and clearly signifies the deficiency in service of the O.P who is also found to have practised unfair trade by repudiating the claim of the complainant by taking the plea of non-disclosure of material fact.  Thus, this Commission comes to a conclusion that there was indeed deficiency in service on the part of the O.P by repudiating the claim of the complainant unilaterally and arbitrarily.

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.P.  Thus, the O.P is directed to pay the claim amount of Rs.61,773/- alongwith interest thereon @ 12% per annum from 28.12.2020 till the total amount is quantified.  The O.Ps are further directed to pay the complainant a sum of Rs.1,00,000/- 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 17^th day of July,2023 under the seal and signature of this Commission.          

                                                                        

                                                                                                           Sri Debasish Nayak

                                                                                                                    President

 

                                                                                                          Sri Sibananda Mohanty

                                                                                                                             Member